The Present Method of Inoculating for the Small-Pox

Of the Progress of Infection

Hitherto very little regard seems to have been paid to the progress of infection discoverable by the part where the operation was performed. But it will appear in the sequel, that an attention to this circumstance is very necessary, because a just prognostic may thence be sometimes formed of the future state of the distemper, and indications may be taken from the different appearances on the arm, that will enable us to prevent inconveniencies.

The former method of covering the place of incision with a plaister, and continuing upon it dressings of one sort or another, prevented much useful information of this kind. They prevented any judgment by the touch, and sometimes rendered that by the eye equivocal.

The day after the operation is performed, though it takes effect, little alteration is discoverable. On the second day, if the part is viewed with a lens, there generally appears a kind of orange-coloured stain about the incision, and the surrounding skin seems to contract. At this time I usually give the following medicine at going to bed, either mixed with a little of any kind of jelly, or more frequently made into a pill.

Calomel and compound powder of crabs claws, of each 3 grains, emetic tartar 1⁄10 of a grain.

A quantity of this medicine should be carefully prepared at once, in order to make the division more exact.

On the fourth or fifth day, upon applying the finger, a hardness is to be felt by the touch. The patient perceives an itching on the part, which appears slightly inflamed; and under a kind of vesication is seen a little clear fluid; the part resembling a superficial burn. About the sixth, most commonly, some pain and stiffness is felt in the axilla; and this is a very pleasing symptom, as it not only foretells the near approach of the eruptive symptoms, but is a sign of a favourable progress of the disease. Sometimes on the seventh, oftener on the eighth day, symptoms of the eruptive fever appear; such as slight remitting pains in the head and back, succeeded by transient shiverings and alternate heats, which in a greater or less degree, continue till the eruption is perfected. At this time also it is usual for the patient to complain of a very disagreeable taste in his mouth, the breath is always fetid, and the smell of it different from what I have ever observed in any case, except in the variolous eruptive fever.

The inflammation in the arms at this time spreads fast; and upon viewing it with a good glass, the incision, for the most part, appears surrounded with an infinite number of small confluent pustules, which increase in size and extent as the disease advances. On the tenth or eleventh day, a circular or oval efflorescence is usually discovered, surrounding the incision, and extending sometimes near half round the arm, but more frequently to about the size of a shilling; and being under the cuticle, is smooth to the touch, and not painful. This appearance is also a very pleasing one; it accompanies eruption; every disagreeable symptom ceases; and at the same time it certainly indicates the whole affair to be over; the pain and stiffness in the axilla also going off.

The feverish symptoms are for the most part so mild, as seldom to require any medicinal assistance, except a repetition of the same medicine that was directed on the second night after the operation; and on the following morning this laxative draught, to procure three or four stools;

Infusion of sena two ounces, manna half an ounce, tincture of jalap two drams.

These are given as soon as the eruptive symptoms are perceivable, if they seem to indicate any uncommon degree of vehemence.

It has been observed, that by attending to the progress of infection, we may be able to prognosticate, with some degree of certainty, the event of the distemper in general. Particular incidents will ever happen, but not sufficient to destroy the propriety of general rules.

If the appearances already described are observed early, a very favourable event is implied: but it happens in some cases, although it may be perceived that the inoculation has succeeded, yet it is barely perceptible; the colour about the wound remaining pale, instead of changing to red or inflamed; the edges of the incision spread but little, they remain flat, scarcely rising at all, and are attended neither with itching or uneasiness of any kind. Nay, sometimes on the fifth, and even the sixth-day, the alteration is so little, as to make it doubtful whether the infection has taken place.

When matters are in this state, the appearance is unfavourable, and implies a late and more untoward disease: to prevent which, I direct the powder or pill to be taken each night; and in case it fails to operate by stool, or there is the least disposition to costiveness, an ounce of Glauber’s salts, or more commonly the laxative draught already mentioned, is given in the morning, once or twice, as the case may require. This course forwards the inflammation, which I always wish to see; as I have constantly observed, that an early progress on the arm, and an early commencement of the eruptive complaints, portend that the distemper will be mild and favourable; and on the contrary, where both are late, the symptoms are usually more irregular and untoward.

Being now arrived at the most interesting period of this distemper, the eruption, a period in which the present practice I am about to recommend, differs essentially from the method heretofore in use, and on the right management of which much depends, it will be requisite to give clear and explicit directions on this head, and to advise their being pursued with firmness and moderation.

Instead of confining the patient to his bed, or his room, when the symptoms of the eruptive fever come on, he is directed, as soon as the purging medicine has operated, to keep abroad in the open air, be it ever so cold, as much as he can bear, and to drink cold water, if thirsty; always taking care not to stand still, but to walk about moderately, while abroad.

This treatment indeed seems as hard at first to the patients, as it must appear singular to the reader; but the effects are so salutary, and so constantly confirmed by experience, and an easy progress through every stage of the disease depends so much upon it, that I admit of no exception, unless the weather be extremely severe, and the constitution very delicate. And it is indisputably true, that in the few instances where the symptoms of eruption have run very high, the patients dreading any motion, and fearing the cold as the greatest evil, yet, when under these circumstances, I have persuaded them to rise out of bed, and go out of doors, though led sometimes by two assistants, and have allowed them to drink as much cold water as they chose, they have not suffered the least sinister accident: on the contrary, after they have been prevailed on, although reluctantly, to comply with these directions, they find their spirits revived; an inclination for nourishment returns; they rest well; a gentle sweat succeeds, accompanied with a favourable eruption; and the fever seems wholly to be extinguished.

In general, the complaints in this state are very moderate, and attended with so little illness, that the patient eats and sleeps well the whole time: a few pustules appear, sometimes equally dispersed; sometimes the inflammations on the arms spread, and are surrounded with a few pustules, which gradually advance to maturity; during which time, for the most part, the eruption proceeds kindly, and there is much more difficulty to restrain the patients within due bounds, and prevent their mixing with the public, and spreading the infection (which I always endeavour to prevent) than there was at first to prevail upon them to go abroad. During this time medicine is seldom wanted; the cool air seems the best cordial; and if any uncommon languor happens, a bason of small broth, or a glass of wine, is allowed in the day, or some white-wine whey at bed time; which are indeed at any time allowed to tender, aged, or weakly persons.

With these exceptions, they have hitherto been kept very scrupulously to the diet at first directed. But after the eruption is completed, if occasion requires, they are indulged in a little well-boiled meat of the lightest kind, as chicken, veal, or mutton.

The regimen above-mentioned, the cooling alterative purges, and the free use of cool air at the season of eruption, almost universally prevent either alarming symptoms, or a large crop of pustules. A few I have seen with such a quantity of pustules, though distinct, that I have neither advised nor allowed them to go out of the house. But the generality of my patients, when the eruptions are few, amuse themselves abroad within proper limits, with the pustules out upon them.

I neither enjoin this, nor maintain that it is necessary; but have not been able to observe that any inconvenience has arisen from it. And, how strange soever it may appear, it is true, that those who are most adventurous, seem to be in better spirits, and more free from complaints, than others who are inclined to keep within-doors. And indeed, such of my patients as have received the benefit of this treatment themselves, seldom permit those who are in the hardest part of the distemper, the eruptive, to keep much in the house; but encourage them to bear a little hardship, by recounting to them the benefit they have reaped from the method they are recommending.

Those who have the disease in the slightest manner first described, viz. without any appearance of eruption but on the inoculated part, are soon allowed to go about their usual affairs; and many instances have happened of very industrious poor men, who have instantly returned to their daily labour, with a caution not to intermix with those who have not had the distemper, for fear of spreading it; and with directions to take two or three times of the purge already directed, or as many doses of Glauber’s salts. Those who have it in a greater degree, are confined somewhat longer; and a very mild laxative is now-and-then exhibited, if there is the least disposition to costiveness; as the progress to maturation appears rather to be advanced than retarded by the operation.

When the maturation is completed, and it is evident we have nothing further to fear from the distemper, I allow my patients gradually to change their course of diet, from the perfectly cooling kind, to one a little more generous; recommending strictly to all a return to their ordinary animal diet with much caution and restraint upon their appetites, both in respect to food and fermented liquors.

It is not often that we are under a necessity of making any application to the part where the operation was performed; it most commonly heals up, and is covered with a scab, about the time when, in a natural way, all the pocks would have been dried up: but there are some cases wherein the incisions continue to discharge a purulent matter longer; in these instances it is sufficient to cover the place with the white cerate, or any other mild emplastic substance, which may at once prevent the linen from adhering to the sore, and defend it from the air. And as in these cases the part remains unhealed from some peculiar cause in the habit, it will be necessary to give gentle purgatives, and proper alteratives, as particular exigencies may require.

Of Anomalous Symptoms and Appearances

In the preceding pages I have described the usual progress of the small-pox from the inoculation. There are, however, deviations from this course, and indeed not a few; some of the most material of which, as they may embarrass the inexperienced, and create a real difficulty, as well as apprehensions of danger, it seems necessary to describe, and to point out the means that experience has suggested to remove these symptoms, or the doubts respecting the event.

The first I shall take notice of, and which, though it very rarely happens, sometimes gives much trouble, is great sickness, accompanied with vomiting, coming on during the eruptive state of the distemper. For this complaint it is always necessary in the first place to clear the stomach; which may be effected, either by ordering the patient to drink plentifully of warm liquids to promote vomiting; or, perhaps more properly, by given one grain of emetic tartar to an adult, mixed with ten grains of compound powder of crabs claws; taking care to lessen the dose for very young and weak subjects.

This usually throws off some bilious matter by vomit, sometimes procures stools, or occasions a moderate sweat, and generally administers relief. If, however, no stools should follow from this medicine, and the sickness should remain, a gentle laxative almost certainly procures a respite, and the appearance of the eruption removes the complaint intirely.

Another deviation, of still more consequence, which sometimes happens towards the time of the eruption, and is often, though not always, accompanied with great sickness, is an erysipelatous efflorescence. This, if it shews itself on the skin partially, and here and there in patches, is not very alarming, and soon wears off.

But sometimes the whole surface of the skin is covered with a rash intimately mixed with the variolous eruption, and so much resembling the most malignant kind of confluent small-pox, as scarcely to be distinguished from it: and indeed some cases of this sort have happened, where, being accompanied with petechiæ and livid spots, I have been much alarmed; not being able, by inspection only, though assisted by glasses, to determine whether what I saw was an inoffensive rash, or tokens of the greatest malignity. Very strict attention, however, has enabled me to distinguish the difference clearly; and the following observations will, I hope, tend to relieve others from the anxiety they would feel upon such an appearance.

The real and essential difference then is to be gathered from the concomitant symptoms. In the erysipelatous or variolous rash, there is not so much fever, nor is the restlessness, or a pain of the head or loins, so considerable; neither is there that general prostration of strength, which are almost never-failing attendants on a confluent small-pox, especially when accompanied with such putrid appearances. Besides, upon a careful examination, there may sometimes be discerned a few distinct pustules, larger than the rest, mixed with the rash, which are indeed the real small-pox. In these cases the patients are ordered to refrain from cold water, or any thing cold, and to keep within doors, but not to go to bed. If any sickness yet remains, a little white-wine whey, or other moderate cordial, is advised; and this method has hitherto been so successful, as to prevent any alarming complaint. After two or three days, the skin from a florid changes to a dusky colour, a few distinct pustules remain, and advance properly to maturation, without any further trouble ensuing from this formidable appearance¹.

This rash has often been mistaken for the confluence it so nearly resembles, and has afforded occasion for some practitioners, either ignorantly or disingenuously, to pretend, that after a very copious eruption of the confluent pox, they can by a specific medicine discharge the major part of the pustules, leaving only as many distinct ones as may satisfy the patient that he has the disease. Such pretensions have certainly been made; and the patient, who has been deceived in this manner, has contributed to spread reports untrue as to the fact, and probably prejudicial to the health of others, who in like circumstances have been sent into the open air, by which, and other cool means, the rash has been repelled, and the bad effects experienced afterwards.

I must also observe here, that rashes of the kind I have described frequently happen during the preparation (whether owing to the regimen, or medicine, or both, I cannot say) and cause the operation to be postponed: and I have observed, that in such cases they are apt to return at the time of the eruption of the small-pox.

In general, as has been already said, the symptoms which precede eruption commence at the end of the seventh, or in the eighth day, inclusive from the operation; but it often happens that they appear much sooner, and sometimes much later, than the time above-mentioned. For instance, I have seen some cases wherein the disease has happened so suddenly after infection, and with so little complaint or uneasiness, that the whole affair has been terminated, purges taken, and the patient returned home perfectly well in a week’s time; before others, inoculated at the same time, from the same patient, and under the same circumstances, have begun to complain.

In this case the inoculated part shews early certain marks of infection, sometimes on the very next day, or the day after, when the incision will often appear considerably inflamed and elevated. The patient about this time frequently makes some of the following complaints, viz. chillness, itchings, and small pricking pains in the part, and sometimes on the shoulder, giddiness, drowsiness, and a slight head-ach, sometimes attended with a feverish heat, but often without any: the account they themselves give of their feelings, is, in some, as if they had drank too much, and in others, as if they had caught a cold. These complaints seldom last twenty-four hours, often not so long, and with frequent remissions, and never, that I remember, rise to a degree that requires confinement. The inflammation on the arm at the time of the complaints, advances apace, and feels hard to the touch; but upon their wearing off, the inflamed appearances gradually lessen, and the part dries to a common small scab; the skin that was before red, turns livid, and the party is quite well, and nothing more heard of the distemper². In some instances these symptoms attack much later; even on the seventh or eighth day, when an eruption might be expected in consequence of them, yet none appears; but the arm gets well very soon, and the disease is at an end.

In this irregular sort of the disorder there have, however, been some examples where a few eruptions have appeared, and probably in consequence of the inoculation; yet the pustules have not looked like the true pocks, nor maturated like them, nor lasted longer than three days; about which time they, for the most part, have dried away.

As I find it difficult to describe the variety and irregularity of symptoms that occur in this short way of having the distemper, I will give some cases, by way of illustrating the matter more to the reader’s satisfaction.

When subjects of this sort first occurred in my practice, I was in doubt whether they were quite secure from any future attacks of the distemper; and in order to try whether they were so or not, I inoculated them a second time, and caused them to associate with persons in every stage of the disease, and to try all other means of catching the infection; and this method has been practised with the generality of such patients ever since, yet without a single instance of its producing any disorder: so that I now make no scruple of pronouncing them perfectly safe; and experience has enabled me, for the most part, to foretell, in two or three days after the operation, when the disease will pass in this slight manner.

Upon the second inoculation, however, the incised parts are commonly inflamed for a day or two, just in the same manner as I have, in numerous instances, found them to be, as well in those who, though certain of having had the small-pox in the natural way, have submitted to be inoculated merely for the experiment sake, that the result might be observed; as in others, who, being doubtful whether they have had it or not, have been inoculated, in order to be satisfied. But in all such cases the parts soon became well; nor did any of those appearances which have been described as the constant attendants on inoculation, as pain in the head, giddiness, marks of infection in the arm, &c. ensue; nor can they ever be produced upon a person who has had the small-pox before, either in the natural way or by inoculation; and therefore it cannot with reason be suggested, that the patients, whom I suppose to get through the disease in the very slight manner above described, may possibly have had the small-pox unobserved in some former part of their lives.

Another irregularity deserving notice here, is, that sometimes, upon the abatement of the fever and other symptoms, after the appearance of several pustules, and when the eruptive stage of the disease seems completed, it nevertheless happens that fresh eruptions come out, and continue doing so daily, for 4, 5, or even 6 days successively; preceded sometimes by a slight pain in the head, though more frequently they appear without any new disturbance. These are generally few in number, short-liv’d, and seldom come to maturity. But I have seen four cases, in each of which, after a cessation of complaints, and an appearance of few pustules, the eruptive stage of the disease was thought to be over, yet in two or three days a fresh fit of fever has attacked the patients, and after a short illness a quantity of new pustules has broken out, far exceeding the first number, and these remained, and maturated completely. Instances of this kind may be found among the cases annexed³.

Some of my own patients, and, as I am credibly informed, of other inoculators in this way, have had considerable eruptions of this kind after they have returned home; which have probably given occasion for the reports of several having had the disease again in the natural way after inoculation. But that these reports are ill-grounded, will appear from this observation, to wit, that in all the cases of this sort which have occurred in my own practice, or, as far as I can learn, in that of others, the second or latter crop of pustules has always happened within the time usually allowed for the progress of the small-pox from inoculation, and before the inflammation on the arm has ceased, and sooner than they could be supposed to be produced by infection taken in the natural way; and whenever it has happened, it has been to persons in whom, after a slight eruption, and abatement of symptoms, the disease has prematurely been judged to be quite over, and they have therefore been permitted to return to their families.

It will doubtless be asked, how cases of this kind should ever happen among those who return home as cured? To which I answer, That it is no unusual thing for industrious men, after a slight eruption, and cessation of all complaints, to ask leave to return home to their occupations and families; and where it has been thought that no danger would accrue to others, their request has been often granted; for the physician, no more than the patient, can foresee when these accidents shall follow: but it may be observed here, that in all these cases of my own knowledge, very repellent methods have been used in the beginning; and a more generous diet or greater exercise afterwards, has seemed to contribute to this secondary eruption.

Before I conclude this chapter, it may be proper to observe, that inoculated patients, in some stage or other of the disease, may possibly be attacked with diseases altogether independent of the small-pox; such, for instance, as may arise from worms, or be the epidemic of the season, or such as the patient may by constitution be subject to; and some cases of this sort will be found among those annexed.⁴