The Harvard Classics Part 14

"William Morris, aged thirty-two, servant to Mr. c.o.x of Almondsbury, in this county, applied to me the 2d of April, 1798.

He told me that, four days before, be found a stiffness and swelling in both his hands, which were so painful it was with difficulty he continued his work; that he had been seized with pain in his head, small of the back, and limbs, and with frequent chilly fits succeeded by fever. On examination I found him still affected with these symptoms, and that there was a great prostration of strength. Many parts of his hands on the inside were chapped, and on the middle joint of the thumb of the right hand there was a small phagedenic ulcer, about the size of a large pea, discharging an ichorous fluid. On the middle finger of the same hand there was another ulcer of a similar kind. These sores were of a CIRCULAR form, and he described their first appearance as being somewhat like blisters arising from a burn.

He complained of excessive pain, which extended up his arm into the axilla. These symptoms and appearances of the sores were so exactly like the cow-pox that I p.r.o.nounced he had taken the distemper from milking cows. He a.s.sured me he had not milked a cow for more than half a year, and that his master's cows had nothing the matter with them. I then asked him if his master had a GREASY horse, which he answered in the affirmative, and further said that he had constantly dressed him twice a day for the [Footnote: HC--Vol.88] last three weeks or more, and remarked that the smell of his hands was much like that of the horses's heels. On the 5th of April I again saw him, and found him still complaining of pain in both hands, nor were his febrile symptoms at all relieved. The ulcers had now spread to the size of a seven-shilling gold coin, and another ulcer, which I had not noticed before, appeared on the first joint of the forefinger of the left hand, equally painful with that on the right. I ordered him to bathe his hands in warm bran and water, applied escharotics to the ulcers, and wrapped his hands up in a soft cataplasm. The next day he was much relieved, and in something more than a fortnight got well. He lost his nails from the thumb and fingers that were ulcerated."

The sudden disappearance of the symptoms in this case after the application of the escharotics to the sores is worthy of observation; it seems to show that they were kept up by the irritation of the ulcers.

The general symptoms which I have already described of the cow- pox, when communicated in a casual way to any great extent, will, I am convinced, from the many cases I have seen, be found accurate; but from the very slight indisposition which ensues in cases of inoculation, where the pustule, after affecting the const.i.tution, quickly runs into a scab spontaneously, or is artificially suppressed by some proper application, I am induced to believe that the violence of the symptoms may be ascribed to the inflammation and irritation of the ulcers (when ulceration takes place to any extent, as in the casual cow-pox), and that the const.i.tutional symptoms which appear during the presence of the sore, while it a.s.sumes the character of a pustule only, are felt but in a very trifling degree. This mild affection of the system happens when the disease makes but a slight local impression on those who have been accidentally infected by cows; and, as far as I have seen, it has uniformly happened among those who have been inoculated, when a pustule only and no great degree of inflammation or any ulceration has taken place from the inoculation. The following cases will strengthen this opinion.

The cow-pox appeared at a farm in the village of Stonehouse, in this county, about Michaelmas last, and continued gradually to pa.s.s from one cow to another till the end of November, On the twenty-sixth of that month some ichorous matter was taken from a cow and dried upon a quill. On the 2d of December some of it was inserted into a scratch, made so superficial that no blood appeared, on the arms of Susan Phipps, a child seven years old.

The common inflammatory appearances took place in consequence, and advanced till the fifth day, when they had so much subsided that I did not conceive any thing further would ensue.

6th: Appearances stationary.

7th: The inflammation began to advance.

8th: A vesication, perceptible on the edges, forming, as in the inoculated smallpox, an appearance not unlike a grain of wheat, with the cleft, or indentation in the centre.

9th: Pain in the axilla.

10th: A little headache; pulse, 110; tongue not discoloured; countenance in health.

11th, 12th: No perceptible illness; pulse about 100.

13th: The pustule was now surrounded by an efflorescence, interspersed with very minute confluent pustules to the extent of about an inch. Some of these pustules advanced in size and maturated. So exact was the resemblance of the arm at this stage to the general appearance of the inoculated smallpox that Mr. D., a neighbouring surgeon, who took some matter from it, and who had never seen the cow-pox before, declared he could not perceive any difference. [Footnote: That the cow-pox was a supposed guardian of the const.i.tution from the action of the smallpox has been a prevalent idea for a long time past; but the similarity in the const.i.tutional effects between one disease and the other could never have been so accurately observed had not the inoculation of the cow-pox placed it in a new and stronger point of view. This practice, too, has shewn us, what before lay concealed, the rise and progress of the pustule formed by the insertion of the virus, which places in a most conspicuous light its striking resemblance to the pustule formed from the inoculated smallpox.] The child's arm now shewed a disposition to scab, and remained nearly stationary for two or three days, when it began to run into an ulcerous state, and THEN commenced a febrile indisposition accompanied with an increase of axillary tumour. The ulcer continued spreading near a week, during which time the child continued ill, when it increased to a size nearly as large as a shilling. It began now to discharge pus; granulations sprang up, and it healed. This child had before been of a remarkably sickly const.i.tution, but is now in very high health.

Mary Hearn, twelve years of age, was inoculated with matter taken from the arm of Susan Phipps.

6th day: A pustule beginning to appear, slight pain in the axilla.

7th: A distinct vesicle formed.

8th: The vesicle increasing; edges very red; no deviation in its appearance at this time from the inoculated smallpox.

9th: No indisposition; pustule advancing.

10th: The patient felt this evening a slight febrile attack.

11th: Free from indisposition.

12th, 13th: The same.

14th: An efflorescence of a faint red colour extending several inches round the arm. The pustule, beginning to shew a disposition to spread, was dressed with an ointment composed of hydrarg. nit. rub. and ung. cerce. The efflorescence itself was covered with a plaster of ung. hydr. fort. In six hours it was examined, when it was found that the efflorescence had totally disappeared.

The application of the ointment with the hydr. nit. rub. was made use of for three days, when, the state of the pustule remaining stationary, it was exchanged for the ung. hydr. nit. This appeared to have a more active effect than the former, and in two or three days the virus seemed to be subdued, when a simple dressing was made use of; but the sore again shewing a disposition to inflame, the ung. hydr. nit. was again applied, and soon answered the intended purpose effectually. The girl, after the tenth day, when, as has been observed, she became a little ill, shewed not the least symptom of indisposition. She was afterwards exposed to the action of variolous; matter, and completely resisted it. Susan Phipps also went through a similar trial. Conceiving these cases to be important, I have given them in detail: first, to urge the precaution of using such means as may stop the progress of the pustule; and, secondly, to point out (what appears to be the fact) that the most material indisposition, or at least that which is felt most sensibly, DOES NOT ARISE PRIMARILY FROM THE FIRST ACTION OF THE VIRUS ON THE CONSt.i.tUTION, BUT THAT IT OFTEN COMES ON, IF THE PUSTULE IS LEFT TO CHANCE, AS A SECONDARY DISEASE. This leads me to conjecture, what experiment must finally determine, that they who have had the smallpox are not afterwards susceptible of the primary action of the cow-pox virus; for seeing that the simple virus itself, when it has not pa.s.sed beyond the boundary of a vesicle, excites in the system so little commotion, is it not probable the trifling illness, thus induced may be lost in that which so quickly, and oftentimes so severely, follows in the casual cow- pox from the presence of corroding ulcers? This consideration induces me to suppose that I may have been mistaken in my former observation on this subject.

In this respect, as well as many others, a parallel may be drawn between this disease and the smallpox. In the latter, the patient first feels the effect of what is called the absorption of the virus. The symptoms then often nearly retire, when a fresh attack commences, different from the first, and the illness keeps pace with the progress of the pustules through their different stages of maturation, ulceration, etc. Although the application I have mentioned in the case of Mary Hearn proved sufficient to check the progress of ulceration and prevent any secondary symptoms, yet, after the pustule has duly exerted its influence, I should prefer the destroying it quickly and effectually to any other mode. The term caustic to a tender ear (and I conceive none feel more interested in this inquiry than the anxious guardians of a nursery) may sound harsh and unpleasing, but every solicitude that may arise on this account will no longer exist when it is understood that the pustule, in a state fit to be acted upon, is then quite superficial, and that it does not occupy the s.p.a.ce of a silver penny. [Footnote: I mention escharotics for stopping the progress of the pustule because I am acquainted with their efficacy; probably more simple means might answer the purpose quite as well, such as might be found among the mineral and vegetable astringents.]

As a proof of the efficacy of this practice, even before the virus has fully exerted itself on the system, I shall lay before my reader the following history:

By a reference to the treatise on the Variolae Vaccinae it will be seen that, in the month of April, 1798, four children were inoculated with the matter of cow-pox, and that in two of these cases the virus on the arm was destroyed soon after it had produced a perceptible sickening. Mary James, aged seven years, one of the children alluded to, was inoculated in the month of December following with fresh variolous matter, and at the same time was exposed to the effluvia of a patient affected with the smallpox. The appearance and progress of the infected arm was, in every respect similar to that which we generally observe when variolous matter has been inserted into the skin of a person who has not previously undergone either the cow-pox or the smallpox.

On the eighth day, conceiving there was infection in it, she was removed from her residence among those who had not had the smallpox. I was now anxiously waiting the result, conceiving, from the state of the girl's arm, she would fall sick about this time. On visiting her on the evening of the following day (the ninth) all I could learn from the woman who attended her was that she felt somewhat hotter than usual during the night, but was not restless; and that in the morning there was the faint appearance of a rash about her wrists. This went off in a few hours, and was not at all perceptible to me on my visit in the evening. Not a single eruption appeared, the skin having been repeatedly and carefully examined. The inoculated arm continued to make the usual progress to the end, through all the stages of inflammation, maturation, and scabbing.

On the eighth day matter was taken from the arm of this girl (Mary James) and inserted into the arms of her mother and brother (neither of whom had had either the smallpox or the cow-pox), the former about fifty years of age, the latter six.

On the eighth day after the insertion the boy felt indisposed, and continued unwell two days, when a measles-like rash appeared on his hands and wrists, and was thinly scattered over his arms.

The day following his body was marbled over with an appearance somewhat similar, but he did not complain, nor did he appear indisposed. A few pustules now appeared, the greater part of which went away without maturating.

On the ninth day the mother began to complain. She was a little chilly and had a headache for two days, but NO PUSTULE APPEARED on the skin, nor had she any appearance of a rash.

The family was attended by an elderly woman as a nurse, who in her infancy had been exposed to the contagion of the smallpox, but had resisted it. This woman was now infected, but had the disease in the slightest manner, a very few eruptions appearing, two or three of which only maturated.

From a solitary instance like that adduced of Mary James, whose const.i.tution appears to have resisted the action of the variolous virus, after the influence of the cow-pox virus had been so soon arrested in its progress, no positive conclusion can be fairly drawn; nor from the history of the three other patients who were subsequently infected, but, nevertheless, the facts collectively may be deemed interesting.

That one mild variety of the smallpox has appeared I have already plainly shewn; [Footnote: See Inquiry into the Causes and Effects of the Variolae Vaccinae, p. 54 (of original article)], and by the means now mentioned we probably have it in our power to produce at will another.

At the time when the pustule was destroyed in the arm of Mary James I was informed she had been indisposed about twelve hours; but I am now a.s.sured by those who were with her that the s.p.a.ce of time was much less. Be that as it may, in cases of cow-pox inoculation I would not recommend any application to subdue the action of the pustule until convincing proofs had appeared of the patient's having felt its effects at least twelve hours. No harm, indeed, could ensue were a longer period to elapse before the application was made use of. In short, it should be suffered to have as full an effect as it could, consistently with the state of the arm.

As the cases of inoculation multiply, I am more and more convinced of the extreme mildness of the symptoms arising merely from the primary action of the virus on the const.i.tution, and that those symptoms which, as in the accidental cow-pox, affect the patient with severity, are entirely secondary, excited by the irritating processes of inflammation and ulceration; and it appears to me that this singular virus possesses an irritating quality of a peculiar kind, but as a single cow-pox pustule is all that is necessary to render the variolous virus ineffectual, and as we possess the means of allaying the irritation, should any arise, it becomes of little or no consequence.

It appears then, as far as an inference can be drawn from the present progress of cow-pox inoculation, that it is an accidental circ.u.mstance only which can render this a violent disease, and a circ.u.mstance of that nature which, fortunately, it is in the power of almost every one to avoid. I allude to the communication of the disease from cows. In this case, should the hands of the milker be affected with little accidental sores to any extent, every sore would become the nidus of infection and feel the influence of the virus; and the degree of violence in the const.i.tutional symptoms would be in proportion to the number and to the state of these local affections. Hence it follows that a person, either by accident or design, might be so filled with these wounds from contact with the virus that the const.i.tution might sink under the pressure.

Seeing that we possess the means of rendering the action of the sores mild, which, when left to chance, are capable of producing violent effects; and seeing, too, that these sores bear a resemblance to the smallpox, especially the confluent, should it not encourage the hope that some topical application might be used with advantage to counteract the fatal tendency of that disease, when it appears in this terrific form? At what stage or stages of the disease this may be done with the most promising expectation of success I will not pretend now to determine. I only throw out this idea as the basis of further reasoning and experiment.

I have often been foiled in my endeavours to communicate the cow- pox by inoculation. An inflammation will sometimes succeed the scratch or puncture, and in a few days disappear without producing any further effect. Sometimes it will even produce an ichorous fluid, and yet the system will not be affected. The same thing we know happens with the smallpox virus.

Four or five servants were inoculated at a farm contiguous to this place, last summer, with matter just taken from an infected cow. A little inflammation appeared on all their arms, but died away without producing a pustule; yet all these servants caught the disease within a month afterwards from milking the infected cows, and some of them had it severely. At present no other mode than that commonly practiced for inoculating the smallpox has been used for giving the cow-pox; but it is probable this might be varied with advantage. We should imitate the casual communication more clearly were we first, by making the smallest superficial incision or puncture on the skin, to produce a little scab, and then, removing it, to touch the abraded part with the virus. A small portion of a thread imbrued in the virus (as in the old method of inoculating the smallpox) and laid upon the slightly incised skin might probably prove a successful way of giving the disease; or the cutis might be exposed in a minute point by an atom of blistering plaster, and the virus brought in contact with it. In the cases just alluded to, where I did not succeed in giving the disease const.i.tutionally, the experiment was made with matter taken in a purulent state from a pustule on the nipple of a cow.

Is PURE PUS, though contained in a smallpox pustule, ever capable of producing the smallpox perfectly? I suspect it is not. Let us consider that it is always preceded by the limpid fluid, which, in const.i.tutions susceptible of variolous contagion, is always infectious; and though, on opening a pustule, its contents may appear perfectly purulent, yet a given quant.i.ty of the limpid fluid may, at the same time, be blended with it, though it would be imperceptible to the only test of our senses, the eye. The presence, then, of this fluid, or its mechanical diffusion through pus, may at all times render active what is apparently MERE PUS, while its total absence (as in stale pustules) may be attended with the imperfect effects we have seen.

It would be digressing too widely to go far into the doctrine of secretion, but as it will not be quite extraneous, I shall just observe that I consider both the pus and the limpid fluid of the pustule as secretions, but that the organs established by nature to perform the office of secreting these fluids may differ essentially in their mechanical structure. What but a difference in the organization of glandular bodies const.i.tutes the difference in the qualities of the fluids secreted? From some peculiar derangement in the structure or, in other words, some deviation in the natural action of a gland destined to create a mild, innoxious fluid, a poison of the most deadly nature may be created; for example: That gland, which in its sound state secretes pure saliva, may, from being thrown into diseased action, produce a poison of the most destructive quality. Nature appears to have no more difficulty in forming minute glands among the vascular parts of the body than she has in forming blood vessels, and millions of these can be called into existence, when inflammation is excited, in a few hours. [Footnote: Mr. Home, in his excellent dissertation on pus and mucus, justifies this a.s.sertion.]

In the present early stage of the inquiry (for early it certainly must be deemed), before we know for an absolute certainty how soon the virus of the cow-pox may suffer a change in its specific properties, after it has quitted the limpid state it possesses when farming a pustule, it would be prudent for those who have been inoculated with it to submit to variolous inoculation. No injury or inconvenience can accrue from this; and were the same method practiced among those who, from inoculation, have felt the smallpox in an unsatisfactory manner at any period of their lives, it might appear that I had not been too officious in offering a cautionary, hint in recommending a second inoculation with matter in its most perfect state.

And here let me suppose, for argument's sake (not from conviction), that one person in an hundred after having had the cow-pox should be found susceptible of the smallpox, would this invalidate the utility of the practice? For, waiving all other considerations, who will deny that the inoculated smallpox, although abstractedly it may be considered as harmless, does not involve in itself something that in numberless instances proves baneful to the human frame.

That in delicate const.i.tutions it sometimes excites scrofula is a fact that must generally be subscribed to, as it is so obvious to common observation. This consideration is important.

As the effects of the smallpox inoculation on those who have had the cow-pox will be watched with the most scrupulous eye by those who prosecute this inquiry, it may be proper to bring to their recollection some facts relative to the smallpox, which I must consider here as of consequence, but which hitherto seem not to have made a due impression.

It should be remembered that the const.i.tution cannot, by previous infection, be rendered totally unsusceptible of the variolous poison; neither the casual nor the inoculated smallpox, whether it produces the disease in a mild or in a violent way, can perfectly extinguish the susceptibility. The skin, we know, is ever ready to exhibit, though often in a very limited degree, the effects of the poison when inserted there; and how frequently do we see, among nurses, when much exposed to the contagion, eruptions, and these sometimes preceded by sensible illness! yet should any thing like an eruption appear, or the smallest degree of indisposition, upon the insertion of the variolous matter on those who have gone through the cow-pox, my a.s.sertions respecting the peculiarities of the disease might be unjustly discredited.

I know a gentleman who, many years ago, was inoculated for the smallpox, but having no pustules, or scarcely any const.i.tutional affection that was perceptible, he was dissatisfied, and has since been repeatedly inoculated. A vesicle has always been produced in the arm in consequence, with axillary swelling and a slight indisposition; this is by no means a rare occurrence. It is probable that fluid thus excited upon the skin would always produce the smallpox.

On the arm of a person who had gone through the cow-pox many years before I once produced a vesication by the insertion of variolous matter, and, with a little of the fluid, inoculated a young woman who had a mild, but very efficacious, smallpox in consequence, although no const.i.tutional effect was produced on the patient from whom the matter was taken. The following communication from Mr. Fewster affords a still clearer elucidation of this fact. Mr. Fewster says: "On the 3d of April, 1797, I inoculated Master H--, aged fourteen months, for the smallpox. At the usual time he sickened, had a plentiful eruption, particularly on his face, and got well. His nursemaid, aged twenty-four, had many years before gone through the smallpox, in the natural way, which was evident from her being much pitted with it. She had used the child to sleep on her left arm, with her left cheek in contact with his face, and during his inoculation he had mostly slept in that manner. About a week after the child got well she (the nurse) desired me to look at her face, which she said was very painful. There was a plentiful eruption on the left cheek, BUT NOT ON ANY OTHER PART OF THE BODY, which went on to maturation.

"On enquiry I found that three days before the appearance of the eruption she was taken with slight chilly fits, pain in her head and limbs, and some fever. On the appearance of the eruption these pains went off, and now, the second day of the eruption, she complains of a little sore throat. Whether the above symptoms are the effects of the smallpox or a recent cold I do not know.

On the fifth day of the eruption I charged a lancet from two of the pustules, and on the next day I inoculated two children, one two years, the other four months old, with the matter. At the same time I inoculated the mother and eldest sister with variolous matter taken from Master H--. On the fifth day of their inoculation ALL their arms were inflamed alike; and on the eighth day the eldest of those inoculated from the nurse sickened, and the youngest on the eleventh. They had both a plentiful eruption, from which I inoculated several others, who had the disease very favourably. The mother and the other child sickened about the same time, and likewise had a plentiful eruption.

"Soon after, a man in the village sickened with the smallpox and had a confluent kind. To be convinced that the children had had the disease effectually I took them to his house and inoculated them in both arms with matter taken from him, but without effect."