The Present Method of Inoculating for the Small-Pox

Conclusion

Before I dismiss the subject, it may not be improper to give some account of the motives that induced me to adopt this method.

During the course of many years practice of inoculating in the former usual method, I generally committed to writing the most remarkable occurrences to have recourse to. Among these, I had recorded some cases, which proved, that those who had suffered most, were in general such as have been kept warm, and nursed with the greatest tenderness and care. These facts disposed me to think of a cooler manner of treating the disease, and made me attentive to the reports of such a method having been practised in some parts of this country with great success, though too extravagant at first to deserve credit.

The reports, however, of this practice still gained ground; and, upon the strictest inquiry, I found they were for the most part true, and that such who were treated in this way, passed through the distemper in a more favourable manner than my own patients, or those of the most able practitioners in the old method of inoculation; also that the inoculators in this new way, enjoined a stricter regimen as to diet, than I had hitherto thought necessary; and that they frequently brought their uninfected patients into the presence of those who had the disease, and inoculated them immediately with fluid matter, taken on the point of a lancet, and by a very slight puncture or incision; applying no dressing or covering afterwards.

This way of performing the operation pleased me, as far as related to the slightness of the incision, and the use of fresh matter; for I had (in common with other inoculators) sometimes failed of infecting, by using a thread that had been kept too long in a phial: but the circumstance of bringing the person to be inoculated into the presence of one who had the small-pox, seemed hazardous, lest there might be an accumulation of infection.

All doubts, however, were at last removed by the authenticated accounts that I received of these particulars, and of the good success that attended the practice; and I began to try it in January 1765; when, after having directed a strict regimen and some mercurial purges, I inoculated with fluid matter, proceeding with much circumspection and attention; my patients being exposed to the open air in that cold season. The great advantage they received from this treatment was soon apparent, and more than sufficient to encourage my continuance in the practice; till repeated experiments induced me to think, that instead of supposing the fever in the small-pox to be the instrument employed by nature to subdue and expel the variolous poison, we should rather consider it as her greatest enemy, which, if not vigorously restrained, is apt to produce much danger; and that all such means should be used as are most likely to control its violence, and extinguish the too great fervor of the blood. Pursuant to this opinion, besides keeping my patients in the open air, which I had learned from others, I first directed the mercurial and antimonial medicine, and the laxative course in the eruptive state; the manner of administering which, and the success attending, has been already related.

It may perhaps appear singular that bleeding has neither been once mentioned or directed in the course of this work, though by general consent it is allowed to be the most efficacious remedy in all inflammatory cases. To this I can only say, that the regimen and medicine above prescribed commonly reduce the patients so much as to render bleeding unnecessary. And in the natural small-pox it seemed most reasonable to adhere, as strictly as possible, to those measures which had contributed apparently so much towards passing so easily through inoculation. I doubt not, however, that cases will arise, in which bleeding may not only be safe, but extremely salutary.

It will, I hope, be needless to tell the reader, that I have disclosed the whole of what I know with certainty relative to this process, as the regimen, medicines, different types of the disease, the rules of prognostic, and various events, &c. are fully and faithfully related, according to the best of my judgment and experience. And I believe, if the method now recommended is carefully pursued, it will be found to answer with a success at least equal to any yet discovered. Nevertheless it is reasonable to suppose, that further experience may produce some improvements: yet when it is considered, how short a time is required for preparation; how few medicines are to be taken; that those medicines are neither nauseous in themselves, nor violent in their operation, and of a kind likely to be beneficial to most constitutions, and hurtful to none, unless injudiciously administered; that the disease is usually so mild, as to require little or no confinement (the complaints of far the greater number being that they have too little of the distemper); and that the disagreeable consequences which sometimes happened after the former method of inoculation are likewise by this most commonly obviated; I do not see that much alteration can be even wished for. That which appears most likely to be made, is in shortening the time of preparation; for as I have often been obliged to inoculate without any, and have always had the same success, it has inclined me to think, that much, if not the whole, of this process, may be dispensed with, except in very full habits, or where other particular circumstances may require it. But in all these cases, from the insertion of the matter to the time of the eruptive complaints, the patients have been kept to a close observance of diet, and the use of the preparatory medicines, proportioned as well as I could to their condition: for I durst not, by way of experiment, dispense with the use of measures that had been hitherto so successful.

Should it be asked then, To what particular circumstance the success is owing? I can only answer, that although the whole process may have some share in it, in my opinion it consists chiefly in the method of inoculating with recent fluid matter, and in the management of the patients at the time of eruption. If these conjectures should be true, perhaps we should be found to have improved but little upon the judicious Sydenham’s cool method of treating the disease, and the old Greek woman’s method of inoculating with fluid matter carried warm in her servant’s bosom.

CASES

CASE I

Nov.

23d.

A very strong, fat, middle-aged man was inoculated with fluid matter, from a person pretty full of the natural small-pox, and near the crisis.

26th. He came to me, that I might inspect the arm, which then appeared to be certainly infected, and very forward.

28th. He came to the house, and informed me he had been taken very ill on the 26th in the evening, and continued so all the next day. His complaints had been, great pains in his head and back, with heat, thirst, and restlessness. He was at this time, however, pretty well; but on inspecting the arms, they appeared much inflamed for a considerable space round the incision, and the erysipelatous appearance gradually extended itself over the greatest part of the arms between the elbow and shoulder. He now complained only of slight flying pains in his head and limbs, but without the least degree of fever: after a bad night’s rest several eruptions were discovered on the hips, and one on the neck. Some of these maturated, others dried away; and, upon the whole, the procedure was such as would not by any have been called variolous, if unattended with other circumstances.

CASE II

Nov. 23d.] A healthy strong man, inoculated at the same time, and from the same person, with the last, accompanied him also on the 26th, when the arm of this patient appeared in a very doubtful state respecting the infection.

On the 28th, when he came to the house, the skin at the incision was discoloured, felt hard, seemed thickened, did not appear inflamed; nor did he allow it had itched, or that he had perceived any alteration in his health.

Things remaining in this state, I inoculated him again on the 30th in the morning, being the eighth day from the first inoculation. On the evening of the same day he complained of chilliness, attended with pain in his head and limbs, and passed an uneasy night. These complaints lasted in a very moderate degree for two days more, but without the least appearance of a fever. A very few pimples were discovered upon the decline of these symptoms, but they soon vanished without maturating.

CASE III

Nov. 23d.] A third patient, a young man twenty years of age, was inoculated with the two last. I had not seen his arm from the time he was inoculated to the 28th, when he came to the house in company with the others. He said the incised part had itched very much the first three or four days, but it now appeared nearly in the same state as the preceding.

He was also inoculated again on the 30th. But as the succeeding complaints, and doubtful eruption in this case, bore an exact resemblance to those of the former, it is needless to repeat them.

Nothing happened to either from the second inoculation.

CASE IV

1765, May 5th.] A man aged twenty-four was inoculated; after which he went to visit a relation, till it should be thought proper for him to come to the house, which I directed him to do on the 11th, if he should continue well till that time.

He took with him two calomel pills, one of five and the other of ten grains. He was ordered to take the least on the 8th, the other on the following night, and an ounce of purging salts the next morning.

I did not see him till the 11th, when he came to the house: he was then perfectly well, but said he had been a little giddy for the last day or two, and that his head had ached very much the preceding day for about an hour, insomuch that he thought he must have come over; that his arm had itched very much, and the purge had worked very briskly.

Upon examining the arms, both incisions appeared to be considerably inflamed, and looked just as is usual on the approach of the eruptive fever, which I had not the least doubt would soon happen.

On the 12th he complained of some pain in the right shoulder, and under the arm, which he said was stiff, and felt as if it was swelled. However, he continued perfectly well and free from all complaints to the 15th; the arms appearing as is usual when the distemper is attended with very few pustules; that is to say, not quite free from inflammation, but with a slight one.

The case being not so clear as could be wished, in order to be thoroughly satisfied, I inoculated him again, taking particular care to infect the part well.

On the 16th in the morning he took a dose of Inf. Sen. and Manna.

He continued quite well, and no itching or signs of infection appeared from the last inoculation.

CASE V

May 3d.] A man of 44 was inoculated. I saw him every day, and it was easy to perceive that the infection had taken place very early.

On the 7th it appeared so forward, that I ventured to prognosticate he would have a very early and mild disorder, and no eruption.

On the 8th he complained of a pain in his head and back, and that he felt a general uneasiness, attended with a loss of appetite, which at other times was very good. He continued complaining in this manner that whole day, but on the next found himself pretty well, and continued so without any other illness. The inflamed appearance on the incision abated from this time.

His health returned, and he still remains perfectly well.

CASE VI

A middle-aged man was inoculated at the same time; whose case in every circumstance so nearly resembled the former, as to render it needless to enumerate the particulars.

Both were inoculated a second time without any eruption or signs of infection happening in consequence of it.

CASE VII

Dec. 5th.] A healthy man of 38 was inoculated. On the 7th he called on me, when his arm itched very much, and shewed certain marks of the infection having succeeded.

The inflammatory appearance was then considerably abated, and the incisions seemed disposed to heal. He felt no uneasiness on the part, nor had he any illness.

On the 12th and 13th he complained of pains in his head and limbs, as also of stiffness under his arms, which I esteem one of the most certain proofs of the infection having taken place. There was no alteration in the pulse, nor any other sign of a fever; a few pimples about the neck and arms followed these complaints, yet not such as I should have esteemed variolous on any other occasion: for some soon disappeared; and others, which remained long enough to have a little matter formed in them, proceeded to this state with great irregularity.

He was inoculated again, but without the least effect.

CASE VIII

A man between 50 and 60 was inoculated about four in the afternoon: on the morning of the third day after the inoculation I first saw his arms, when they shewed uncommon signs of infection, being already much inflamed; and upon inquiry, I received from him the following account: that on the same evening he was inoculated, he felt an uneasiness and numbness at and near the place of insertion; and that the day following, these complaints increased, and spread up to the shoulder of one arm, which was very stiff and numbed; that the incision had itched several times, and his arms felt as if he had been bruised by a blow with a very large stick. And on the preceding evening, which was the second from the inoculation, his head had been giddy and in pain, accompanied with some chilly fits; but all these sensations went off without any other illness. He had rested well, and never thought himself in better health.

From this time I saw him at different times every day, and he continued in perfect health; only sometimes, especially towards evening, he said he felt as if he had drank too much. The arms were much inflamed; but on the 6th and 7th day they altered their colour to a darker hue, and the inflammation and hardness were evidently abating. He now desired to go a journey of about 20 miles on business; and this I consented to, from an absolute confidence that he was secure from any alarming attack; having first enjoined him not to go into company where he might risque spreading the infection; for his breath at this time had that peculiar offensive smell which accompanies the disease.

He returned the following day, being the 8th, in the afternoon, making no complaint, but of hunger; yet said his head had ached the preceding night after his journey. His arms were now rather more inflamed, which I attributed to the friction they might have in the chaise; but from this time all complaints of every kind ceased. His arms soon became quite well; he took his first purge on the following day, a second on the 11th, and returned home on the 13th from the inoculation, without having a single eruption of any kind.

It is remarkable in this gentleman’s case, that being so well he did not chuse to live with those who had the distemper, but continued in a lodging with his wife, who accompanied him by way of nurse, in full confidence of having had the small-pox many years since. However, after they got home, she fell ill, and had the distemper in a very clear but favourable manner, and doubtless caught it off her husband.

CASE IX

A young gentleman aged nineteen was inoculated June 2d, 1765.

On the 3d he rode out with a friend in an open chaise, and it being stormy weather, returned home wet. I called on him next morning, and found him in bed, complaining that he had rested ill, felt shooting pains in his head, his throat a little sore, thought himself feverish, and that he had taken cold the preceding day. All this seemed very probable; his pulse was too quick, though the heat not considerable, and he was in a moderate sweat.

He rose about ten, and kept within doors the whole day, complaining of weariness, slight pain in the head and about the shoulders; also that the incised parts felt uneasy, and itched.

On the 5th he thought his cold considerably better, and ventured abroad. His arm appeared certainly infected, and very forward; insomuch that I suspected he would have no more illness in consequence of the inoculation.

On the 7th the inflammation on the arm was considerably abated, and the incision seemed disposed to heal.

Apprehending from these circumstances that nothing more was to be expected from the operation, he was inoculated again in the evening, from a person who had the distemper pretty full, though of a distinct kind, in the natural way.

No marks, however, of infection ensued from this last operation; and he continued visiting with me many patients in all stages of the disease: so that it is probable he was then in more danger of infection than he will ever be again.

CASE X

Dec. 19.] A healthy florid young man was inoculated in both arms; and soon after on the same day he felt a disagreeable numbness and stiffness, beginning at the incision in one arm, and extending as high up as the shoulder. That night at going to bed he took five grains of calomel in a pill.

On the 20th the same kind of sensation in the arm remained, extending also to that side of the head, which was in some pain. These complaints continued this day and the next. I ordered him to take the same mercurial pill at going to bed.

22d. Another indifferent night, with the same complaints, and a stiffness in both shoulders. The pulse appeared to be rather quickened, but without any such increase of warmth as was sufficient to be called fever. The incisions were unusually forward.

23d. In the morning I was told he was better, and had taken a ride to visit his mother at about ten miles distance; also that he had several pimples, which were believed to be the distemper.

In the afternoon he returned, when I found there were several pustules out, which had the appearance of being true small-pox; and his arms were as forward as is usual at the time of eruption. All his complaints were now gone off, and he seemed quite well.

24th. Gone abroad for his pleasure.

25th. He called on me; and the pustules having advanced properly towards maturation, I ordered him immediately to the house, where he remained perfectly well, and the pustules, which were about twenty, maturated very kindly.

27th. He took a purgative, which operated moderately. On the 28th he returned home in good health, and has continued so ever since.

CASE XI

Two men were inoculated at the same time, the one about 40 years of age, corpulent, and subject to the rheumatism; the other between 50 and 60, very thin and healthy.

I saw both these patients on the third day, when the places of insertion were in each so very much inflamed, that I was pretty certain they would scarce have any eruption, and acquainted them with my opinion. Both made complaints of itching and uneasiness in the part; there was however this difference, the elder said he had felt a numbness and smarting from the time of inoculation, particularly the following night; that his head had been in pain, and that he had had several chilly fits: the other complained that his arms felt hot, and itched, but said he was very well. They both came to me on the sixth day, when the inflammation on the arm of the elder was considerably abated; and he said that from the time that I saw him last, he had remained free from any complaint, except a slight uneasiness at the parts infected. The incisions of the other were still in an inflamed state; he said that his head had ached, and that he was very chilly the preceding night: both these symptoms continued for two days more; but the attacks were irregular, lasted but a very short time, and there was not the least appearance of fever. The other held perfectly well, and all signs of inflammation on the arms of both soon disappeared.

They both remained several days in the same house, and kept company with others in different stages of the disease; the elder of the two was inoculated again, but without the least signs of the infection taking place, and both remain in good health.

CASE XII

A gentlewoman turned of 50, of a corpulent habit and clear complexion, was inoculated about noon. On the following morning she informed me that the inoculated parts, and more especially one arm, had smarted very much, and felt benumbed up to the shoulder, and had been sufficiently troublesome to disturb her rest: upon inspecting the parts, they were found much inflamed, and a little elevated. These kinds of feelings were complained of that whole day, and towards night her head ached; but she had no increase of heat, or alteration in the pulse. On the third morning there was a flushing on the skin round the puncture on each arm, nearly the breadth of a sixpence; on applying the finger, it felt hard about the middle; and upon the whole, the appearances of infection were as evident as are usually observable on the 9th or 10th day. I therefore ventured to assure her, that the disease would pass over in a very slight manner, and most probably without any eruption; and the event justified my prognostic.

She complained a little of pain in her head for several evenings, and the inflammation on her arm increased; but on the 6th day it began to turn to a yellowish brown, and every inflammatory appearance wore off: she remained perfectly well, living with those who had the distemper, and in an infected house, without any illness.

CASE XIII

January 9. A strong healthy man, aged 24 was inoculated. The eruptive complaints began on the 8th day, ran pretty high, and on the inoculated parts of each arm he felt very great and unusual pains. On the 10th a true erysipelatous swelling attacked one arm, and extended from the shoulder to the elbow; the other was also affected in the like manner, but not so considerably. In the evening of the same day he complained of great pain and soreness about his stomach, and at this time the whole surface of the skin was nearly covered with a rash and petechial spots of different colours and sizes.

What I distinguish by the name of rash, were pimples much resembling the confluent pocks, and rising above the skin; the petechial spots were interspersed, and even with the skin; some of these were small like flea-bites, others were near as large as a silver penny; some were of a very dark purple, and others of a livid colour. I observed them carefully, assisted by a good convex glass, and found the appearances singular and alarming. But as the fever was not high in proportion to such appearances, the head and back free from pain, and no great weakness attended, the event seemed to be the less doubtful. The patient drank a bason of white wine whey at going to bed, and I found him pretty well in the morning: the erysipelas began to be less fiery, and put on a darker hue; a few large distinct pustules of real small-pox soon discovered themselves, and from this time all went on very well; the arms indeed were of a livid colour for some time, but gave the patient no pain or uneasiness, so that he passed through the whole process perfectly well in every other respect.

CASE XIV

A healthy young woman 20 years of age, after having taken two of the preparatory powders, had a slight fever, accompanied with sickness at stomach, which were followed by an erysipelatous rash; on this account inoculation was postponed four days, when the rash was totally gone. On the 7th day from the inoculation she began to have the eruptive symptoms, which were accompanied with more fever and pain in the head and back than is usual, also very great sickness and vomiting; these were succeeded by an universal rash, of the same kind as had happened before; in this situation she was ordered to keep her room, and the following medicine was directed:

Take compound powder of crabs claws, one scruple; emetic tartar, one grain.

This operated moderately by vomit, discharging some bile, and also twice by stool. The stomach was much relieved, but the rash remained, and put on so much the appearance of a confluent eruption, that I could scarce be satisfied it was not so, though I had seen in the same person but a few days before a smaller degree of the same rash. What made the case more doubtful was, that the fever still remained pretty high; and her head and back were not much relieved by this eruption. In this situation I did not think it adviseable to expose the patient to the open air, but directed only a saline mixture, with compound powder of crabs claws, and that she should keep her room, but not her bed.

On the 10th a few distinct pustules were to be distinguished, the rash began to look fainter, and the whole terminated in a very favourable distinct eruption, without any particular accident: the skin peeled off universally, as is not uncommon after a rash.

CASE XV

A man aged 44, on the sixth day after inoculation, began to complain of pains in his head and back, and of being frequently very cold. These lasted with great severity, insomuch that he took the alterative pill, a purging draught, and kept much in the air till the 9th, when about ten pustules appeared, and his complaints ceased. These seemed likely to dry away without maturating, which is not unfrequently the case where there are very few.

On the 12th he took a purge; his arm remained considerably inflamed; but as he was very desirous of going to a relation’s house, where he proposed to be aired, I consented to it.

On the 16th I was told he had been much indisposed since his removal, and that he wished to see me.

On the 17th I visited him, and found a considerable number of pustules, to the amount of about 40, in the face, of true small-pox. The account he gave me was, that he found himself very ill on the evening after his removal, and that he perceived the pustules the next morning. This was on the 14th day from the inoculation, and the forwardness they were in agreed well with his account. His arm continued much inflamed, with many pustules near the incision.

CASE XVI

A healthy young man was inoculated December the 6th, 1766. On the 11th and 12th he was cold and hot alternately, and complained of great pain in his head, back, and limbs.

The 13th he was much easier, but still felt pains in his head and back. The inoculated parts, which from the operation till this day I had no opportunity of seeing, shewed evident signs of infection; but the skin at the incision was pale, not elevated, nor did a thin fluid appear under the cuticle, as is usual when the progress of infection is favourable; neither had he felt much uneasiness about the incisions, or stiffness in the axilla.

14th. He was free from all complaints; the discolouration on the arm had spread wider, and two or three pustules were discovered near the place of insertion.

15th. Many pustules appeared in different parts, about one hundred.

16th. The pustules were properly advanced, and the man seemed to be perfectly well. But there were now some appearances in the arm which I was dissatisfied with: for the inoculated part was covered with a great number of very small pale-coloured confluent pustules; and the incision, instead of being elevated, was depressed, and of a livid colour in the middle: this sometimes happens, and denotes an eschar and ulceration at the conclusion of the disease.

17th. He was seized in the middle of the day with a shivering fit, succeeded by great heat and pain in the head, back, and limbs, which continued all the following night. He likewise felt considerable pain at the incision, and in the shoulder, extending to the axilla.

18th. In the morning he complained of great pain at the incision up to the shoulder and the axilla of one arm. The pulse was very quick, and the fever high. In this situation I made no doubt but there would be a second eruption, and therefore persuaded him to get up and go into the air, and directed an infusion of senna and manna to be taken immediately.

This operated four times, and he was considerably relieved of all his complaints; but fresh pustules now made their appearance on the face and other parts, to the amount of double the number at least of the first. From this time he remained quite free from fever, and every other complaint; the last pustules, as well as the first, maturating in the most favourable manner. But what is very remarkable, both crops of pustules ripened nearly about the same time; for the progress of those which came out first seemed to be retarded by the second eruptive fever, and the latter pustules advanced quicker than usual.

CASE XVII

June 2d. Twenty-two persons were inoculated, who lodged at two neighbouring houses.

On the 4th in the evening one of them, a man aged 30, had a shivering fit, succeeded by fever, with pain in the head, back, and side, which continued all night.

5th. In the morning, when I first visited him, the pulse was very quick, full, and strong, and the former complaints remained; but I found him walking about the house. On inspecting the incisions, both were quite well; while those of every one of his associates, which I saw at the same time, shewed evident marks of infection.

This patient had been very much in the way of infection, and I suspected that he was going to have the small-pox in the natural way: I therefore directed the mercurial and antimonial pill to be taken at night, and that he should go into the air as much as he could bear, but not go into bed.

6th. In the morning I was informed that he had been sick and vomited, without having a stool: and that all his complaints remained, though not quite so violent. I prescribed half an ounce of Glauber’s salt, and half an ounce of manna, dissolved in water-gruel, to be taken immediately.

In the afternoon I found him in bed, but was told he had been in the air, and that the purge had operated four times. He was now disposed to sweat, and his pains were abated; but the fever remained as before, with a white dry tongue: he had a troublesome cough, difficult respiration, and great oppression at his stomach; but there was not the least sign of infection in the arm.