Hitherto very little regard seems to have been paid to the progress
of infection discoverable by the part where the operation was
performed. But it will appear in the sequel, that an attention to this
circumstance is very necessary, because a just prognostic may thence be
sometimes formed of the future state of the distemper, and indications
may be taken from the different appearances on the arm, that will
enable us to prevent inconveniencies.
The former method of covering the place of incision with a plaister,
and continuing upon it dressings of one sort or another, prevented much
useful information of this kind. They prevented any judgment by the
touch, and sometimes rendered that by the eye equivocal.
The day after the operation is performed, though it takes effect,
little alteration is discoverable. On the second day, if the part is
viewed with a lens, there generally appears a kind of orange-coloured
stain about the incision, and the surrounding skin seems to contract.
At this time I usually give the following medicine at going to bed,
either mixed with a little of any kind of jelly, or more frequently
made into a pill.
Calomel and compound powder of crabs claws, of each 3 grains,
emetic tartar 1/10 of a grain.
A quantity of this medicine should be carefully prepared at once, in
order to make the division more exact.
On the fourth or fifth day, upon applying the finger, a hardness is to
be felt by the touch. The patient perceives an itching on the part,
which appears slightly inflamed; and under a kind of vesication is seen
a little clear fluid; the part resembling a superficial burn. About the
sixth, most commonly, some pain and stiffness is felt in the axilla;
and this is a very pleasing symptom, as it not only foretells the near
approach of the eruptive symptoms, but is a sign of a favourable
progress of the disease. Sometimes on the seventh, oftener on the
eighth day, symptoms of the eruptive fever appear; such as slight
remitting pains in the head and back, succeeded by transient shiverings
and alternate heats, which in a greater or less degree, continue till
the eruption is perfected. At this time also it is usual for the
patient to complain of a very disagreeable taste in his mouth, the
breath is always fetid, and the smell of it different from what I have
ever observed in any case, except in the variolous eruptive fever.
The inflammation in the arms at this time spreads fast; and upon
viewing it with a good glass, the incision, for the most part, appears
surrounded with an infinite number of small confluent pustules, which
increase in size and extent as the disease advances. On the tenth or
eleventh day, a circular or oval efflorescence is usually discovered,
surrounding the incision, and extending sometimes near half round
the arm, but more frequently to about the size of a shilling; and
being under the cuticle, is smooth to the touch, and not painful.
This appearance is also a very pleasing one; it accompanies eruption;
every disagreeable symptom ceases; and at the same time it certainly
indicates the whole affair to be over; the pain and stiffness in the
axilla also going off.
The feverish symptoms are for the most part so mild, as seldom to
require any medicinal assistance, except a repetition of the same
medicine that was directed on the second night after the operation; and
on the following morning this laxative draught, to procure three or
four stools;
Infusion of sena two ounces, manna half an ounce, tincture of jalap
two drams.
These are given as soon as the eruptive symptoms are perceivable, if
they seem to indicate any uncommon degree of vehemence.
It has been observed, that by attending to the progress of infection,
we may be able to prognosticate, with some degree of certainty, the
event of the distemper in general. Particular incidents will ever
happen, but not sufficient to destroy the propriety of general rules.
If the appearances already described are observed early, a very
favourable event is implied: but it happens in some cases, although
it may be perceived that the inoculation has succeeded, yet it is
barely perceptible; the colour about the wound remaining pale, instead
of changing to red or inflamed; the edges of the incision spread but
little, they remain flat, scarcely rising at all, and are attended
neither with itching or uneasiness of any kind. Nay, sometimes on the
fifth, and even the sixth-day, the alteration is so little, as to make
it doubtful whether the infection has taken place.
When matters are in this state, the appearance is unfavourable, and
implies a late and more untoward disease: to prevent which, I direct
the powder or pill to be taken each night; and in case it fails to
operate by stool, or there is the least disposition to costiveness, an
ounce of Glauber’s salts, or more commonly the laxative draught already
mentioned, is given in the morning, once or twice, as the case may
require. This course forwards the inflammation, which I always wish to
see; as I have constantly observed, that an early progress on the arm,
and an early commencement of the eruptive complaints, portend that the
distemper will be mild and favourable; and on the contrary, where both
are late, the symptoms are usually more irregular and untoward.
Being now arrived at the most interesting period of this distemper,
the eruption, a period in which the present practice I am about to
recommend, differs essentially from the method heretofore in use, and
on the right management of which much depends, it will be requisite to
give clear and explicit directions on this head, and to advise their
being pursued with firmness and moderation.
Instead of confining the patient to his bed, or his room, when the
symptoms of the eruptive fever come on, he is directed, as soon as
the purging medicine has operated, to keep abroad in the open air,
be it ever so cold, as much as he can bear, and to drink cold water,
if thirsty; always taking care not to stand still, but to walk about
moderately, while abroad.
This treatment indeed seems as hard at first to the patients, as it
must appear singular to the reader; but the effects are so salutary,
and so constantly confirmed by experience, and an easy progress through
every stage of the disease depends so much upon it, that I admit of no
exception, unless the weather be extremely severe, and the constitution
very delicate. And it is indisputably true, that in the few instances
where the symptoms of eruption have run very high, the patients
dreading any motion, and fearing the cold as the greatest evil, yet,
when under these circumstances, I have persuaded them to rise out of
bed, and go out of doors, though led sometimes by two assistants, and
have allowed them to drink as much cold water as they chose, they have
not suffered the least sinister accident: on the contrary, after
they have been prevailed on, although reluctantly, to comply with
these directions, they find their spirits revived; an inclination
for nourishment returns; they rest well; a gentle sweat succeeds,
accompanied with a favourable eruption; and the fever seems wholly to
be extinguished.
In general, the complaints in this state are very moderate, and
attended with so little illness, that the patient eats and sleeps well
the whole time: a few pustules appear, sometimes equally dispersed;
sometimes the inflammations on the arms spread, and are surrounded with
a few pustules, which gradually advance to maturity; during which time,
for the most part, the eruption proceeds kindly, and there is much more
difficulty to restrain the patients within due bounds, and prevent
their mixing with the public, and spreading the infection (which I
always endeavour to prevent) than there was at first to prevail upon
them to go abroad. During this time medicine is seldom wanted; the
cool air seems the best cordial; and if any uncommon languor happens,
a bason of small broth, or a glass of wine, is allowed in the day, or
some white-wine whey at bed time; which are indeed at any time allowed
to tender, aged, or weakly persons.
With these exceptions, they have hitherto been kept very scrupulously
to the diet at first directed. But after the eruption is completed, if
occasion requires, they are indulged in a little well-boiled meat of
the lightest kind, as chicken, veal, or mutton.
The regimen above-mentioned, the cooling alterative purges, and the
free use of cool air at the season of eruption, almost universally
prevent either alarming symptoms, or a large crop of pustules. A few
I have seen with such a quantity of pustules, though distinct, that I
have neither advised nor allowed them to go out of the house. But the
generality of my patients, when the eruptions are few, amuse themselves
abroad within proper limits, with the pustules out upon them.
I neither enjoin this, nor maintain that it is necessary; but have
not been able to observe that any inconvenience has arisen from it.
And, how strange soever it may appear, it is true, that those who
are most adventurous, seem to be in better spirits, and more free
from complaints, than others who are inclined to keep within-doors.
And indeed, such of my patients as have received the benefit of this
treatment themselves, seldom permit those who are in the hardest
part of the distemper, the eruptive, to keep much in the house; but
encourage them to bear a little hardship, by recounting to them the
benefit they have reaped from the method they are recommending.
Those who have the disease in the slightest manner first described,
viz. without any appearance of eruption but on the inoculated part, are
soon allowed to go about their usual affairs; and many instances have
happened of very industrious poor men, who have instantly returned to
their daily labour, with a caution not to intermix with those who have
not had the distemper, for fear of spreading it; and with directions
to take two or three times of the purge already directed, or as many
doses of Glauber’s salts. Those who have it in a greater degree, are
confined somewhat longer; and a very mild laxative is now-and-then
exhibited, if there is the least disposition to costiveness; as the
progress to maturation appears rather to be advanced than retarded by
the operation.
When the maturation is completed, and it is evident we have nothing
further to fear from the distemper, I allow my patients gradually
to change their course of diet, from the perfectly cooling kind, to
one a little more generous; recommending strictly to all a return to
their ordinary animal diet with much caution and restraint upon their
appetites, both in respect to food and fermented liquors.
It is not often that we are under a necessity of making any application
to the part where the operation was performed; it most commonly heals
up, and is covered with a scab, about the time when, in a natural way,
all the pocks would have been dried up: but there are some cases
wherein the incisions continue to discharge a purulent matter longer;
in these instances it is sufficient to cover the place with the white
cerate, or any other mild emplastic substance, which may at once
prevent the linen from adhering to the sore, and defend it from the
air. And as in these cases the part remains unhealed from some peculiar
cause in the habit, it will be necessary to give gentle purgatives, and
proper alteratives, as particular exigencies may require.