2. All the good effects of mercury may be produced by PURGES, which do not subject the body to the above-mentioned inconvenience.
The PURGES may be suited to the constitutions, and in some cases, even to the inclinations of our patients. I have seen jalap, rhubarb, senna, manna, aloes, soluble tartar, glauber and Epsom salts, and the butter-nut pill, all given with equal success. The quantity should be sufficient to procure three or four stools every day. A little magnesia should always be mixed with rhubarb and jalap in preparing children. It will be sufficient for the mothers and nurses of infants to conform strictly to the vegetable diet. I have never seen any advantages from giving them even a single dose of physic.
It is hardly necessary to observe, that the quality, dose, and number of purges are to be determined by the age, sex, and habits of our patients. A constitution enfeebled by a previous disease forbids the use of purges, and requires medicines of a restorative kind. Patients afflicted with cutaneous diseases bear larger and more frequent doses of physic, than are indicated in more healthy subjects.
In adult subjects of a plethoric habit, blood-letting is very useful on the third or fourth day after inoculation. We are not to suppose, that every fat person labours under a plethora. A moderate degree of fat is so far from rendering the disease more violent, especially in children, that I think I have generally found such subjects have the small-pox more favourably than others.
Moderate exercise in the open air should be used during the preparation. But hard labour, and every thing that promotes sweat or fatigue, as also the extremes of heat and cold, should be avoided.
IV. We come now to consider the treatment of the body during the eruptive fever. On the eighth day after inoculation our patients are generally seized with the common symptoms of fever. Sometimes this fever appears on the sixth and seventh day after inoculation. But when it is irregular, it is often delayed till the ninth and tenth days. I have seen many instances of it on the fourteenth, a few on the fifteenth and sixteenth, and one case in which it did not come on till the eighteenth day after the infection was communicated to the body[60]. The place where the puncture was made with the lancet, or needle, generally serves as a harbinger of the approaching fever. A slight inflammation appears about it, and a pock rises up in the centre. But this remark is liable to some objections. I have seen four instances in which the fever came on at the expected time, and the disease went through all its stages with the greatest regularity, and yet there was no sign of an inflammation or pock near the spot where the puncture was made: even the puncture itself became invisible. On the other hand, we sometimes see an inflammation and pock on the arm appear on the eighth and ninth days, without any fever accompanying them. Some physicians suppose that this inflammation and solitary pock are sufficient to constitute the disease; but repeated experience has taught me to be very cautious in relying upon these equivocal marks. It is true, I have sometimes seen patients secured against the small-pox, both in the natural way and by inoculation, where these marks have appeared; but I have as often seen such patients seized afterwards with the small-pox in the natural way, to the great distress of families, and mortification of physicians. Upon this account, I make it a constant practice to advise a second or third inoculation, where a fever and eruption have been wanting. As the absence of these symptoms is probably occasioned by the weakness or age of the variolous matter, or the too high state of preparation of the body, we should always guard against both, by making the puncture the second time with fresh matter, by subjecting our patients to a less abstemious diet, and by giving fewer doses of physic. I have heard it remarked, that if a slight redness and a small pimple appeared on the arm on the third day after inoculation, it was a sign the matter had infected the whole constitution. I acknowledge I have often seen a greater degree of redness on the third than on the second day after inoculation, but I have not been able to establish a diagnostic mark from it; for I have seen the disease produced on the usual days where the redness has appeared on the second day, and in some cases where it has not appeared until the eruptive fever.
I am led here unwillingly to discuss the old question, Is it possible to have the small-pox in the natural way after inoculation?—In many of the cases supposed to be the small-pox from inoculation, it is probable the matter has been taken from the chicken-pox, which resembles the small-pox in many of its peculiarities, but in none more than that of leaving pits or marks on the skin. But there are certainly cases where there are the most irrefragable proofs of the infection implanted by inoculation being of a variolous nature, where the disease has been afterwards taken in the natural way. In these cases I would suppose the variolous matter produced only a topical or cuticular disease. We see something analogous to this in nurses who attend patients in the small-pox. But further, this topical or cuticular infection may be produced by art in persons who have had the small-pox in the natural way. Some years ago, I made a puncture on my left hand with a lancet moistened with variolous matter. On the eighth day an inflammation appeared on the place, accompanied by an efflorescence in the neighbourhood of it, which extended about two inches in every direction from the spot where the puncture was made. On the eleventh day I was surprised to find two pocks (if I may venture to call them such), the one on the outside of the fourth finger of my left hand, and the other on my forehead. They remained there for several days, but without filling with matter, and then dropped off, rather in the form of a soft wart, than of a common scab. Doctor Way of Wilmington repeated the same experiment upon himself, but with an issue to his curiosity more extraordinary than that I have just now related. On the eighth day after he had made a puncture on his hand, a pock appeared on the spot, which in the usual time filled with matter, from which he inoculated several children, who sickened at the usual time, and went through all the common stages and symptoms of the small-pox. It would seem from these facts, that it is necessary the small-pox should produce some impression upon the whole system, in order to render it ever afterwards incapable of receiving an impression of a similar nature. A fever and an eruption therefore seem necessary for this purpose. As the inflammation of the arm on the eighth day is a sign of the topical and cuticular infection, so an eruption (though ever so small) seems to be the only certain sign of the infection of the whole system. The eruption is the more decisive in its report, in proportion as it comes out and goes off in the usual manner of the small-pox in the natural way. In those cases where patients have been secured against a second attack of the disease, when there have been no obvious fever or visible eruption, I think I have observed an unusual inflammation, and a copious and long continued discharge of matter from the arm. Perhaps this may serve as an outlet of the matter, which in other cases produces the fever and eruption. I am the more disposed to embrace this opinion, from the testimony which several authors have left us of the effects of ulcers in securing the body from the infection of the plague. The effects of issues are still more to our purpose. We observe a plentiful discharge of matter from them every time the body is exposed to cold, and the febrile effects of it upon the system are thereby frequently obviated. How far a ratio exists between the degrees of inflammation and the discharge of matter from the arm, and the degrees of fever and eruption, must be determined by future and very accurate observations. If it should appear, that there are the least inflammation and smallest discharge, where there have been the highest fever and most copious eruption; and, on the contrary, if it should appear that there are the greatest inflammation and discharge, where there have been the least fever and smallest eruption, I must beg leave to add, without attempting in this place to explain the reasons of it, that the remark, if generally true, is liable to some exceptions. But the subject is involved in darkness; I shall be satisfied if I have brought you within sight of the promised land. Your own ingenuity, like another Jewish leader, must conduct you thither.
The indications in the treatment of the body during the eruptive fever are,
I. To regulate the degree of fever.