Thomas Dimsdale - The Present Method of Inoculating for the Small-Pox

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.