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THE PRESENT METHOD OF INOCULATING FOR THE SMALL-POX.

To which are added, Some EXPERIMENTS, instituted with a View to discover the Effects of a similar Treatment in the Natural Small-Pox.

By THOMAS DIMSDALE, M. D.

PHILADELPHIA: Printed by JOHN DUNLAP, for JOHN SPARHAWK, MDCCLXXI.

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INTRODUCTION.

FROM the time that I entered into the practice of medicine, and saw the danger to which the ge­nerality of those who had the small-pox in the na­tural way, were exposed, I could not but sincerely wish, with every sensible person of the faculty, that ino­culation might become general.

A considerable share of employment in this branch of my profession has for upwards of twenty years occurred to me; and altho' I have been so fortunate as not to lose a patient under inoculation, except one person, about four­teen years ago, who after the eruption of a few distinct pustules died of a fever, which I esteemed wholly inde­pendant of the small-pox, yet I must acknowledge that in some cases the symptoms have cost me not a little anxiety for the event.

Nor have the subsequent effects of this practice always been so favourable as one could wish; and tho' far from equalling those which too often follow the natural small-pax, either in respect to difficulty or number, yet they sometimes gave no small uneasiness to the operator.

It cannot likewise, it ought not to be concealed, that some of the inoculated have died under this process, even under the care of very able and experienced practitioners. But this number is so small, that, when compared with the mortality attending the natural small-pox, it is reduced almost to a cypher.

These circumstances, however, tended to discourage the operation in some degree. Practitioners were cautious of [Page 6] urging a process, of whose event they could not be cer­tain: and parents who were sensible enough to observe, that tho' the chance was greatly in their favour, yet as a blank might cast up against them, they engaged in it with hesitation.

Humanity, as well as a wish to promote the honour and advantage of the art I profess, made me ever attentive to the improvement of this part of my employment. Dissatis­fied with the common methods, I had carefully attended to the circumstances that seemed to contribute to the good or ill success of this practice in the course of my own business, as well as to the best information I could get of the success of others.

Many facts had induced me to think, that regimen, pre­paration and management would do much: that as the disease was of an inflammatory kind, a cooling regimen must certainly for the most part be reasonable. Some faint essays were made to try how far this sentiment might be just. But those who are the best acquainted with the first aphorism of Hippocrates, will be the first in justifying a cautious procedure, where the object is no less than the life of an individual.

In this situation I first heard, and with the utmost sa­tisfaction, that in some parts of the nation, a new and more successful method of inoculating was discovered, than had hitherto been practised. The relators gave incredible accounts of the success, which was the more marvellous, as the operators were chiefly such, as by report could lay but little claim to medical erudition.

[Page 7]Knowing that improvements which would do honour to the most elevated human understandings, are sometimes stumbled upon by men of more confined abilities; and that in medicine, as well as in every other circumstance in life, it is our duty to avail ourselves as much as possible, of all discoveries tending to the common benefit, I embraced every just opportunity of informing myself of facts, circum­stances and events, that either public fame, or more pre­cise relations brought to me. I use the term just oppor­tunity, because, if I am not misinformed, endeavours have been used, inconsistent with equity and candour, to rob those who are intitled to our gratitude for assisting us in this im­portant process, of that share of private emolument which is their due, let their title to the discovery be ever so pa­radoxical.

To expose patients, even in the inoculated small-pox, to all weathers, was a thing unheard of. To permit them through the whole progress of the disease to go abroad, and follow their usual vocations, and that they should neither suffer any present evil, nor experience any disagreeable con­sequences, was still more surprizing; yet an infinite num­ber of instances have confirmed all this; and some of these instances will appear in the sequel of this performance.

The design of this treatise is to bring the practice still one step nearer to perfection, and lessen the ravages of a distemper, which is not a native of Britain, but, like the plague, has been imported from a foreign country, and de­mands the exertion of all the powers we are possessed of, either to exterminate it from amongst us, which perhaps is not practicable, or to render it less unsafe, if not wholly without difficulty or danger.

[Page 8]The following directions for this purpose are the result of an extensive practice: and if a strong persuasion of the truth of what he writes, founded on repeated trials, and impartial observations, should have led the author to ex­press himself in a very sanguine manner, the future ex­perience of others, he trusts, will be his justification.

Hertford, Nov. 1, 1766.
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Of the AGE, CONSTITUTION and SEASON of the Year proper for INOCULATION.

BEFORE I proceed to describe the regimen and preparatives, it may not be improper to mention what has occurred to me in respect to the most suitable age and constitution for in­oculation, and likewise what seasons seem to be more or less favourable for the practice.

In regard to age, where it is left to my choice, I decline inoculating children under two years old. I know the common practice is against me in this parti­cular; but my reasons for rejecting such are founded on observation and experience. I have, indeed, lately inoculated many under this age, at the pressing en­treaties of their parents, and they have all done well. But it must be considered, that young children are ex­posed to all the hazards of dentition, fevers, fluxes, convulsions, and other accidents, sufficiently difficult in themselves to manage in such tender subjects, inso­much that scarce two in three of all that are born, live to be two years old, as is demonstrable from the Bills of Mortality.

Besides convulsive paroxysms often accompany the variolous eruptive fever in children; and tho' generally looked upon in no unfavourable light, as often pre­ceding a distinct kind of small-pox, yet they are at all times attended with some degree of danger; nay, many, it is well known, have expired under them, while others, who have struggled through with great difficulty, have been so debilitated, and their faculties so impaired, that the effects have been perceptible during the remaining part of their lives.

And even admitting the eruption to be favourable, and not attended with any such alarm, yet should a larger number of pustules than usual appear, or any [Page 10] untoward symptom happen, and require medical help, the unhappy sufferer is much too young to be prevailed on to take unpalatable medicines, or submit to other necessary measures, by persuasions, menaces or bribes. I have often been present at afflicting scenes of this na­ture; and have reason to think that many children have died of the small-pox in the natural way, merely from the impossibility of prevailing upon them to comply with what was proper in cases where little or no danger was discoverable, either from the number or species of the pustules, the degree of fever, or any other appa­rent cause.

It must likewise be taken into consideration, that young children have usually a larger share of pustules from inoculation, than those who are advanced a little farther in life; and that under this circumstance it is well known many have died; and the proportion of these, so far as I can learn, is too great to encourage a continuance in the inoculation of young children; so that it seems most prudent to wait till this dangerous period be over, especially as its duration is so short, that the danger of their receiving the small-pox therein in the natural way is very little; and it is at this time much more easy to preserve them from it, than when they are left more to themselves, and may be more in the way of infection. But children above this period may be inoculated more freely; nor does there appear any reason to exclude healthy adults of any age, per­sons of seventy having passed thro' this process with the utmost ease, and without occasioning the least painful apprehension for the event.

In respect to constitution greater liberties may be taken than have heretofore been judged admissible: persons afflicted with various chronic complaints, of scrophulous, scorbutic and arthritic habits; persons of unwieldy corpulency, and of intemperate and irregular lives, have all passed through this disease, with as much ease and safety as the most temperate, healthy and re­gular. But those who labour under any acute or cri­tical diseases, or their effects, are obviously unfit and [Page 11] improper subjects. So likewise are those where there are evident marks of corrosive acrimonious humors, or where there is a manifest debility of the whole frame from inanition or any other cause; all these should be treated in a proper manner previous to the introduction of this disease. Constitutions disposed to frequent re­turns of intermittens, seem likewise justly exceptionable, especially as the preparatory regimen may in some ha­bits increase this tendency. I have known, however, instances of severe ague fits attacking persons between the insertion of the matter and the eruption of the pock, and even during maturation, when the bark has been given liberally and with success, the principal busi­ness, in the mean time, suffering no injury or inter­ruption.

Among the circumstances generally considered as more or less propitious to inoculation, the season of the year has hitherto been deemed a matter of some im­portance. Spring and autumn, for the most part, have been recommended as being the most temperate seasons; the cold of winter, and the summer heats, having been judged unfavourable for this process. But experience does not justify these opinions; for according to the best observation I have been able to make, inoculated persons have generally had more pustules in spring than at any other time of the year; and epidemic diseases being commonly most frequent in autumn, especially fluxes, intermittens and ulcerated sore throats, all which are liable to mix more or less with the small-pax, the autumn, upon this account, does not seem to be the most favourable season in general.

My opinion is, that, considering the surprizing and indisputable benefits arising at all times to patients in the small-pox, from the free admission of fresh cool air and evacuations, which will appear from some cases hereafter subjoined, we may safely inoculate in all sea­sons, provided care be taken to screen the patients as much as possible from heat in summer, and to prevent them from keeping themselves too warm, and too much shut up, as they are naturally disposed to do, from the [Page 12] weather in winter. And it is well known, that many have been inoculated in the depth of winter, and some during the greatest heat in summer, without suffering any injury or inconvenience from either.

When seasons, however, are marked with any pe­culiar epidemics, of such a kind especially as may ren­der a mild disease more untractable, it may perhaps be most prudent not to inoculate while such diseases are prevalent.

An eminent physician of my acquaintance in Lon­don, at that time in considerable business, informed me, that in the year 1756 the small-pox were very rife, in the summer of that year especially. That in most of them the throat was so much affected, that about the seventh day from the eruption, when they ought to have taken liquors in abundance, they could not swal­low a drop. The ptyalism was in the mean time co­pious; and the kind being for the most part confluent, they died on the tenth or eleventh day; and those who perished of this distemper, and much the majority pe­rished, all suffered from this cause. This instance is only given to shew the necessity of regarding the ge­neral state of epidemics when we go into this opera­tion; and to excite those who are friends to this most beneficial discovery, to use every means in their power to provide against a single instance of ill success.

Of the PREPARATION.

IN directing the preparatory regimen, I principally aim at these points: to reduce the patient, if in high health, to a low and more secure state; to strengthen the constitution, if too low; to correct what appears vitiated, and to clear the stomach and bowels, as much as may be, from all crudities and their effects. With this view, I order such of my patients, as consti­tute the first class, and who are by much the majority, to live in the following manner: to abstain from all animal food, including broths, also butter and cheese, and from all fermented liquors, excepting small beer, [Page 13] which is allowed sparingly, and from all spices, and whatever possesses a manifest heating quality. The diet is to consist of pudding, gruel, sago, milk, rice-milk, fruit pyes, greens, roots, and vegetables of all the kinds in season, prepared or raw. Eggs, tho' not to be eat alone, are allowed in puddings, and butter in pye-crust; the patients are to be careful that they do not eat such a quantity as to overload their stomachs, even of this kind of food. Tea, coffee, or chocolate are permitted for breakfast, to those who choose or are accustomed to them.

In this manner they are to proceed about nine or ten days before the operation; during which period, at nearly equal distances, they are directed to take three doses of the following powder, either made into pills, or mixed with a little syrup or jelly, at bed-time, and a dose of Glauber's salt, dissolved in thin water-gruel, each succeeding morning.

The powder is composed of eight Grains of calomel, the same quantity of the compound powder of crabs claws, and one eighth part of a grain of emetic tartar. Instead of emetic tartar, I have sometimes substituted two grains of precipitated sulphur of antimony. In order to facilitate the division of the doses, a large quantity is prepared at once, and great care taken that the mixture is well performed.

This quantity is usually sufficient for a healthy strong man; and the dose must be lessened for women or children according to their age and strength, as well as for persons advanced in years.

The first dose is commonly ordered at the com­mencement of the course; the second, three or four days after; and the third, about the eighth or ninth day; and I chuse to inoculate the day after the last dose has been taken. On the days of purging, broths are allowed, and the patients are desired to abstain from unprepared vegetables.

What has hitherto been said concerning the prepara­tion, must be considered as proper only for the young or middle aged, in a good state of health; but among [Page 14] those who are desirous of inoculation, are often found tender, delicate and weakly women, men of bad sta­mina, valetudinarians by constitution, by illness, or intemperance, also aged persons and children; and for these a very different treatment is directed; a milder course of medicine, rather of the alterative than purga­tive kind, is here preferable; and in many instances, an indulgence in some light animal food, with a glass or two of wine in case of lowness, is not only allowable, but necessary to support a proper degree of strength, especially in advanced age.

Children, whose bowels are often tender, and ought not be ruffled by strong purges, yet require a mild mer­curial, and bear it well: besides emptying the bowels of crudities, it is a good security against worms and their effects, which are sometimes of themselves per­plexing enough, and produce very alarming and even fatal disorders.

Indeed the particular state of health of every person entering upon the preparatory course should be inquired into and considered. Inattention to this has, I am sa­tisfied, done great mischief, and particularly the indis­creet use of mercurials, whereby a salivation has often been raised, to the risque of impairing good constitu­tions, and the ruin of such as were previously weak and infirm. The distinctions and treatment necessary, will be obvious to those who are acquainted with the animal oeconomy and medical practice.

The time of menstruation has generally been the guide in respect to the inoculation of women; that the whole of the disease might be over within the menstrual period. This I commonly observe, when I can chuse my time without any inconvenience, and inoculate soon after the evacuation ceases: tho' I have no reason to decline performing the operation at any time, as I can produce many examples in which no inconvenience has arisen, nor any difference been observable, when this circumstance has been disregarded.

Women with child have likewise been inoculated and done well, yet some particular emergency should [Page 15] be pleaded in excuse for it in their situation, as it may be attended with some hazard. I have not inoculated any women whom I knew to be pregnant; but some who concealed their pregnancy, have been inoculated by me, who, I fancy, hoped for an event that did not happen, I mean miscarriages; one of these had a child born nine weeks after inoculation, at the full time, with distinct marks of the disease, tho' the mother had very few eruptions.

Of INFECTION.

THE manner of communicating this distemper by inoculation in this country, has of late been the following: A thread is drawn thro' a ripe pustule, and well moistened with the matter: a piece of this thread is insinuated into a superficial incision made in one or both arms, near the part where issues are usually fixed; this thread is covered with a plaister, and there left for a day or two. This is the most usual way, tho' others have been practised by several in the profession.

At present, very different methods are pu [...]ued; two of which, that vary in some respects, I have frequently practised, and shall describe; but the following has been so invariably successful as to induce me to give it the preference.

The patient to be infected being in the same house, and, if no objection is made to it, in the same room, with one who has the disease, a little of the variolous matter is taken from the place of insertion, if the subject is under inoculation; or a ripe pustule, if in the natural way, on the point of a lancet, so that both sides of the point are moistened.

With this lancet an incision is made in that part of the arm where issues are usually placed, deep enough to pass through the scarf skin, and just to touch the skin itself, and in length as short as possible, not more than one eighth of an inch.

The little wound being then stretched open between the finger and thumb of the operator, the incision is [Page 16] moistened with the matter, by gently touching it with the flat side of the infected lancet. This operation is generally performed in both arms, and sometimes in two places in one arm, a little distant from each other. For as I have not observed any inconvenience from two or three incisions, I seldom trust to one, that neither I nor my patient may be under any doubt about the suc­cess of the operation from its being performed in one place only.

I have also tried the following method, with the same success as that above described, but do not so well ap­prove of it, because I have been credibly informed that it has sometimes failed in the practice of others. A lancet being moistened with the variolous fluid in the same manner as in the other, is gently introduced in an oblique manner between the scarf and true skin, and the finger of the operator is applied on the point, in order to wipe off the infection from the lancet, when it is withdrawn. In this method, as well as in the former, a little blood will sometimes appear; but I neither draw blood with design, nor do I think it necessary to wipe it off before the matter is introduced.

In both these ways of inoculating, neither plaister, bandage or covering is applied, or in any respect ne­cessary.

These methods of producing the disease never once have failed me: and experience has sufficiently proved, that there is no danger from additional infection by the natural disease at the same time. I therefore make no scruple of having the person to be inoculated, and the patient from whom the infection is to be taken, in the same room; nor have ever perceived any ill consequences attending it. But I advise the inocu­lated patients (tho' perhaps there is no necessity for that precaution) to be afterwards separated from places of infection till certain signs of success appear, when all re­straint is removed, there being no danger from accu­mulation.

It seems to be of no consequence whether infecting matter be taken from the natural or inoculated small-pox, [Page 17] I have used both, and never have been able to discover the least difference, either in point of certainty of infection, the progress, or the event; and therefore I take the infection from either, as opportunity offers, or at the option of my patients or their friends.

Nor is it of consequence whether the matter be taken before or at the crisis of the distemper. It is, I be­lieve, generally supposed, that the small-pox is not in­fectious till after the matter has acquired a certain de­gree of maturity; and in the common method of in­oculation, this is much attended to; and when the ope­ration has failed, it has commonly been ascribed to the unripeness of the matter.

But it appears very clearly from the present practice of inoculation, that so soon as any moisture can be taken from the infected part of an inoculated patient, previous to the appearance of any pustules, and even previous to the eruptive fever, this moisture is capable of commu­nicating the small-pox with the utmost certainty. I have taken a little clear fluid from the elevated pellicle on the incised part, even so early as the fourth day after the operation; and have at other times used matter fully digested after the crisis, with equal success. I chuse, however, in general, to take matter for infection during the fever of eruption, as I suppose it at that time to have its utmost activity.

In all cases when I take matter from an inoculated person, it is from the place where it was inserted; as I am always sure to find infection there, if the disease suc­ceeds, and always of sufficient energy.

It may appear strange, that no bandage, dressing or application whatsoever is made use of to the part in­fected; but that, the most simple incision being made, and moistened with the smallest particle of the recent fluid matter, the whole is committed to nature. This method is however perfectly right, because the appli­cation of either plaister or unguent, as is the usual practice, will occasion an inflammation on some skins, and in all tend to disguise the natural appearance of the incision, and prevent our forming a proper judgment [Page 18] of the progress of the infection, which will afterwards appear to be a matter of much importance.

If neither an inoculated patient is at hand, nor any one in the neighbourhood has a distinct kind of the na­tural disease, a thread may be used as in the common manner, provided the thread be very recently infected, but I think it ought to be used as soon as possible, after being charged with infecting matter.

The following method of introducing the disease has likewise been found effectual, but I have never practised it myself. Dip the point of a lancet in variolous mat­ter, let it be held in the air till it is dry, after which it may be closed and kept in the common case without any further care; and with this prepared lancet raise the scarf skin obliquely, and keep the lancet a little time in motion between the two skins, that part of the matter may be mixed with the animal juices; then withdraw the lancet, and leave the incision uncovered as before.

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 pro­gnostick 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. [Page 19] 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 one tenth 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 resembles 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 their smell dif­ferent from what I have even 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 [Page 20] 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 [Page 21] 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 thro' 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.

[Page 22]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, prevent them from 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 compleated, 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, tho' 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 [Page 23] permit those who are in the hardest part of the distem­per, the eruptive, to keep much in the house; encou­raging 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 the 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 compleated, 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 the 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 [Page 24] to give gentle purgatives, and proper alteratives, as particular exigencies may require.

Of ANOMALOUS SYMPTOMS and APPEARANCES.

IN the preceding pages I have prescribed the usual progress of the small-pox from 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 real diffi­culty, as well as apprehensions of danger, it seems ne­cessary to describe, and 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, tho' 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 giving 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 entirely.

Another deviation, of still more consequence, which sometimes happens towards the time of the eruption, and is often, tho' 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 [Page 25] 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 pe­techiae and livid spots, I have been much alarmed; not being able, by inspection only, tho' 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 observation 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 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 appearance.

This rash has been often 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 [Page 26] 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 abroad, and other cool means pursued, by which 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: But 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. chilliness, 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 24 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 [Page 27] 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 distemper *. In some instances these symptoms attack much later, even on the 7th or 8th 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 [Page 28] of having had the small-pox in the natural way, have submitted to be inoculated merely for the experi­ment's 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 of 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 and less favourable appearance to be men­tioned under this head, is when the inoculated part, though shewing certain signs of infection, yet the dis­colouration round it, instead of being florid, is of a pale hue, remains flat, and is very little elevated. This does not promise kindly; and therefore I give the al­terative pill more frequently; and if it fails to operate by stool, I add a laxative.

By these means the advancement of the disease is usually forwarded, which I am always pleased to see, and promote as much as possible; for I have constantly remarked, that an early seizure is one of the best signs that the whole progress will be mild and favourable; and, on the contrary, where it is late, the symptoms are often irregular and troublesome.

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 [Page 29] new disturbance. These are generally few in number, short-lived, 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 broke out, far exceeding the first number; and these remained, and maturated completely. In­stances of this kind may be found among the cases annexed.

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 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 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 complai [...], 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 [Page 30] 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 independant of the small-pox. Such, for instance, as may arise from worms, or be the epidemick 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.

CONSEQUENCES of this Method of INOCULATION.

I Shall now consider the consequences that follow this very cool and repelling method, and how far the patient's future state of health may be affected by a practice so new, and opposite to all established theory.

I need not say how much it has been thought right, in most or all eruptive complaints, especially in the small-pox, to forward by every gentle means the efforts of nature in producing an eruption; and on the con­trary, how dangerous to check it, either by cold air, cold drink, or any considerable evacuations; or that the use of warm diluents therefore, and the lying in bed, especially if the fever and symptoms run high, or at least confining to the house, have been generally ap­proved and recommended for the purpose. But when a practice so foreign to this, and almost totally different, is inculcated, it is no wonder if mens minds are alarm­ed, and those evils expected that were supposed to be the unavoidable consequences of it.

Experience, however, and instances of so many thou­sands succeeding by this method, without any consider­able bad effects from it, either immediate or remote, are irresistible arguments for its support and justification, and the best proof of its utility and safety. I have said, without any considerable bad effects, for in reality I have seen none that deserve that name, if compared [Page 31] with what sometimes follow the natural small-pox, or frequently happen after the old method of inoculation.

Every one who has had any share in this practice ac­cording to the common or old methods, will allow, that after passing through the disease in a very favour­able manner, their patients (children especially) were frequently liable to abscesses in the axilla and other parts, tedious ophthalmies, and troublesome ulcerations in the place of insertion, which, though they could not be foreseen or prevented, yet frequently gave more pain and vexation to the patients, and trouble to the operator, than the disease itself had done: whereas on inquiry into the fate of those who have been treated in the cool way or this new method, I can say that in more than 1500 there has been only one who has had so much as a boil in the axilla, and that was in a child who had an issue in the same arm, and which was at that time dried up; and I have only seen two very small superficial boils in others near the place of insertion; and these seemed rather to be occasioned by an irritation from the discharge, than from any other cause, and were all soon healed with very little trouble.

In a few instances also there has been a slough in the incised part, which has made a sore of short duration, but not one instance of an ulcer of any continuance. Such little breakings out too and scabs, as are frequent­ly known to succeed the mild natural small-pox, some­times, though rarely, happen to those inoculated this way, and as they are of the same little consequence, are generally cured by the same method of a few gentle purges.

With regard to ophthalmies from this kind of practice, I have never had an example of one truly deserving that name; the coats of the eye have been a little in­flamed in a very few, but they soon became clear without any means used for that purpose. And I know but two cases where I thought the inflammation great enough to require bleeding, and not one where a blister was neces­sary. So that these complaints, heretofore so frequent and grievous, seem by this new method to be much re­duced: [Page 32] a circumstance, which, if it does not amount to a proof, admits at least of a fair conjecture, that the state of health is better here, than where those remains of putridity are so evidently existing in the habit.

Discoveries in physic, as in every other science, are in their infancy liable to censure and opposition; and to one of so extraordinary a kind as the present system of inoculation, it would not be strange if a greater portion of both than usual should fall to its share; ac­cordingly, since no charge of fatality during the disease, nor instances of bad effects soon after the recovery, can be produced, recourse has been had to other measures to calumniate and discredit the practice. It would be tedious to enter into a detail of the many false and ridi­culous reports that have been spread against it. In ge­neral the constitution is said to be injured, and the dread­ful effects are to appear at some distant period, but at what time, or what kind of disease, nobody pretends to determine. To these general accusations it cannot be expected I should give other than a general answer; which is, that from the strictest observation and inquiry I have been able to make, those who have been ino­culated in this way, have continued to enjoy as good a state of health as their neighbours; nay, many of them have thought their constitution better after the process than before.

But it seems as if these opposers expected that in­oculation should not only free the inoculated from the small-pox, and any early bad effects, but must preserve them too from all other disorders through the rest of their lives. To such I can say nothing; but if others who are more reasonable, require further satisfaction as to the consequences of this method, I must desire them to make inquiry of those who have been inoculated under my direction.

Another charge against this method of inoculation is, that some have had the distemper afterwards in the na­tural way. What I have said under the head of ano­malous small-pox, will, I believe, sufficiently account for the appearances which have occasioned these false [Page 33] reports; and if that does not satisfy, I can only add this positive declaration, that nothing of the kind has ever happened to any patient inoculated by me; and I firmly believe, no one has ever had, or can have, the distemper a second time, either in the natural way, or from inoculation.

The EFFECTS of this TREATMENT applied to the natural SMALL-POX.

THE very great relief which persons under in­oculation experience from fresh air, cold water, and evacuations by stool, during the fever preceding eruption, soon determined me to make trial, how far the like treatment might be useful to those who might be seized with the small-pox in the natural way; more especially in such cases, where from the violence of the symptoms, a confluent kind was justly to be ap­prehended.

But opportunities of making experiments of this sort in a satisfactory manner are rare. First because a phy­sician, or even medical assistance of any kind, is not often called in till the eruption shews itself, when it is too late to expect all the good effects that might be hoped for from an earlier trial of this method; and se­condly, because the first attack of the small-pox is so much like the beginning of some other fevers as not easily to be distinguished; though a diligent attention to the symptoms will generally, if we are called in time, enable us to form a pretty certain prognostic. For if the attack of the cold fit be pretty severe, and the subsequent fever unusually high; if a nausea and vomiting succeed, together with great pains in the head, back and loins, especially the last; if a delirium, great restlessness, disagreeable taste in the mouth, and a pe­culiar fetid smell in the breath, or even if several of these symptoms are observed, the small-pox may with great reason be expected; and if upon enquiry, which should always be made, it appears that the patient has [Page 34] been in the way of infection, there will be little reason to doubt of it.

It may be objected, that notwithstanding the closest attention and enquiry, symptoms of the like nature may precede fevers of other kinds; to which I answer, that some such cases, though few, have happened, and the treatment I am about to recommend, has been practised not only without prejudice to the patient, but manifestly to his benefit.

But waving for the present all considerations respect­ing the treatment of fevers in general, I shall only relate what has occurred to me in respect to the natural small-pox.

In several instances where I have been concerned, and where the symptoms and other concurring circumstances induced me to think the small-pox was at hand, I have directed the like management as I recommend to in­oculated patients.

I have been called also to others at the time of erup­tion, where some pustules having already appeared, made the matter clear; and in every case of this kind, I have endeavoured to get the sick person into the open air, have generally given the mercurial and antimonial pill, and directed a laxative to be taken some hours after it, in order to procure three or four stools; and this method I have more particularly enjoined, and sometimes repeated where the kind has appeared to be bad, and where little or no relief has been found from the partial eruption, the symptoms continuing to be such as por­tended great danger. I have followed the same method during every part of the eruptive fever, intending there­by to abate its violence, to check the eruption, and prevent the conflux, and consequently the danger.

The success attending this practice has hitherto ex­ceeded my expectations, though it must be confessed, that as the symptoms run much higher in the natural, than they are found to do in the inoculated disease, the relief has not been so considerable; and I have found it extremely difficult to persuade such whose complaints have been very severe, to quit their beds, and attempt [Page 35] to go abroad; indeed the exceeding feeble state they are sometimes in, sufficiently shews that great resolution is requisite to put this in practice.

Among those who have been treated in this manner under my own care and inspection, not one has died, and the number amounts to about 40. Some of the most remarkable cases will be subjoined, which will more satisfactorily explain the practice, and demonstrate its success.

The immediate sensible effects of going into the open air, are a very great abatement of heat upon the whole surface of the skin, which, tho' but just before intensely hot, generally in a short time feels not much warmer than that of a person in health. The pulse from being very strong, full and quick, becomes less hard and full, but continues quick; and I have sometimes observed it to intermit; which, however alarming it may seem, is not a dangerous symptom.

The pain in the head is always relieved, but that in the back and loins does not abate in proportion; and altho' it costs no little pain and trouble to persist in moving abroad under such circumstances, attended for the most part with great lassitude, yet the patients are sensible of the benefits they receive, and entertaining a good opinion of the usefulness of the practice, com­monly behave with great resolution, and, what is very encouraging, in general think themselves stronger.

Upon going within doors to rest themselves, the pain in the head grows worse, but is again relieved so soon as they return into the air.

The effects of the medicines are usually these;

If there has been much sickness at stomach, a vomit­ing frequently happens soon after the pill: this the pa­tients should promote by drinking plentifully of some warm diluents; and till the fatigue occasioned by it is over, they certainly ought not to go abroad.

By this operation, and the stools which succeed, the feverish and internal heat, thirst, sickness and pains, are for the most part considerably abated. The patients commonly complain of being very low and faint after [Page 36] these evacuations; but the most urgent symptoms being alleviated thereby, a disposition to receive nourishment hourly increases. They are then allowed to drink thin mutten or chicken broth, milk pottage or tea, as the most grateful and refreshing cordial sustenance they can take; sleep likewise now most commonly comes on spontaneously. But they are only permitted to enjoy this refreshment by day upon the bed, for I always dis­suade them from going into it till night.

From the foregoing account it appears, that the fever preceding eruption, and the most grievous symptoms accompanying it, may often be greatly mitigated by this practice; and I will here add, that the eruption is most certainly retarded, that is, it does not appear so soon after the attack of the disease, nor come out so precipitately when it has begun to appear, as it seemed likely to have done if the natural progress had not been interrupted; an effect, which, however dangerous it may have been thought, may be done with the utmost safety, and clearly shews the utility of the practice; for it is evident from experience, that the later the eruption shews itself after the beginning of the disease, and the slower it comes out, the more mild and favour­able is the subsequent disorder. And I am of opinion, that the eruption is not only retarded and protracted by this method, but likewise that it is in some degree re­pressed, having had strong reasons to apprehend in se­veral instances, that the number of pustules which ap­peared at first, were by such repression actually dimi­nished, and those that remained seemed larger and of a milder kind.

What has hitherto been said on the subject, relates only to the disease in its eruptive state, which is certain­ly a very interesting period; but that which follows, is not less so, tho' not always attended to so much as it deserves; for when the eruption is compleated, the symptoms abate, the patients seem relieved, and often to such a degree, that both they and their attendants flatter themselves with hopes of a happy event, and think, it unnecessary to apply for any medical assistance; [Page 37] yet with all these hopeful appearances, the number and kind of the small-pox are frequently such, as would make a judicious practitioner apprehensive of much dan­ger in the subsequent stages.

And where the practitioners themselves may see rea­son to doubt of the event, yet few or none of them have attempted, I believe, to do much towards preventing the danger; for unless some pressing symptoms call for immediate relief, it is the general practice to wait till maturation comes on, and brings with it such a train of dreadful complaints, as are more than enough to em­ploy, and too often baffle the best abilities.

In this neglected interval, from the eruption being compleated, to the accession of the fever of maturation, and its concomitants (an interval which in point of du­ration is very different in different constitutions and kinds of small-pox) I will venture in general to recom­mend the same mercurial antimonial medicine as was prescribed in the eruptive fever, to be repeated at pro­per intervals, till the maturation advances, at which time it must certainly be discontinued: and these cir­cumstances can be regulated only by those who attend according to the urgency of the symptoms, and the strength of the patients: A cupful of the following apozem should, if necessary, be now and then taken after the mercurial medicine, often enough to procure 3 or 4 stools a day, especially if the patient is costive.

Take cream of tartar two drachms; of manna one ounce; dissolve them in one quart of barley water, or the pectoral drink.

How far it may be safe or adviseable for the patients to venture out into the open air during this stage of the disease, I will not yet pretend to say, but they will cer­tainly be both refreshed and invigorated, by being kept out of bed as much as they can bear, without being over-fatigued; and by fresh air let in sometimes through an open window: as the violence of the eruptive fever with its attendant complaints must necessarily exhaust the strength and spirits, both should in this interval be re­cruited, by as much proper nourishment (such as has been [Page 38] mentioned in the former part of this chapter) as can be taken down without offending the stomach, and also, if occasion requires, with medicines of a cordial and ano­dyne quality; for this is the time to recover as much strength as possible, in order to be better able to en­counter and bear the pain and fever, which will most certainly happen, as the state of maturation advances.

Medicines, except what have been already mentioned, seem at this time unnecessary, and they would interfere with and prevent the true relish for food.

But for the best method of treating the small-pox in its most dangerous stage, I mean that of maturation, I must refer to the several learned and eminent practition­ers who have professedly written upon the subject, whose opinions and practice I neither pretend to correct or amend. I shall however take the liberty to recommend one medicine to be used in that stage of the disease, which I have found to abate heat, and allay thirst, in such a manner as to afford a very pleasing refreshment.

Take of the weak spirit of vitriol one part, of the sweet spirit of vitriol two parts; mix. Of this the quan­tity of half an ounce may be added to a quart, or perhaps three pints of barley water, or the pectoral drink, or any other diluent, and to be drank of at pleasure.

I have at present nothing farther to recommend; but what has been said will, I presume, be sufficient with the cases annexed (in which the method will be more plainly described) to justify further trials of the cooling, repel­ling and evacuating practice in the beginning at least of the natural small-pox, till the eruption is compleated, especially where the physician has an opportunity of making the trial before the eruption appears, and can be pretty certain, or has good reason to conclude, that his patient's disorder is variolous, and the more violent the symptoms are in this stage of the disease, the more we shall be induced to employ the means which have been attended with so much success, in the same stage of the disease after inoculation.

[Page 39]But it may be asked, if I was called to a patient in a bad confluent small-pox, and finding the eruption compleated, whether in such a case I should venture to give and continue the use of the alterative and purgative medicine, and advise the patient to go out, if he can bear it, into the open air, in cold weather, or direct air to be let in thro' a window, even while the mercurial purge may be operating?

Before I give a direct answer to this question, let me first ask the most experienced practitioner, whether he knows any method of cure, which may in bad cases be safely relied on, to avert the impending danger, and save his patients? The too well known fatality of all kinds of small-pox, very clearly proves that he does not, and that no such method has been yet discovered. And if this be the case, surely, a bold, and even ha­zardous practice is very justifiable in any such unhappy patients, who lie as it were under sentence of a cruel death, not to be prevented by what are called the re­gular and usual methods. But still it may be urged, that no impending danger, however great, can suffi­ciently justify the trial of any hazardous experiment, unless we can have recourse to reason founded on ex­perience: happy, indeed, it is, when we have these two guides before us; but when they are separated, the latter is certainly most to be relied on, and her I have endeavoured hitherto to follow.

For in the practice of inoculation experience has taught me, that after as well as before the eruption, persons may safely take mercurial purges, and go out during their operation (though I never advised any to do so) into the cold air, in inclement weather, without suffering the least harm or subsequent ill consequence from it. And by this experience I was led, tho' with great caution, to try, whether the same practice might not be safely employed in the cure of the natural small-pox, as well as the inoculated; nor have the trials been unsuccessful; for though among the patients I have treated in this manner, some had confluent sorts, yet were the complaints unusually moderate throughout the [Page 40] whole progress of the disease, and the maturation was compleated without such troublesome and alarming symptoms and events as might be expected under any other known method of treatment, nor did any secondary fever ensue.

I would not however be understood to entertain so good an opinion of this method, as to insinuate that it will save all who have the bad confluent kind; too many of these are for the most part incurable; but I am not without hopes, that it may give a chance of re­covery, hitherto untried of, to many; and even if this alterative and evacuating course in the early part of the disease should not succeed, so as to avert the approach­ing danger, I think there is great reason to suppose that nourishment, cordials and opiates, which may be wanted in the state of maturation, will be administered with more advantage and security after it, than if that me­thod had not been previously taken.

It seems necessary however to declare, that nothing which has been said, is meant to relate to practice in the bleeding or purple small-pox; though very cold repellent methods may perhaps deserve to be tried in these hitherto fatal cases, provided it can be done early; but the mercurial evacuating course seems quite im­proper.

Upon the whole, what has been said on the natural small-pox, must wait the award of time and experience, the only tests of the utility of any practice; for I have lived long enough to have seen several instances where very ingenious and well meaning men have been greatly mistaken, by relying too much on the first impressions made by a few successful experiments.

[Page 41]

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 recorded some cases, which proved that those who had suffered most, were, in general, such as had been kept warm, and nursed with the greatest tenderness and care. These facts dis­posed me to think favourably 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, tho' too extra­vagant at first to deserve credit.

The reports however of this practice still gained ground; and, upon the strictest enquiry, I found they were for the most part true, and that such who were treated in this way, passed thro' 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 [Page 42] 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 dis­gust and danger; and that all such means should be used as are most likely to controul 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 learnt from others, I first directed the mercurial and antimonial medicine, and the laxative course in the eruptive state; the manner of admi­nistring 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, tho' by general consent it is allowed to be the most efficacious remedy in all inflammatory cases. To this I can only reply, that the regimen and medicines above prescribed commonly reduce the patient 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 [Page 43] in which bleeding may not only be safe, but extremely salutary.

It will probably be needless to acquaint the reader, that I have disclosed the whole of what I know with cer­tainty relative to this process, the regimen, the medi­cines, the different types of the disease, the rules of prognostick, and various events. 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, those medicines neither nauseous in them­selves, nor violent in their operation, 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, [Page 44] 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 shall 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.

[Page 45]

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.

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

28 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 erisypelatous 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 were 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.

[Page 46]On the 28th, when he came to the house, the skin at the incision was discoloured, felt hard, seemed thicken­ed, but 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 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 20 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 24 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 Wednesday, the other on the following night, and an ounce of purging salts next morning.

[Page 47]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 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 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.

[Page 48]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 [Page 49] 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 aked 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 bring 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, upon full con­fidence of having had the small-pox many years since. [Page 50] However, after they got home, she fell ill, and had the distemper in a very clear but favourable manner, and doubtless caught it of her husband.

CASE IX.

A young gentleman aged 19 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 [...] [...]bout 10, and kept within doors the whole day, [...] of weariness, slight pain in the head and [...] 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, tho' 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.

CASE X.

Dec. 19.] A healthy florid young man was inoculated in both arms; and soon after on the same day he felt [Page 51] 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 5 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 10 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 20, maturated very kindly.

27. 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, [Page 52] 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 he had had several chilly fits. The other complained that his arms felt hot and itched, but he felt 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, from the time that I saw him last, he had remained free from any com­plaint, except a slight uneasiness on 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 keeping 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 numb 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 sixpence; on applying the finger, [Page 53] 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 sixth 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.

CASES attended with an ERYSIPELATOUS RASH.
CASE XIII.

JAnuary 9th 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 differen 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, [Page 54] 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 ago, 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 a universal rash, of the same kind as had happened before; in this situation she was ordered to keep her room, and the following medicine 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 [Page 55] 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 10 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 the evening after his re­moval, and that he perceived the pustules 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 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 [Page 56] 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 sena 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.

[Page 57]

CASE XVII.

June 2d.] Twenty-two persons were inoculated, who lodged in 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 repression at his stomach, but there was not the least sign of infection in the arm.

7th. In the morning he was much in the same state, only weaker. I prescribed a salt of wormwood mixture, with Minderus's spirit, an oily mixture for his cough, and one grain of emetic tartar mixed with 10 grains of com­pound powder of crabs claws to be taken in the evening.

8th. He had four stools in the night, sweated pretty well, and got some sleep; but he coughed much, breath­ed with difficulty, expectorated some thin frothy phlegm, and complained of great pain in his breast and side. Eight ounces of blood were directed to be taken away; [Page 58] the antimonial powder was repeated, with an addition of one grain of calomel; and he was directed to drink fre­quently a cupful of pectoral decoction, to a quart of which was added one ounce and a half of Minderus's spirit.

9th. The blood taken away yesterday was very sizy, the pain in the breast and side much abated, but the cough very troublesome, and the expectorated phlegm streaked with blood. The inoculated parts were now discoloured, shewed evident signs of infection, and that we should soon have the small-pox to encounter, toge­ther with the peripneumonic disorder.

10th. Very restless all the night, coughed much, and with great difficulty expectorated brown viscid phlegm. The bleeding was repeated, and the use of the antimonial powder and other medicines continued; which had every day procured some stools, and supported a constant breathing sweat.

11th. The blood was still found sizy, and the fever, cough, difficulty of respiration and expectoration, were increased. The progress of infection in the arm was slow, but shewed, however, that the eruptive fever would soon come on; and I was apprehensive that it would be so confounded with the peripneumonic disor­der as to cause much perplexity. I determined never­theless to attempt to relieve the latter by whatever means I could, and wait the event; and therefore ordered more blood to be taken, a blistering plaister to be applied be­tween the shoulders, and a small quantity of gum am­moniacum to be added to his pectoral medicines. In the evening I was informed that all the troublesome symptoms were considerably abated.

It must here be noted, that all the company, who had been inoculated at the same time, were now ill, and most of them had some eruptions.

12th. He had had more rest; but though most of his complaints were relieved, yet the fever still con­tinued, and he expectorated with difficulty some very dark-brown phlegm, so that no alteration was made in his medicines.

[Page 59]The appearance on the incision spread, but did not look as is usual when the eruptive complaints are begun.

13th. The fever, pain in the side, cough, and diffi­culty of expectoration, being again increased, I ordered a vesicatory to the side, and some oxymel of squills in a pectoral mixture.

14th. The fever and pain of the side were abated, and he had obtained some little sleep, which was how­ever much disturbed by sudden [...]artings. The skin at the incisions had an unusual appearance, not easily to be de­scribed; and instead of being inflamed, as it usually is, where the progress of the infection is favourable, and not interrupted by some extraordinary accident, it was of a pale hue.

15th. He had rested ill, and the cough was so trou­blesome, that I ordered more blood to be taken, and the medicines to be continued. The incisions this day looked like pustules irregularly shaped, and a fluid ap­peared under the cuticle.

16th. All symptom [...] were more moderate; two pus­tules were discovered in the face, and those at the inci­sions seemed tending to maturation.

17th. All complaints much easier; the pustules at the incisions were more elevated, and had matter in them; but the others were but little advanced, and looked pale.

18th. He was in all respects so much better, that he ventured to ride out on horseback, and I was released from my attendance; nor did I see him afterwards, till he called at my house in good health on the 5th of July. But he then informed me, that in the afternoon of the 19th of June▪ the day after I took my leave of him, he had been extremely hot and feverish; was relieved on the 20th from all feverish symptoms, and discovered a great number of pustules, which rose, filled and ripened without any further illness; so that he did not think it necessary to send me any notice of them. Looking in his face, I saw about thirty marks of small-pox, which confirmed the truth of his report.

I have also since received a very satisfactory account that many pustules in his face and other parts, which [Page 60] came out after the time I saw him, stayed a proper time, and maturated completely.

CASE XVIII.

A middle-aged man, on the sixth day after he had been inoculated, complained of pain in his head and back, and had a slight degree of fever. The complaints remained till the 8th, when there appeared some erup­tions on the face, which I took to be variolous: but it is to be noted, that having lived pretty freely, his face was very red and full of pimples; and neither the prepa­ration nor medicines had much altered that appearance; so that it was no easy matter to distinguish between those which were habitual to him, and the fresh ones. The arm at this time was very considerably inflamed, as is usual about the time of eruption.

On the 9th he was perfectly well, and no more erup­tions shewed themselves.

Having had several patients, who undoubtedly passed through the distemper with no more illness than this man had felt, and sometimes even without any eruption, I really thought that the affair was over.

On the 10th he took a laxative draught, eat a piece of mutton, and drank some ale. On the afternoon of the same day I found him complaining of a pain in his head, which he thought was occasioned by his venturing abroad during the operation of the purge. He had now more fever than at any other time before; however, as he averred, that his complaints were such as he usually felt from a slight cold, I did not apprehend any thing more.

On the 11th in the morning he was still much indis­posed, and had rested ill. In the evening of the same day I found him much better, but he said there were more pustules on his back. These I did not see.

Next morning I found he was gone to a friend's house, having left word that he was quite well, and I should hear from him, if there was occasion.

On the 14th I was desired to visit him, when I found a moderate number of fresh pustules on the face and limbs, and in such forwardness, that I was convinced they had been [...] since his removal; which indeed [Page 61] was confirmed by the account he gave me: these ma­turated kindly, and he remains in good health.

CASE XIX.

A gentleman's son in perfect health, between four and five years of age, on the third day after inoculation voided a long round worm alive, after having taken on the preceding night a dose of mercurial physic. No signs of worms had hitherto been observed in him, and he afterwards seemed to be quite well, till the symptoms which usually precede the small-pox, came on.

After a very moderate illness, an eruption of about twenty pustules succeeded, and all complaints then ceased; so that on the 4th day after the eruption, I pro­posed, and was permitted, to discontinue my visits for the present I called again however on the 6th day, and found him well as usual, and at play, the pustules being then nearly maturated.

I was informed, however, that in the night of the 4th day he had been hot, feverish and restless; was very well the day following, and hot again at night, but in a lesser degree; so that this slight illness did not then give the least alarm. But on the 7th day early in the morning I was called up to visit him as soon as possible, and was informed, that in the beginning of the night he grew ex­tremely hot and delirious, and soon became stupid, drow­sy and senseless, in which condition I found him, grating his teeth, with convulsive motions about the mouth.

The pustules were at this time quite ripe, and looked, as they always had done, extremely well. His pulse was very quick, though the heat was now moderate, and the respiration free and easy; but he was so comatose, as not to be roused, even so much as to open his eyes by any disturbance that could be given.

In this alarming situation I desired the assistance of the physician, who on other occasions had usually attended the family. At our consultation, which soon followed, it was agreed, that as the small-pox were very few in num­ber, had always looked well, and were now completely maturated, the present symptoms must be occasioned by worms, or some irritating cause in the bowels.

[Page 62]With this view a dose of rhubarb and calomel was im­mediately prescribed and exhibited, though we were obliged to open the mouth by force, and this not with­out some difficulty. The operation of this medicine was accelerated by a clyster, and a large fetid slimy stool, followed by some smaller liquid ones, was procured that afternoon.

The child, however, seemed to be almost totally in­sensible during this time; nor did he yet appear to be in any respect relieved by these evacuations: blisters therefore were successively applied to the back, head and legs, and sinapisms to the feet; leeches were likewise fixed to the temples, and rhubarb with calomel, after some little interval, again directed; tin medicines being given between whiles.

By these means, though not till a considerable quan­tity of slimy and extremely offensive faeces had been dis­charged, some signs of amendment appeared. But the child still remained in some degree comatose till the fifth day from this attack, after which the progress of amend­ment was very quick, and in two or three days he got quite well, and has so continued.

CASE XX.

In May 1766, I was desired to visit a considerable farmer, aged 68, to give my advice for a complaint in his legs.

About two years before he had been seized with a numbness and coldness in both legs and thighs, which it was apprehended would end in a palsy. For this dis­order he took many medicines, and both his legs were blistered, by which he found relief; but from this time the legs were affected with troublesome itching and burn­ing pains, attended with a sharp serous discharge thro' innumerable excoriations. These complaints destroyed his rest, and made him unhappy.

After relating his case, he told me, that, as almost every body in his neighbourhood, who had not had the small-pox, was either under inoculation, or preparing for it, he could scarcely expect to escape the infection, and had therefore a strong desire to be inoculated, and [Page 63] that his wife, of the same age with himself, was likewise desirous of it.

This proposal induced me to examine the present con­dition of his legs more strictly. They were now, he said, in their best state; that is, not so full of pain as usual; they were dry and scurfy. His face was likewise scurfy, and of a settled deep red colour; the consequence, as he told me, of a repeated Erysipelas in it, and not of any intemperance.

Upon considering the case, and reflecting that the pre­paratory course of diet and medicine would probably amend the condition of his legs, I encouraged him to pursue his intention, and both he and his wife, after a fortnight's preparation, were inoculated on the 3d of June.

On the 9th both made some slight complaints; and on the 12th the wife grew better, on the appearance of a very few distinct pustules, which maturated afterwards in the most favourable manner. But the man still com­plained of pain and weariness till the 13th, when he grew easier in that respect, and felt a smarting pain in his legs, which were very red, and had several pustules on them. Towards evening they grew more painful, more swelled, and a further eruption was discernible, though not easily to be distinguished, by reason of their diseased state.

He slept very little this night; but on the 14th I found him free from fever, and pretty well in all respects, ex­cept the pain in his legs: on which, and under the hams, a great number of distinct, but almost coherent pustules appeared. There were several also in the neck and face, but very few on the body or arms. He had all along been advised not to stir much, but had taken greater li­berties of walking about than I had allowed of.

15th. He had not slept a minute during the night. I found him up, and walking about the house, complaining much of pain, but saying that in other respects he was well; but he was now rather cool than warm, his pulse very low, his aspect languid, the colour of the face in­clined to livid and pale, and he complained of faintness and sickness. I could not avoid being alarmed. The legs also were swelled considerably, but not inflamed. [Page 64] I therefore ordered him instantly to bed; and as the ten­tion was great, applied a cataplasm of bread and milk (being what was nearest at hand) all over each leg, and directed the following medicine to be taken as soon as possible.

R. Mithrid. ʒss. Decoct. Cort. Peruv. ℥ij. Tinct. Cort. Peruv. simpl. ʒij. M. f. haust. quam primum su­mend. & sexta quaque hora repetendus.

R. Sal. Absinth. ʒj. succ. Limon. ℥jss. Decoct. Cort. Per. ℥vj. Tinct. Cort. Per. simpl. ℥jss. Syr. e Cort. Aur. ʒss. M. f. Mixtura, cujus capiat Coch. iv. horis intermediis.

In the evening his pulse was raised, he was easier, and had rested about an hour.

16th. In the morning, after he had rested some hours in the night, he was easier, warmer, and the pulse better.

17th. After a good night, he found himself free from complaints, and from this time every circumstance went on favourably; the pocks maturated on the 7th day, his legs however were both considerably ulcerated for a fortnight after, but then soon healed. He remains at present in good health, and feels less uneasiness from his legs than he did before the inoculation.

CASE XXI.

A middle-aged woman was inoculated May 15, 1765. She began to complain on the 23d; the fever and other symptoms were very moderate. On the 26th an eruption, distinct in kind, small in number, shewed itself; all the eruptive symptoms ceased, and she seemed perfectly well.

On the 29th she complained that her throat was sore, felt stiff and swelled; but as this is not unusual, little regard was paid to it.

30th. She rested ill, her throat was worse, and it now gave her great pain to swallow. She had also been taken with a shivering fit, succeeded by fever. On inspecting the throat, I could not perceive one pustule there, but the uvula and tonsils were very much swelled and inflamed. An acidulated gargle was directed, and a lenitive purge, which in the evening had operated thrice; the gargle had been frequently used, but the difficulty or swallowing was [Page 65] greatly increased, insomuch that she could get nothing down; the fever too was rather increased. Further help could not now be expected from internals; for upon making the trial, liquids returned through the nose. I directed a blister to be applied to the throat, and that she should frequently gargle with warm pectoral drink.

31st. She had not slept a minute, being disturbed whenever she attempted it, with such sudden startings as made her afraid to sleep. The feverish heat was not very great, the pulse extremely quick, and all the liquids she attempted to swallow, still came through the nose. She could not lie down in bed, and therefore sat up in an easy chair the greatest part of the night.

The pustules, which in the face did not exceed 20, and very few appeared elsewhere, advanced to matura­tion kindly, without receiving the least check from this adventitious illness. Her speech was so much affected as scarce to be understood. She informed me, however, that she was subject to an illness of this kind, and had once narrowly escaped with her life, but had never been so bad before. I directed 12 ounces of blood to be taken from the arm, and that the sublingual vein should be pricked. But no relief seemed to be derived from any of these measures; and upon inspecting the throat again, the glands, uvula and fauces were very much in­flamed and distended. The tonsils were then lanced pretty deep, and a good deal of blood being discharged, the swelling of the parts subsided, so as to admit her to swallow, though with difficulty, a little pectoral drink, and afterwards a few spoonfuls of milk pottage.

June 1st, she had rested but very little, though ex­ceeding drowsy, and worn out for want of sleep; for the sudden startings, upon closing her eyes, still remained, though not in so great a degree as the preceding night; but she had swallowed some liquids, though with great difficulty. The feverish heat was not very great, the pulse quick and more feeble.

On inspecting the throat towards noon, the swelling, though somewhat abated, was still considerable enough to prevent much being swallowed.

[Page 66]In this dangerous situation, the operation that had ad­ministered some relief, was repeated, and other parts of the tonsils and fauces, which had not been wounded be­fore, were now lanced pretty deep; a large quantity of blood was discharged, the parts collapsed, and in less than an hour she was able to swallow liquids; after which she got some refreshing sleep, recovered fast, and is now in good health. The pustules, notwithstanding this illness, advanced very kindly to maturation, and turned on the 7th day from the eruption.

CASE XXII.

A healthy middle-aged man, rather of a corpulent habit, was inoculated Feb. 9, 1767, had a slight cold fit (on the 5th day inclusive after the operation) which lasted but a very short time, and was not succeeded by either fever or complaint of any kind.

His arms at that time shewed certain signs of the in­fection having succeeded, which continued advancing to the 9th day, when the inflammations about the incisions appeared considerably spread, and were surrounded with confluent clusters of very small pustules. In other re­spects he was perfectly well, and felt not the least stiff­ness or pain in the axilla, or elsewhere, insomuch that he began to be uneasy lest he should have no appear­ance of small-pox.

On the 10th several small pimples were to be seen on the forehead, which I should have thought small-pox, if he had not at this time been quite well, brisk and hearty, without having felt any previous complaint.

On the 11th in the morning many more were to be seen on the face, limbs and body, so that he might be said to be very full. I now examined him again very strictly, and could not find that he had been in the least ill; and on enquiring how he had slept, he answered, never bet­ter; for he went to bed about ten, and did not wake till near seven in the morning: the eruption on a close inspection, had such an appearance as would have made me pronounce it the small-pox of an unfavourable kind, if it had been preceded or attended by any feverish or other complaints; but I must confess, that even at this [Page 67] time I supposed it was only an inoffensive rash, as the patient was then, and had been, entirely free from any complaint.

All this day he continued perfectly well, had walked out of his own accord into the fields, and in the evening asserted that he never had been easier or better in all his life; though, as he confessed to me afterwards, he had been in some company, where he smoak'd his pipe, and drank his share of a quart of ale. Still the pustules re­mained, and increased in number, though not in size; and nothing but the consideration of his having had none of the complaints which usually precede even the slightest kind of small-pox, kept me in any doubt whether they were the small-pox or not.

The next morning, being the 12th, the attending nurse told me, that he had passed a very restless night, with much complaint of pain in his head and back; and I found him very uneasy, with great heat, a quick pulse, and very full of a small sort of small-pox, indis­putably.

These complaints coming on at this unusual time, made me apprehensive of the consequences. I gave him directly calom. gr. iij. tart. emet. gr. ⅛, and ad­vised him to get up and go into the air, but not to fa­tigue himself too much. I also directed, that after two hours he should take a purging draught. [It is to be ob­served, that he had had stools every day regularly; and remaining perfectly well, had taken no medicine for some time.] I called on him again about two, and found him walking about the house, when he said he was better, for that the physick had worked him five times very sufficiently, and each time he had been abroad to the privy, though it rained pretty smartly.

I saw him again in the evening, and then he made but little complaint of pain in either head or back, but was almost incessantly teized with a short tickling cough, and complained of his throat being sore. He then took another pill of the same kind as that in the morning.

Early the next day, the 13th, the nurse informed me, that he had been very restless the whole night, had put on [Page 68] his cloaths and came down stairs, but was now gone into bed again, in hopes of getting a little rest. On going into his room, I found him almost dressed again, com­plaining that he had an almost constant irritation in the throat, and finding it impossible to get any sleep, was therefore coming down stairs. I enjoined him, how­ever, to keep within doors.

About one I saw him again; he had had two stools, and was better. His cough remained somewhat trouble­some, and his throat grew sore.

In the evening I found him in good spirits, with a re­gular quiet pulse, and he had one more purging stool. I ordered another pill of the same kind to be taken at going to bed, and a bason of small white wine whey after it, also an oily mixture to be taken occasionally, to re­lieve his cough, and the tickling sensation in the throat.

The 14th in the morning he had some comfortable rest, and felt himself refreshed; his cough had been much bet­ter, so that he had taken but once of the oily mixture. This day he had three stools from his pill; and the small-pox had advanced in an unexpected kind manner.

From this time nothing material happened; the cough left him, and his throat gave him no trouble.

The pustules filled with good matter in a shorter time than I ever saw such a number of so small a sort, and many were brown on the 17th day, being the 7th from the first appearance.

On the 19th he took a purge, and was perfectly well.

To these cases many others of a similar nature might be added. But by several unforeseen delays, not in my power to prevent, I have been obliged to trespass so much already on the patience of those who wished to see some account of this practice, that I shall only mention a few, which by a partial or untrue relation might possibly be construed to the disadvantage of inoculation; though, when the particular facts are candidly exhibited, every just occasion of prejudice will undoubtedly be removed.

During the autumn of the last year the chin-cough was epidemick at Hertford, and as the winter approached, the small-pox also broke out in many places; and almost [Page 69] every child, who before had the chin-cough, and was seized with the natural small-pox, died of a confluent kind. This calamity fell severely among the poor of this place, many of whom earnestly intreated me to inoculate their families; but this was scarce possible without some ne­cessary provision could be obtained [...] from the pa­rishes to which they belonged: I therefore acquainted the clergymen of the respective parishes, that if proper care was taken that necessaries were not wanting, I would freely inoculate and attend all such as I thought were proper subjects.

Both the gentlemen approved the design; but after a short consultation with their parishioners, the affair was pu [...] off, the parish-officers alledging they could not pro­vide proper places.

That such a design had been in agitation, soon became known, and a number of poor people were continually soliciting me to inoculate them and their children at all events, promising to provide for themselves to the utmost of their power. Some had the disease already in their fa­milies. It was so much in the neighbourhood of others, that they were in daily fear of taking the infection, and their distress on this occasion great. Women with chil­dren at their breasts in want of all necessaries, yet solici­tous for the safety of their offspring, pressed me to ino­culate them and their children with an importunity not to be described. I acquainted them with the danger at­tending the infant state; but reasons availing nothing, I yielded to inoculate all who had not the chin-cough, or any other dangerous illness, though against my opinion and inclination, almost against my determined resolution. Amongst a very great number of subjects of all ages and constitutions, and where some might reasonably be pre­sumed to have taken the infection in the natural way, I expected some disagreeable events would happen, but the probability of saving the lives of many prepon­derated. The following however are the only cases that border on the unfortunate, and the reader will, if skil­ful and candid, easily place them to the right account.

[Page 70]A mother and three children (one of them at the breast) were inoculated. The children had then the chin-cough; but this was carefully concealed from me, as I had re­fused all under such circumstances. The youngest of about five months old had only five or six pustules in the face, and not more, elsewhere proportionably. She lived past the crisis; but the cough remained violent, and she was much enfeebled, and died as children do who pe­rish by the chin-cough, and without any one circum­stance of danger that could be supposed to proceed from inoculation.

Another weakly child, about five months old, I had persuaded the mother to wean, in order that she herself might be inoculated. During the preparation this woman fell ill of a fever, as supposed; but on visiting her, I found the confluent small-pox appearing, and that the child had lain with her constantly. I was earnestly solicited to ino­culate this infant, in order to give it a better chance, which with great reluctance I yielded to. It had a very small number of distinct pustules, and passed through the disease safely; but not being reconciled to any food but the breast, it died soon after, languishing for want of pro­per sustenance.

Another unfortunate subject was also a child at the breast, one of eight children, who with the father and mo­ther were inoculated together. On the third day from the inoculation this child was seized with a fever, which from the symptoms I suspected arose from worms. I gave it a grain of calomel; a large worm was voided the next day, and the child was seemingly better; but the fever returned at night, and continued without remission in such a manner as to be very dangerous in itself, and pre­vented any distinction of the eruptive symptoms: at length a confluent kind appeared, though the number was not great; the bad symptoms were not alleviated by the eruption, and the child died early in the disease.

All these cases happened since the introduction and first chapter was wrote, and have confirmed my opinion, that it is better, both on account of the subject and the reputation of the practice, to defer inoculating children till they are about two years old.

[Page 71]It seems not improper likewise to mention the fol­lowing cases; which, if the whole truth is not related, may possibly afford matter of cavil against inoculation.

A short, thick set, middle-aged man was seized with the usual symptoms on the eighth day after inoculation. The eruption was favourable, the crop moderate, the pustules large and distinct, and no peculiar care was ei­ther required or observed. The pock maturated in seven days; after which he took two purges, and had fixed the day for his return to London.

Two days before his intended journey I found him in the morning sitting by the fire, with his hand upon his head; upon enquiring the reason, he answered, my head feels very queer to-day: a person in company added, that he had made to free with mutton the day before; but this he denied. He did not however seem much indis­posed; he had taken a purge, and I expected he would be relieved by its operation.

Next morning he told me he had a good night's sleep, and was perfectly well; nevertheless two hours after he fell down suddenly in a fit, and senseless. In this con­dition I found him about six in the evening, and so he continued till the night of the following day, when he expired, perfectly apoplectick, in spite of every means we could attempt for his relief.

CASES of the natural small-pox, treated in the preceding method.
CASE XXIII.

ONE morning about ten I was desired to visit a poor man in a fever. Two days before, in the evening, he had been seized with a shivering fit, which was then supposed to be the ague; he soon grew ex­tremely hot, with pain in his head, back and loins, which continued till I saw him, the 24th October; he had kept his bed, had scarce any sleep, his heat great, pulse strong and quick, and the pain in his loins very severe. This man had applied to me to be inoculated a little be­fore he was taken ill, on account of the small-pox being [Page 72] very much in his neighbourhood; but he had not as yet taken any preparatory steps. I made no doubt but he was now attacked with this disease, and from the severity of the symptoms expected it would prove of the confluent kind. As he lived near me, and I could easily attend to every circumstance, I determined to try how far the cooling method might be beneficial in treating the na­tural pox.

I found it very difficult to persuade him to rise out of bed, as he thought himself utterly unable to support himself, notwithstanding he was on other occasions a re­solute man. Assuring him however, that I would not attend him, unless he would comply, he promised to use his utmost endeavours. I left him to put this advice in practice, and ordered him to a carpenter's yard about one hundred yards distant, where I promised to meet him.

In about a quarter of an hour I found he had reached the place of appointment, by the assistance of a neigh­bour, and was sitting on a bench, complaining of great weakness, and pain in his loins; which he described, by saying he felt as if he was cutting in two; but allowed that his head was easier since he had been in the air. Finding that he had had a stool the preceding day, but none since, I gave him a pill, containing about six grs. of calom. and 1/ [...] gr. of emet. tartar, immediately; and as he complained of great thirst, I permitted him to drink half a pint of cold water after it. I advised him not to sit, but to endeavour to walk about a little, though ever so slowly; this he attempted, but went al­most double. At this time the weather was not very cold, but there was a pretty brisk wind, with small rain.

About a quarter of an hour after I saw him again; he had resolutely persisted in following my directions, and said, his head was greatly relieved, but the pain in his back and loins were much the same. His pulse was now much altered; instead of being full and strong, as before, it was low, but quick, and the heat on the skin greatly abated.

[Page 73]As he seemed much fatigued, I did not insist on his keeping abroad longer, but permitted him to go home, desiring him to refresh himself, not to pull off his cloaths, or go into bed.

At two o'clock I saw him again; his pill had then worked twice; he seemed fatigued and faint, but was abroad, for he said the air refreshed him, and his head was easier in the air than within, so that as soon as he was a little rested, he came out by choice. The pain in his loins still remained very grievous, but his head was much easier, and his back and loins became less painful towards evening. I allowed him to go to bed about seven; but being desirous of observing the full effect of this kind of treatment, I ordered no medicine.

25th. Had but little rest, and his complaints nearly the same as when he went to bed. His pulse was now raised, and more full than in the evening, and the de­gree of heat greater than over night. A few small pus­tules were now beginning to shew themselves on his face; I directed a purging draught of infusion of sena and manna, quickened with jalap; advised him to get out of bed, and venture again into the air. This he did: by two o'clock the purge had worked thrice, and he was freer from the pain in his back and loins: more pustules now appeared in the face, but scarce any on the limbs. He had hitherto taken nothing since his first seizure, but tea with milk, sage and balm tea, loathing all other nou­rishment. He persisted in keeping out the greatest part of [...]e afternoon; and at seven went to bed, when I found the pulse more calm and regular, and as his com­plaints were less violent, he began to think of nourish­ment.

26th. I saw him at seven in the morning; he had slept but little, had one purging stool in the night, and felt himself low and languid; his pulse was now even, full and regular, and his heat moderate. Many more pustules were out in the face, though but few on the limbs, and his complaints of pain in the head and back gone off. He took milk pottage with some ap­petite, and spent the greatest part of the day abroad.

[Page 74]At three in the afternoon I saw him, and was told, that lying down in the bed, he had fallen asleep, and waked almost choaked with blood; that he had vomit­ed up a considerable quantity, which doubtless had been swallowed, as he was found bleeding at the nose. From what I could learn, the whole scarcely exceeded six or eight ounces. He complained of faintness, and said his pains were removed. I ordered him to drink the pec­toral decoction, acidulated with a mixture of equal quantities of sweet and weak spirit of vitriol. The number of pustules continued increasing slowly on the face and other parts.

Late in the evening I saw him again; two more pur­ging stools had followed; he complained of being very faint and low, and feared he should have no rest.

I now thought it proper to give him an anodyne cor­dial, and therefore ordered mithrid. ʒss. which he took immediately. By the help of this he passed a very re­freshing comfortable night, and thought himself quite well. The eruption was now completed; the small-pox might be properly called distinct: though full in the face, he had only a moderate number of a large sort on all the other parts; and he went through the succeeding stages without any difficulty.

CASE XXIV.

A young woman, who was servant in a house where a child had the small-pox in the natural way, determined to stay there and take her chance.

December 25th, 1765, I was desired to see her. She had been taken with a cold fit the preceding afternoon, which was succeeded by a fever, and the usual symp­toms attending the eruption, but in a severe manner. I found her in bed, making great complaints of pain in her head, back and loins; her pulse strong, quick and full; a flushing red colour in the face, and the fe­ver very high.

With much difficulty I prevailed upon her to get up; ordered her to drink some cold water, and go abroad into the air, though it was a very frosty morning, with [Page 75] sleet. At one o'clock I called again, and found her then below stairs walking about. The heat was much abated, her complexion pale, the pulse small and quick, and all her complaints considerably abated.

The account I received from her, and the persons who attended her, was, that upon first going into the air, she was so feeble, that the nurse, and another to assist, could scarce support her, and it was with much difficulty, that she could walk with this assistance; that she drank a glass of cold water from the pump, and before she had been abroad many minutes, found her­self much easier, and had remained so ever since. It now rained pretty hard, which had obliged her to come in; but she said, if her complaints returned, she would certainly go out again, be the weather ever so bad, and in this resolution I encouraged her.

On the 26th, about 11 in the morning, I visited her again, found she had passed a pretty good night, and had felt no remarkable uneasiness; she had been abroad several times the preceding day, to which she imputed the ease she enjoyed. Two pustules of a distinct kind were now out in the face, and she had the disease in a very favourable manner, without the least bad symptom during the progress, or any ill consequence afterwards.

CASE XXV.

Jan. 3d, 1766.] A healthy young man was ino­culated in company with four of his neighbours. On the sixth, presuming that none of them would be ill, I went to London on business. Returning on the 7th in the afternoon, I was met by a servant, who informed me, that this man had been taken ill on the 5th in the afternoon, had continued very bad ever since, and now had something broke out, which was suspected to be the small-pox, and that I was desired to visit him im­mediately: this I complied with, and found him in bed, complaining much of pain in his head, back and loins, with great heat. Some small pustules were out in his face, which I perceived to be small-pox; this was at five in the evening, and much about forty-eight hours from the first seizure.

[Page 76]The weather was at this time exceeding cold, and it froze very hard. I ordered him out of bed immediate­ly, to drink a glass of cold water, and to get some as­sistance, and walk abroad in the air. Upon inquiry I found he had passed without a stool the whole day. Five grains of calomel in a pill were ordered to be taken immediately. He rested but little this night, and next morning a great many more pustules were out in the face, sufficient to shew a disposition to flux. As this pill produced no manifest effect, I ordered sal. Glaub. ʒvi. dissolved in water gruel, to be taken im­mediately. The vehemence of the fever and other symptoms were scarce moderated by this eruption.

Notwithstanding the medicine and the severity of the weather, I desired he would get on his cloths, and go into the air as much as he could possibly bear, and in the evening ordered him to be carried in a chaise to the house provided for him, in case he had been ill from inoculation. I examined the incisions carefully, but there were not the least signs of the infection having succeeded, either by discolouration, hardness, or any alteration on the skin, nor could he recollect that they had itched or given him the least uneasiness.

In the evening he came to the house, as ordered, but was so very feeble and full of complaints, that it was with great difficulty he was got to his room. Upon inquiry I found he had vomited up the salts soon after taking them, and had only one costive stool; he had complied with my orders about getting into the air se­veral times in the day, though with great difficulty. His complaints of thirst, pain in the head and back were at this time very great. I directed him to sit with his feet in warm water for a short time, and on going into bed to take a few spoonfuls of a laxative mixture, which was to be repeated till he had stools.

9th. He had been delirious in the night, but rested a little towards morning; the number of pustules was now considerably increased. This day he had three stools from his purging mixture, by which he was re­lieved, and bore sitting up better.

[Page 77]10th. He passed the night easy, but without sleep. He was very full in the face, but had a smaller number on the body and limbs. No complaint, deserving no­tice, happened during the progress to maturation. He sat up a part of every day to the eighth from the erup­tion, when, being blind, and very sore, he kept in bed: they turned on the eleventh, and he recovered perfectly.

It was remarkable in this case, that the inoculated parts never shewed the least signs of infection; nor did a greater number of pustules appear near them than might have been expected, if nothing had been done; nor is there to be seen the least mark where the inoculation was performed, though in all other inoculat­ed patients who have had the disease, even in the slight­est manner, there constantly remains a scar.

It appeared, on inquiry, that this man had been for a considerable time before in a constant inter­course with families in the small-pox, and there seems not to be the least doubt but his was the natural disease.

CASE XXVI.

A young woman was seized with a fever, and the usual symptoms. The next day an eruption appeared, which gave some suspicion of the small-pox: on the third day more spots were discovered, but she was not relieved. The disorder was now supposed to be an inflammatory fever, attended with a rash; and as she was extremely delirious, a blister had been applied about two hours before I first saw her. The face was extremely full of very small pustules, which indeed were the small-pox, and there was a considerable num­ber on the neck and limbs; but notwithstanding this eruption the fever was very high, and the degree of heat so excessive, that I scarce ever felt a person hotter; she was so far sensible as to complain of great pain in her head, stomach and loins, though very delirious, and extremely restless. She was at an inn much used by carriers, and it was highly improper she should re­main [Page 78] there. In her present situation I was sensible it might appear very hazardous to move her, but it was evident, that the small-pox would be confluent. I judged from the violence of the symptoms, the dis­ease would be dangerous, and the event doubtful, and was therefore desirous of trying how far the same method and remedies which were used so successfully in the inoculated small-pox as well as in some cases of the natural disease, would avail in this. The ne­cessity of removing the patient afforded me a good opportunity, without any imputation of rashness. I therefore proposed her being taken down stairs into a parlour under the room where she then lay, while I was present, and ready to assist, if the fatigue should be too much for her; this was consented to; the women assisted in getting her cloaths on, which she seemed much pleased with, being then delirious. She was al­together unable to stand, and was therefore brought down by three persons in the same manner as if she had been dead. She was then placed in a chair, but had not even strength to hold herself upright, but was sup­ported in that posture by the women about her.

The fatigue of moving, and change of posture oc­casioned a faintness, in which she lost all colour, and the pustules for a time disappeared; upon this the chair was leaned quite back, the bed was brought down, and laid on the floor, she was placed on it with her cloaths on, and eagerly drank a glass of cold water. Her colour soon returned; the pustules appeared as before; but she was considerably cooled, and her pulse, tho' it retained the quickness, was not near so strong: I staid with her about half an hour, during which time she was more sensible, not so restless, but seemed languid and tired. I ordered the window to be open­ed, the room to be kept cool, and gave her three grains of calomel, tart. emet. gr. 1/ [...], in a pill, and directed a purging draught to be taken as soon as it could be pro­cured, and as there seemed no occasion for the blister, it was taken off.

[Page 79]I saw her next morning at a house to which she had been removed at a small distance, and found her almost free from complaints; she had rested moderately well, was perfectly sensible. Those about her dated her amendment from the time when the purge (which had procured three stools) began to operate.

She was however extremely full all over of a very small confluent kind; yet these inflamed and maturat­ed in a very favourable manner. From the minutest observation I could make, it seemed to me, that by this management the number in the face was less than when I first saw her, consequently that some pustules were repressed after they had appeared.

CASE XXVII.

In the beginning of June 66, a young woman was taken with a shivering fit, succeeded by a fever, and the symptoms that usually precede the small-pox, in a very violent degree; these were attended with such ge­neral weakness, that in a few hours after the seizure she was obliged to go to bed, where she soon became de­lirious, and afterward insensible, her urine passing in­voluntarily. In this condition I saw her first about forty hours after she was taken ill. The heat was excessive, her pulse extremely quick, but not strong, and a few small eruptions appeared on the face, sufficient to ascer­tain the distemper. Upon raising her up, she did not make the least effort to support herself, and therefore was permitted to lie down, and as the room was small, the window was set open. Five grs. of calomel were with great difficulty got down, and an infusion of sena with manna being prepared, the person attending was desired to give a little and often, till she had a stool.

It was very improper, that she should remain in the house where she was, on account of the family; yet there was no possibility of moving her in her present condition. Next morning I was informed she had re­mained in the same stupid way the whole night, but was now rather better, and had spoke more sensibly, [Page 80] had two stools, and vomited up some bilious matter. The heat was still great, the pulse quick, and many small confluent pustules were out in the face and other parts; this was the third day of her illness. I advised her being got out of bed, and the windows to be kept open; but was in doubt whether she had strength enough to be taken into the open air.

In the evening the eruption was increased consider­ably in number, and she was so much easier of her complaints as to bear being removed in a cart to a house in the neighbourhood, where I gave her calomel three grains, emetic tartar one eighth of a grain.

She had some rest this night; but the fever con­tinued, and not having had any more stools, I or­dered a laxative potion of inf. of sena and manna. She had three stools before evening, and all her com­plaints abated. She was very full all over of a very confluent kind.

This young woman sat up the greatest part of se­veral days after she was quite blind, by her own choice; and I do not recollect ever seeing one with so large a crop of pustules, who went through the disease so easily; for she made no complaint but of soreness, nor took any medicine but a few drops of thebaic tincture at bed­time, towards the crisis.

CASE XXVIII.

A poor man about 35 years of age, who had gone through the preparatory course, came to my house in company with several more, in order to be inocu­lated. As soon as he came into the room, I perceived he was ill; and on enquiring he told me, that about two hours before he had been taken with a fit of the ague, and that his head, back and loins were in great pain. Feeling his pulse, I found a good deal of fe­ver; his skin was also very hot. I knew the small-pox was in his neighbourhood, and thence concluded, he was seized with ths distemper. I advised him to keep abroad in the air as much as possible, and directed [Page 81] a pill of the kind already mentioned at night, and a purging draught the following morning.

These operated four or five times, and he persisted in obeying my orders; the fever and other complaints were not so high as to give any great alarm; he had a pretty large number of a distinct pock, and went through the distemper very well.

CASE XXIX.

About three in the afternoon I visited a middle-aged man, who after two days illness had an eruption, which the neighbours suspected to be the small-pox; I found him in bed, very hot, and in a sweat; his pulse quick, full and strong, his face pretty full of small-pox, which had begun to appear in the morning. I received the usual account of the preceding symptoms, which had been pretty severe, and he still made great complaints of pains in his head, back and loins. I immediately gave him a pill, containing cal. gr. v. tart. emet. gr. ⅛, which I had taken with me upon a presumption that I might want it. I also insisted on his getting up, and going abroad into the air, notwithstanding the sweat he was in, which it was my intention to restrain. I met with the usual difficulty in getting this advice com­plied with; however he was assisted, came down stairs, and went abroad, being supported by his wife; for he seemed very weak, and had not been out of his bed for two days before. As he complained of great thirst, I gave him a glass of cold water, and stayed about half an hour to see the effect of this treatment. He was at first very faint and sick, and vomited up some bilious matter, but not the pill he had lately taken. After this, while I stayed, he said his head was better, and allowed he was refreshed by the air. I desired him to continue abroad as much as he could, and when he found himself tired, to go in and lie down a little; but as soon as he was able, to get out again, and if thirsty, to drink as much cold watet as he pleased. I then took my leave, ordering a purging draught to be [Page 82] taken as soon as he received it, which I concluded would be at least three or four hours from that time.

Next morning, on visiting him, I was told, that the purge had operated four times, that he found himself considerably relieved, both in his head and back, and had rested better than any time since he had been taken ill. The eruption proceeded slowly; but many more pustules now appeared in his face and other parts, than before. He kept abroad, and his complaints continued wearing off. Next morning I found him quite easy; he was pretty full of a distinct pock, and from this time all went on well, without having occasion to take any more medicines.

FINIS.

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