A Treatise upon the Small-Pox/Part 1

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A Treatiſe upon the Small-Pox
by Richard Blackmore
Fleuron page 35 A Treatise upon the Small-Pox.jpg





Part I.

Sect. I.

Of the Nature of the Small-Pox.

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t is universally acknowledged that this great Distemper is to be ranged in the Class of Fevers, and I shall enquire to what Kind or Species it properly belongs.

A Fever is an inordinate Elevation of the oyly or fiery Parts of the Blood, by which the balance of Power between the active and governing Principles being broken, a great Tumult and Disorder arises in the animal Oeconomy, attended with immoderate Heat and Thirst, too high and often too swift a Pulse, Head-ake, and sickness of Stomach, and is either original in the Blood and Humours of the Body, or secondary and derived from some other previous Distemper. Of the first sort are all Fevers call'd acute, produced by the Admission of noxious Matter into the Blood, while the solid Parts are sound and entire: The Secondary are but an Effect or Symptom of some other Disease, of which Kind are hectick, scorbutick, wandring and white Fevers, which proceed from some antecedent Distemper, and that chiefly in one of the Bowels, and these being slow and lingring, and protracted to a considerable space of Time, are therefore called Chronical.

Original or primary Fevers may be justly divided into simple, inflammatory, and malignant; simple Fevers are the Effects of a Disturbance and Breach of the natural Order of the Blood, and a deprav’d Disposition of the animal Spirits, proceeding from an immoderate and irregular Exaltation of the sulphurous or fiery Ingredients in its Composition. Inflammatory are such, as are attended ordinarily with painful Swellings or Eruptions in the solid Parts, when the active Principles of the Blood, by a vigorous Effort, not only resist the Progress of the Fever, but wholly or in part, disengage the Matter of it, and breaking off its Complication force it to lodge in the solid Parts either external or internal. If the Seeds of the Fever, which are cast out in part from the Blood, by reason of their crude and indigested State, are uncapable of breathing through the Pores of the Skin, but are caught and entangled in the small Strainers which they are unapt to pass; this Settlement at first, by the continual Supplies, and Accession of new Forces, is gradually augmented in Breadth and Size. If the Matter of the Disease be lodged on the Joints, accompanied with a threading painful Swelling, it produces an acute Rheumatism; if any where on the Surface of the Body, which happens most frequently in the Face, the Effect is an Erysipelas or St. Anthony's Fire; but if the Matter intercepted in its Passage is stop’d and confin’d in the Glands, and breaks out on the Skin in small Spots at first, which afterwards by Degrees encrease, it lays the Foundation of the Meazles or Small-Pox; and if it appears in a red Eruption, diffus’d in wider Patches on the Skin, it becomes a Scarlet Fever: But if the noxious Matter is discharg’d upon the Muscles of the Throat, it proves a Quinsy, or a painful Swelling of the Tosills; if on the internal Skin of the Chest or Thorax, a Pleurisy; if on the Lungs a Peripneumony; if on the Liver, Kidney, Bladder or Guts, it produces hot painful Swellings, which by Degrees often ulcerate, and sometimes mortify.

The Reason of naming this kind of Fever Inflammatory, is taken from the Custom of Surgeons, who call the Tumours of the Body Inflammations, which accompanied with Redness, Pain, and Heat, proceed by Degrees to Digestion and Maturation: So Boils, Phlegmons, painful scorbutick red Swellings, are term’d Inflammations; and therefore acute Rheumatisms, St. Anthony's Fire, the Meazles, Scarlet Fevers, and the Small-Pox, that are attended with Symptoms of the like Nature, I call Inflammatory; for this Name does not arise from the feverish Disorder of the Blood; which notwithstanding it is excessively hot and boiling, yet it cannot in simple and malignant Fevers be said to be inflam’d; for if any Fever upon that account may be called Inflammatory, then all others likewise may be so denominated, since the Effect of all Sorts of this Disease is excessive Heat; and then the Distinction of Inflammatory Fevers would be unreasonable and impertinent. That Distinction therefore depends not upon the Symptoms which accompany the Fever in the fluid, but in the solid Parts of the Body.

A malignant Fever, the third Species above-mentioned, does not only by the excessive Power and licentious Encroachments of the fiery Particles upon the other Principles, break the Order and Oeconomy of Nature, in which a healthful State or Confutation is founded, but causes likewise that Disunion and Ruin of some Parts of the Blood, in which Corruption, or Putrefaction does consist. And this is the essential Difference, that constitutes and distinguishes this from all Fevers of another Nature and Denomination; and of this I have discoursed at large in a former Writing, where I made an imperfect Division of Fevers, that is only into simple and malignant, which however was sufficient for the Subject I had then in hand. But it must be here observed, that sometimes the inflammatory Fevers are likewise malignant, by the Accession of noxious and putrid Particles, which they meet with in the Blood. And as this is evident in the worst Kind of Small-Pox, so it often falls out in the Meazles, Scarlet Fevers, acute Rheumatisms, and other Distempers of this Nature, which by the Adhæsion of ill-condition’d putrid Matter, become hazardous, and frequently of fatal Consequence.

The Small-Pox, the Subject of this Discourse, belongs to the second Division, which may be thus describ’d. The Small-Pox is an Inflammatory Fever, accompanied by an Eruption or breaking out of small red Spots, like Flea-bites, that by degrees encrease, and ripening like little Boils, grow full of Matter, and at length, but not in less than in ten Days after the first Assault, compleat their Course. The intrinsick Nature and Properties that distinguish and diversify this from other inflammatory Fevers, consist in the peculiar Figure and Size of the Matter of it, that make it uncapable of being disengaged and separated from the Blood by any other Strainers, or by any other Way, than that before described; and therefore the active Principles of the Blood are, by their natural Oeconomy, necessarily determined to take this one Way, of casting off the unsound Parts for the Preservation of the whole. But what that peculiar Figure, Structure, and Disposition are, cannot be discovered by the sharpest Sight; for this, like other intrinsick essential Differences, that constitute any one Sort or Species of Things, and separate and distinguish it from all others, lying not within the Compass of human Understanding, disappoint our most diligent Enquiries, and triumph over the Endeavours of the acutest Philosopher. We must be contented in this, as in all other Diseases, to understand the Cause by the Effect, and essential Principles by their Symptoms, as we know the internal Nature of the Tree by its peculiar Fruits; and therefore I shall enter upon a fuller and more particular Description of the Small-Pox, that I may shew the Properties and Qualities by which it is discriminated from other inflammatory Fevers.

This, like all other Fevers, is introduced into the Body by a cold Fit and Shiverings, or Rigours, which after an Hour or more disappear, and are succeeded by an inordinate Heat, and a disturb’d Pulse, both which are soon accompanied with great Pains, sometimes in the Head, sometimes in the Side, sometimes in the Limbs, but much more frequently in the Back, where often they are very acute and scarce sufferable; attended with great Sickness and violent Vomitings, which so nearly resemble a Fit of the Stone, that sometimes the Physician, imposed upon by the Similitude of Symptoms, has pronounced it to be that grievous Distemper. When the enormous Pain in the Back happens at the beginning, it always presages a mortal or very doubtful Event; for the dangerous Nature of the Small-Pox may be foreseen by the Violence of the Symptoms. By this Account of the first Assault of the Small-Pox, before any Eruption appears upon the Skin, it is evident, that the animal Spirits bear the first Onset, and receive the first Impression of the Enemy’s Force; which is still more manifest, by observing that Lightness of Head, or Suspension of Reason and Reflection, often goes before the breaking out of the Distemper in Spots.

Sect. II.

Of the several Sorts or Species of the Small-Pox.

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HE lowest and most favourable are those of the distinct Sort, which are cast forth upon the Face and Body in broader red Spots, with considerable Spaces between them, and are for that Reason call’d the distinct Sort, to discriminate them from others of a more dangerous Nature, that shall afterwards be accounted for, and not being accompanied with violent Disorders, they make their Appearance most commonly on the fourth Day: And therefore it has been a great Mistake in Judgment, and a pernicious Error in Practice, by warm and cordial Medicines, to hasten and drive out the Small-Pox, and by that Means, to precipitate Nature’s Intentions, and disturb her regular Progress; which Custom too much prevails at this Time among many ignorant and injudicious Persons, especially in the Country, who by giving at the beginning Venice-Treacle, Sack, Mithridate, Saffron, and other Medicines of like active Quality, design to promote their coming forth speedily, by which inconsiderate Conduct, they will not suffer the operative Principles of the Blood to do their Duty in their own orderly Way, but spur them on, and force them to expel the Matter of the Disease before its due Time, and so often make a harmless Distemper dangerous, and a dangerous one fatal. It is certain, that the longer it is before this Disease appears in Spots, the safer and more favourable it proves; for I never saw a Patient miscarry by the coming forth of the Pustules too slowly, though Multitudes have been lost by their coming out too soon. The Reason of the different Event is this; the diseasy Matter being neither of a malignant Quality, nor in great Quantity, the active Principles of the Blood are not provok’d and excited to throw it off immediately, for fear of being oppressed by it, and therefore have Time and Room to labour, prepare, and qualify it for a due Separation and Expulsion. And Nature generally finishes this Stage in the Space of four Days, as I have said before, by which Time it has subdued and conceded the crude Seeds of the Distemper, and made them fit to be separated from the Blood by the Strainers of the Skin, where they are compelled to stay and slick fast, not being able to pass through the Pores, by Reason of their improper and unequal Size and Figure. The Matter of the Disease being thus intercepted and entangled in the outward Glands, usually appears first in the Face, the Lips, Neck, and Breast, in small red Spots of the broadest Kind in this Distemper, which rise above the Surface of the Body, and gradually encrease in Bulk, by the constant Accession of new Matter prepared by the Blood, and excluded thence to their new Settlement in the Glands of the Skin; so that by fresh Supplies, continually poured on and determined to the Places where the first Matter was lodg’d, the little red Spots swell to minute Boils, and like them are painful and inflammatory, and gradually proceed to a mature or ripe State. There is therefore no Reason that can support the Distinction, which Surgeons lay down between Swellings or Tumours by Congestion, and others to which they give different Names; for all are caus’d by Congestion, that is, the Accumulation or heaping on of fresh Matter, whether that Matter be deriv’d and communicated gradually from the Blood or from the Nerves, whether they arise to a Maturity in a shorter or longer space of Time, and whether accompanied with a Fever or not; for all acquire their Growth and Augmentation, whether by a swift or slow Progress, from the continual access and flowing of new Particles on the obstructed Places, where the Matter of the Swelling was at first laid down: Those indeed, that at first arise and are after fed from the Blood, arrive sooner at their Maturity, than those that receive their Supplies and Reinforcement from the Nerves, and which are very slowly, if at all, ripen’d; but in the manner of their Generation and Increase, there is no Difference, all being form’d by Congestion, that is, the gradual Addition or Afflux of new Matter, from what Sources soever it is deriv’d.

In a short Time after the Appearance of this milder Kind of the Small-Pox, of which we are discoursing, the previous Symptoms are in a great Measure mitigated, that is, the Pains in the outward Parts; Headach, Thirst, labouring Pulse, and disturb’d Imagination or Delirium: 'Tis observable, that in Children convulsive Motions, a harmless Symptom, often usher in the Eruption of this Distemper, which confirms what I have before asserted, that the Nerves and animal Spirits are first affected by this Disease; and when the Matter or Principles of it are cast off from the Nerves into the Blood, and are thence after a due Preparation and Digestion thrown out into the Surface of the Body, the Symptoms which before that Time afflicted the Patient in a very great Degree, are removed. Things now having taken another Turn, the Fever is greatly abated, and the Blood and Spirits restored almost to a State of Quiet and Tranquillity; and now Nature as fast as it has concocted and dispos’d the noxious Parts for Exclusion, drives them out to feed the Seeds of the little Swellings or Ulcers, till at length it has entirely freed the Blood, and produced a compleat Harvest, which it usually accomplishes in three Days.

And now the noxious Matter being subdued and entirely expelled from the Blood, Nature, as said, is more at ease, and seems to revive and triumph, as conscious of its own superiour Strength, and the Weakness of its Enemy, which clearly presages a happy Event. During this Stage of the Disease, while all Things are in a greater Quiet and Repose, the Small-Pox being constantly recruited by new Supplies from the Blood, swell to a larger Size, if compared with that of the worst Sort, and continue red and separated from each other by intervening Spaces: But after three Days, which forms the second Stage from their Invasion, or the first from the Eruption; on the eighth Day begins the third, when the small Swellings or Boils begin to acquire a State of Maturity, which appears by their whitening Heads, the Mark of Suppuration; and at this Time the Patient undergoes much Pain: for the greatest Part of these little Boils, as well as the Skin about them, continuing red, fiery, and crude, an extraordinary Effort of the active Principles of the Blood is required to digest them; for as Nature in the first Stage of this Disease, by exerting her Force and Vigour to concoct in some Measure, and dispose the putrid Particles for Separation, was during that Labour and Conflict in a feverish State; so now, when she undertakes to ripen and digest entirely these numerous little Boils, her Attempt must be accompanied with the like feverish Symptoms, which arise from her Strife and Contest with the Matter as yet crude and not mastered by Suppuration; and if the ripening of one common Boil demands so great a feverish Ferment, it is no Wonder that such a mighty Number, though of small ones, dispersed over the whole Body, should be attended with so much Heat, when they grow to Maturity.

This is called the Fever of Maturation, or the second Fever. It must however be acknowledged, that there is but one and the same continued Fever from the Beginning, though under various Appearances of Heat, sometimes greater, sometimes more moderate, according to the several Stages of the Distemper, and the different Exigencies of Nature. The Small-Pox is allowed to be a Fever; and if that which accompanies their first breaking out, is a distinct Fever, as some have asserted, from that, which attends the ripening of them, then it is manifest, that every Small-Pox is two Diseases, which would be a very harsh and absurd Position. If a Fever, that is simple and not putrid at the Beginning, should by irregular Conduct, or by its own intrinsick Nature, after a considerable Time, degenerate into one that is Malignant, which often happens, attended with the worst Symptoms, could the different States or Stages of this one, be reckoned so many distinct Fevers?

It is the constant Property of this mildest Sort of Small-Pox, that the Pustules or Boils continue distinct and separate on the Face and Body, till their whole Course is compleated; and in some Cases they are very few, and large, not perhaps more than eighty or a hundred in all, and sometimes not so many; and they of this kindly Sort are generally judged fully ripened by the tenth Day from the first Illness, or the sixth from their first Appearance; the eleventh Day therefore is not justly fixed for the Completion of all of this Kind, as the eighth Day from the first Attack is not truly assigned as their most dangerous Season. By the continuing of this Sort so long, they are distinguished from the Chicken or Swine Pox, which as they are larger, and often full of Water, so they disappear before the eighth Day, though in that Space they sometimes stay long enough to leave Impressions or Prints in the Skin; and by this it may be known, that is, by their Continuance till the tenth Day, whether the Eruptions or Pustules were truly the Small-Pox or no.

But there are yet higher Degrees of the distinct Kind, of which the highest of all produces such a Number of Pustules or little Boils, that when they are ripe and full of Matter, they almost flow together, and become the Flux Kind; and this Sort proves sometimes fatal, by the great Quantity to be cast forth and digested, as well as by the ill Quality of the Matter, approaching too near to Malignancy.

As Nature begins with low and mean Productions, and arises by several Steps and various Degrees to Beings of the greatest Perfection, which Degrees are diversified by such nice Limitations, that it is difficult to determine where one Kind ends, and another begins; so she proceeds in like Manner, in the Unravelling and Dissolution of the Bodies of Men by Distempers and Diseases, which is not more remarkable in any Instance, than in this of the Small-Pox. The first Sort which I have mentioned is called Distinct; but even in this are found many different Steps or Gradations, as I have suggested above; before you arrive at the worst of this Sort, some consisting of very few Pustules, some of more, and that in various Degrees till you come to the highest; and when you are gotten thither, you do not presently step into the Confluent or Flux Kind, as some have asserted, who make but two Sorts of Small-Pox, the Distinct, and Confluent. For Nature, according to her Custom, does not proceed so fast and hasty; but before it arises to the Confluent Species, it produces a middle Sort between both, that is, when in some parts of the Face and Body the Pustules are Distinct, and in others Confluent; and sometimes it happens that while all in the Face are Distinct, many in the Body shall flow together in Patches, like a redish scorbutick Tetter. If these confluent Patches appear at the Beginning, it is an Argument of an ill-conditioned Distemper, but if they run together and break in upon one another only at the latter End, when the Boils ripen, swell, and want room to spread themselves, then their Nature is more favourable, and the Danger less; and therefore it is from Inadvertence and Want of Attention, that those Physicians, who have wrote the History of the Small-Pox, have not taken Notice of this middle Sort as a different Kind from the other two, having the same Grounds and Reasons for doing so, as they have to make a Division between the Distinct and Confluent Species.

As a simple continued Fever consists in the irregular Disposition, and shattered Frame of the Blood, while the sulphurous Particles are exalted to an excessive Power, and an unnatural Dominion over the rest, and so have ruffled and disordered the Mass, which however suffers not any Degree of Putrefaction, that is, any minute Division of its Parts, that destroy their Coherence with each other, and their Union with the whole; so in the distinct Kind of the Small-Pox the Blood is in the like irregular State, but yet free from the Corruption before described: But in the middle Sort, which is partly distinct and partly flowing together, there is a considerable Degree of the Putrefaction which I have mentioned before, and have more fully explained in my Discourse of the Plague and malignant Fevers; yet it must be acknowledged, that sometimes, though very rarely, it happens, as I have seen, that great Putrefaction accompanies even the distinct Sort, which shews it self sometimes in scarlet, and sometimes in blue Spots, dispersed over the Body in great Numbers; and then the Distemper, though it appears favourable in Respect of the Distinction of the Pustules, yet by Reason of the Malignancy and Corruption discovered by the other Marks, it is no less fatal, than the worst of the confluent Kind; and had not those malignant Particles, by some extraordinary Way been separated from the Matter of the Pustules, no doubt the Distemper had been of the worst confluent Sort.

I shall here make only this farther Remark, that in the mildest Sort of the distinct Species there is not any Danger, and the worst of the Confluent are as much incurable, as the Plague it self; and therefore as the first does not require the Attendance of the Physician and the Use of Medicines; so in the last they are unequal to the Disease, and altogether insignificant; whence it follows that the only Province in which the Physician is useful, must be the intermediate Degrees, that is, the most favourable Sort of the confluent Kind, that of a middle Nature, and that of the worst of the distinct Sort.

By orderly Steps we are now advanced to the confluent Species of the Small-Pox, that is, when the Eruptions or Pustules, that appear upon the Skin, break their Partitions and run into one another; this Conjunction often happens in the Face, while the Pustules in the Body are separate and disjoyned, and therefore they are denominated Confluent from the Face only, which is chiefly affected by this Disease: For if in several Parts of the Body many Pustules flow into one, while in the Face they are parted and divided, this is not the Confluent, but the middle Kind; and on the other Hand, if the Pimples run together in the Face, though they are ever so distinct in the Limbs and the Body, this is reckoned in the Class of the Confluent: And in this Kind also are found many Gradations, before we ascend to the most terrible and malignant of all. The least dangerous Sort of these is when the Eruptions appear on the third Day after the first Illness; for the longer they stay before they break out, as I have observed before, the milder and safer they are; for then Nature is allowed longer Time to digest the noxious Matter, and dispose it for Exclusion; whereas it is an Argument of the highest Putrefaction, when Nature, that is the active Principles of the Blood, are forced to attempt a too hasty Separation or Expulsion of the Matter as yet crude and unconcocted, to ease her self of the vast Oppression of the poisonous Ferment, under which she is ready to lye down and dye. Thus the mildest Sort of the Confluent, that approach the nearest in Nature to the distinct Sort, come nearest to them likewise in the Time of their Eruption, which is in the fourth Day after the first Attack, as in this Sort on the third.

The Symptoms, that attend the confluent Kind of all Sorts are as before enumerated, but in an higher Degree, cold Shiverings or Rigours, great Pains commonly in the Back, sometimes in the Side or Limbs, an inordinate, labouring, and swift Pulse, Sickness in the Stomach, Vomitings and Strainings to vomit, Thirst, Aching and Lightness of Head, excessive Heat, Oppression of Spirits, and great Inquietude, till the Time of their Appearance. If this happens on the first Day, the Case is deplorable, and eludes all the Art and Care of the Physician; and that Sort is likewise very dangerous, which breaks out on the second Day after the first Seizure; for herethe Matter of the Pustules being expelled to the Skin, before sufficient Time is allowed for their Digestion, rarely proceed in a regular Manner to a safe Maturity, but continue crude and unconcocted so long, that it protracts the Fever, and extinguishes the Spirits by its malignant Quality, till exhausted Nature is at length subdued and yields to the Enemy. Tho’ this fatal Event sometimes happens on the seventh or eighth Day, where the Putrefaction is found in a very high Degree, and next to pestilential; yet most commonly the Distemper is prolong’d to the eleventh, and often to the thirteenth, seventeenth, twenty first, and twenty fifth Day, and sometimes yet farther, so that the eleventh is not the decisive Time in this worst Sort.

The Fever in this Species that accompanied the Eruption of the Pustules, and was necessary for that Purpose, is not reduced and mitigated to that Degree, as it is after the breaking out of the Matter in the Distinct Kind, but continues, tho' with Abatement of Symptoms, in a considerable Degree thro' all the Stages of the Distemper; which confirms what I asserted before, that there is no first and second Fever in the Small-Pox, but it is one and the same from the Beginning to the End, and only varied in the different Stages of the Disease, as it is accompanied with greater or less Symptoms; and in their State of Maturation the Fever is more painful and intense in finishing the Small-Pox, as it happens in the Ripening of all inflammatory Tumours; but therefore must not be called a second, that is, another Disease.

It must be here observ'd that tho' the Confluence of the Pustules in the whole Face or at least the greatest Part of it, diversifies this from the distinct Kind; yet the chief Difference lyes in the intrinsick Nature of it, which consists in its malignant Property; for in the mild Sort there is no Putrefaction or destructive Separation of the Parts of the Blood, but only a Violation and Discomposure of their natural and healthful Order and Disposition, while their Connexion is not ruin'd and destroy'd, but is still preserved, though weakened, and and continued under the Animal Oeconomy; but in the Confluent Small-Pox it is a great deal worse, for in this Case many Parts of the Blood undergo such a Solution and Division, that the natural Structure is not only impair'd but in a great Measure broken, and many of the integral Parts are so far separated and putrefied, as to be cast out of the Animal Government, and are so corrupt and lifeless that they cannot be restored to their former Station and Union with the Blood, but must be digested and expelled into the Skin by the sound and active Principles, or Nature must be overcome and fall in the Combat; and this I call a State of Mortification in the Blood. And it is to be observed, that in the worst Kind of Small-Pox, as in the Plague and high malignant Fevers, the Patients feel little Pain or Sickness, and are insensible of their Danger, and wonder when they are told they have so short a time to live; which is the Case of those that die of Gangreens or Mortifications in the solid Parts, either external or internal; for when the Mortification begins, the Pain ceases, and the Patient is actually dying, when on a Sudden he is at Ease, and looks upon himself as in a better Way of Recovery. It is remarkable, that when a Toe or Finger, especially of Persons advanc'd in Years, mortifies from an inward Cause; tho' the Surgeon takes them off, yet the Parts next above, from which they are severed, will soon undergo the same Fate, and so on; the Reason is because the cutting off the Member could not free the Blood from the putrefied Parts, that fed the Gangreen, and therefore it still continues to discharge and lay down in some other Place the corrupt Materials, till it has destroyed the Fabrick. This Observation makes it evident that corrupt and lifeless Particles may be contain'd in the Mass of Blood; which I therefore call a State of Putrefaction or Mortification, as said before; for as I have elsewhere asserted this Notion, so I still believe it is just and well founded upon Reason and Experience.

The Confluent Kind then are diversified from the Distinct externally by the running together of the Pustules and copious Spitting or Salivation at the eighth or ninth Day, and internally by the Corruption of some Parts of the Blood, which in the last Sort is unbroken and entire, tho' flutter'd and disorder'd in its Texture and Symmetry. There are also various Steps and Gradations to be observ'd in this Species of the Small-Pox arising from the different Degrees of Putrefaction, which constitutes this Kind; the lowest and most favourable come out on the third Day distinct at first, and almost as large, as the Sort of that Denomination, but after some Time they run together, when in their Growth they swell, and by enlarging their Borders, they break the thin Fences that separate them from one another, and shew themselves to be of the Confluent Sort. In this Species the Pustules are often more elevated and bold, and being constituted of less noxious or malignant Matter, they are not accompanied with violent or threatning Symptoms, and they generally compleat their Course with good Success, which most commonly is done on the eleventh Night after the first Attack, when many likewise expire; that Period of Time then is only properly assigned as commonly decisive in the lowest Degree of the Confluent Sort.

The next Gradation in the Confluent Kind is, when the Eruptions are smaller and more numerous, which proceed from higher Degrees of Corruption; that is, when many more Ingredients of the Blood are divided and ruin'd than in the former Degree. In this Case the Pustules are so small, so many, and so contiguous, that they soon flow together, and in a shorter Time than the former; and this is the Sort that is indeed dangerous to the Patient, and most tries the Skill and Judgment of the Physician; for now there appears a great Variety of grievous and formidable Symptoms, violent Vomitings, great Head-achs, Delirium or Suspension of Reason, obstinate Wakefulness, excessive Heat, great Inquietudes, and often laborious and short Breathing. The ninth Day from the first Invasion the Pustules rise higher, and the Face swells and grows redder, the Fever that continued all along, is now augmented, and without Reason, as I have said, is called the second Fever, it being the same with the first, only higher rais'd. The Pustules usually in their State of Maturation swell the Face very much, and turn by degrees to a dark brown Crust or general Scab, which often continues undigested and unseparated from the Skin many Days: So that in this Case, which is the chief Province of a Physician, it is an Error to assign the eleventh Day as decisive of the Event; for it often happens that this is not the determining Period in this Kind of Small-Pox; for all Practisers must know that the Small-Pox of this Sort are most frequently carried on beyond those Limits for many Days; and after the Face is altogether, or almost, clear'd of the Pustules, the Fever will often survive and maintain its Ground a great deal longer,, and till that be reduc'd, and the Pulse restor'd to their natural Standard, the Distemper cannot be looked upon as judg'd and concluded; for after the eleventh Day the Fever proves often fatal, sometimes by terminating in Convulsions, sometimes in a hectical and consumptive Wasting; and it is absurd to say, that the Patients in such Cases did indeed escape the Small-Pox, but dyed of Convulsions, or, a Consumption, after they were recover'd from the other Disease whence those Symptoms proceeded.

Sometimes the Confluent Crust, or general Scab on the Face is of a dull, leaden Colour, which it acquires from the great Crudity and ill Condition of the Matter, of which they are form'd; and I have known that the Confluent Pustules of this Aspect have continued on the Face more than three Weeks, before they have been fully digested and separated from the Skin.

Sometimes on the ninth, tenth, and eleventh Day, during the Maturation, the Face, from the Colour of the digested Matter, beneath the Skin, grows pale, and sometimes white as a Sheet, with little Swelling or Elevation of the Cheeks, Lips or Nose, which is a Case always very dangerous, and most commonly fatal; tho' I acknowledge I have seen some escape in a very wonderful Manner, when not only the Face has had this Aspect, but even the Arms and Wrists have turned white by the purulent Matter, and the Confluence has been so great, that the concocted Contents have hung down in Bags like Bladders rais'd by Blistering Plaisters, which Bags being cut to discharge their purulent Matter, the Muscles were left all raw and uncover'd: But it sometimes happens that there is little or no Protuberance, or Swelling of the Confluent Eruptions, but the Face lyes flat and equal, while the minute, and scarce distinguishable Pustules growing dry only turn the Skin into the Likeness of an old Piece of Parchment, or dull Russian Leather, and even then the Patient has sometimes recover'd.

Another important Discriminating Property of this Kind of Small-Pox is the Spitting or Salivation that Nature raises usually about the eighth or ninth Day from the first Invasion, and this is so constant and so necessary, that it seems equally required for the Recovery of the Patient with the ripening of the Eruptions it self; and this Evacuation by the Glands of the Mouth is more or less copious, and continues a less or greater Space of Time, according to the different Degrees of Putrefaction in the Blood, a considerable Part of which is destin'd to be excluded by these Sluices; for tho' the greatest Portion of the corrupt or mortified Particles of the Blood and Humours are expelled by the sound and active Principles into the external Parts of the Body, yet a great Quantity of it, which is not by Reason of its disproportion'd Bulk and Figure capable of being determined and transmitted to the Surface of the Body, is drain'd through the Salival Glands, and carried off by copious Spittings; as Nature as well as Art in some other Cases discharges the noxious Humours that cause Distempers by a Flux of Humours issuing from the Glands of the Guts; so by this inverted Purgation, performed by the Strainers of the Mouth, the Blood is freed in a great Measure from the Matter of the Disease mingled and diluted with the ejected Serum. This Evacuation, I have said, begins usually about the eighth Day, and continues according as the Exigencies of Nature require, that is, till that Part of the purulent Matter which is communicated to it, is discharged: But sometimes this Province of Salivation is executed in an irregular Manner both in respect of its Rise and Appearance, and also of its Continuance; for sometimes the Salivation is suspended, even till the Scabs on the Face are dry, and sometimes longer. I remember an extraordinary Case of a Lady, that had no Spitting till the fourteenth Day, and till she was recovered and sat up, and then the Salivation began and continued about a Week; and I have observed likewise, this Salivation in some others, that appeared at its usual Season, has after the fourteenth Day been greatly augmented, and continued many Days.

The Swelling of the Face, which usually begins on the eighth Day in the distinct Kind, happens most commonly on the ninth in this Sort; and the greater the Swelling is, the greater Prospect there is of the Patient’s Recovery. This Swelling arises from the inflammatory little Tumours that flow together: It is the Nature of all Inflammations, to cause Prominence in the Parts affected: A Boil, a Phlegmon, an Erysipelas, or St. Anthony's Fire, Anginas, Rheumatisms, or scorbutick Inflammations, are all accompanied with Swellings in the Places where they happen; which Tension, that is, the Stretching of the Fibres beyond their Staple, creates Pain; and the Swelling is produced by an afflux of Humours to the Part, from the Vellication of the Muscles, or Tendons, by the sharp and crude Matter of the Distemper; and the immoderate Heat is occasioned in the solid Parts affected, as it is in the fluid; for as an unnatural feverish Heat is raised by the Conflict in the Blood, while the active Principles labour to digest, and exclude from the Mass, the degenerate and corrupt: So in the solid Parts there follows excessive Heat, as well as Pain, while those sound and active Parts strive to concoct, and bring the Matter of the Distemper to Maturity and Suppuration; and when this is compleated, the Heat in the inflamed Member, and the Fever in the Blood, quickly disappear. It is not only the Face that swells and continues so, till the Suppuration is compleated, but wherever the inflammatory Pustules are Confluent, they swell the Part in the fame Manner, and for the same Reason, as they do in the Face: This happens in the Hands, and Feet, and other Members, whenever the Quantity of the Pustules is very great, and their Quality malignant. The Hands begin to rife, when the Swelling in the Face begins to subside, which usually happens on the eleventh Day; for the Pustules in the Body, the Hands, and Feet, coming out about thirty Hours after those of the Face, they are in Proportion, as slow before they reach Maturity. An eminent Physician, that has deserved well of the Profession, by his History of the Small-Pox, and his Method of Cure; though as all human Works are, it is imperfect; observing, that as the Swelling in the Face abated, that in the Hands began; imagined that the Matter which caused the first, was in some Measure translated to the last, and so was the Cause of it; and this Opinion has generally obtained among the Gentlemen of the Faculty. But this I look upon to be a great Mistake; for though the Swelling of the Hands immediately follow the sinking of the Face, yet it follows not as an Effect from a Cause, but as a Consequent succeeds an Antecedent; for that Swelling necessarily arises from the inflammatory Pustules in the Hands themselves, which at that Time come to Suppuration, as those in the Face swelled by their own Heat thirty Hours before, and not from any Matter communicated to it from the Face: For when the Digestion is fully, or almost compleated, and the Inflammation ceases, the Swelling does of Course subside; as it plainly does in all Kinds of inflammatory Cases whatsoever, that come to Suppuration; as in Boils, Phlegmons, scorbutick Tumours, &c. and when the Feet swell, as they often do, if the Number of the Pustules is great by the Anguish and Pain affecting the Fibres, this Symptom does not proceed from the Matter translated from the Face, or Hands, to the Feet, but from the Suppuration of their own Pustules, as the Face and Hands swell by the ripening of theirs; If a Boil is digested and ripened in the Arm, and another, that rose two Days after in the Thigh, begins at this Time to swell to a greater Degree by the Pain and Suffering in the Maturation; will it not be absurd to say that the Matter which caused the Swelling of the first, even after it is concocted and ripened, is translated to the last? And the like may be argued from other inflammatory Tumours, that should in Time succeed one another.

And as there is no Need to fetch any noxious Humours from the Face, to furnish out Materials for the Tension of the Hands, the Heat and Anguish of their own Pustules being abundantly sufficient for that Purpose, as well as those in the Face were able to cause the Protuberance or Elevation there, so no Manner of Conveyance, no Road or Passage, can be accounted for to favour this Supposition: For the Matter must of Necessity retreat from the Cheeks into the Blood, and then the Consequence will be, that the Blood must suffer a new feverish Conflict, while Nature struggles with these returning malignant Particles, and exerts its Force to exclude and send them to the Skin, which Event however does never happen, for the Fever at this Time is generally abated: And why should the Blood expell it, to augment and raise the Pustules in the Hands, rather than those in the Breast, or any other Part of the Body? But to put it out of Doubt, that Confluent Pustules may swell and ripen of themselves, without any Communication of Materials from the Face; I have known in the middle Kind of Small-Pox, which I have described before, that the Pustules in the Face have continued all Distinct, through their whole Course, with little or no rising; and at the same Time one of the Arms, on the Outside from the Shoulder almost to the Elbow, was covered with an infinite Number of small Pustules with the least Space imaginable intervening, which soon flowed together, and the Arm swelled in the usual Time, like the Face in the Confluent Sort; and other such Instances I have seen in those of the middle Kind, and no doubt other Physicians have observed the like. I conclude, that all the Pustules in whatsoever part they arise, whether they continue separate, or run into one Surface, rise, grow, ripen, and acquire Suppuration by their own native Heat and Activity, and swell, and are digested independently on one another, and without the Translation of any Matter, from those of one part of the Body to those of another.

But to return to the History of the lowest Degree of the Confluent Kind, where many Patients escape, and many miscarry; Besides the sad Train of Symptoms, which I have described before, that attend this Sort; there is another more grievous, that is sometimes added to this formidable Retinue, that is, scarlet, bluish, or purple Spots, sometimes in a small Number, which often disappear before the Maturation of the Eruptions, and then the Patient sometimes escapes; but if those Spots are numerous and of a deep Colour, as in spotted Fevers, they are usually fatal, and therefore I reckoned them among Symptoms of the most dangerous Nature.

The highest Kind of the Small-Pox, are those that appear on the Skin the first Day of the Attack, and the next in Malignancy are those that break out the Day following; the Symptoms peculiar to this dangerous and usually mortal Species, is a violent and unsufferable Pain most commonly in the Back, with grievous Vomiting, by which it imitates a sharp Fit of the Stone, and has sometimes imposed upon the Physician, as well as the Standers by, and made them conclude it was that Distemper: But sometimes this previous acute Pain is felt in the Side, and sometimes in the Limbs. Another discriminating Property in this Case, is the vast Number and minute Size of the Pustules, that are scarcely elevated above the Skin, and being continued and united for the most part, especially on the Breast, form the Appearance of a scarlet Fever, or St. Anthony's Fire, such is their redness and unequal rough Surface, like that of the Seal's Skin; and this Sort has often been mistaken by inattentive and undistinguishing Practisers, for the Meazles, the ranker Sort of which are more protuberant, or rise higher than this Kind of Small-Pox; this Profusion and enormous Quantity of Pustules, so small, that their inequality or unevenness is scarce perceptible, overspreading almost the whole Body, especially the Breast, as well as the Face, may at first Sight be pronounced fatal; their Nature being so malignant, and their Number so immense, that it is not possible for the active Principles to digest and bring them to Maturity, especially if at the same Time a Multitude of scarlet or livid Spots are interspersed and scattered over the Skin, particularly in the Neck and Breast, for this shews the Putrefaction to be in a very high Degree. This Symptom therefore presages the greatest Danger, for notwithstanding, as I have said, a few such Spots are sometimes consistent with Recovery, as well in the Small-Pox, as malignant Fevers; yet when they appear in great Numbers, they discover such a degenerate State of the Blood, as cannot be repaired by Nature, though assisted by the greatest Art. Another Symptom belonging to this Kind, is a Discharge of Blood by Urine, and sometimes by other Sluices, as by the Seat, by the Mouth, and by the Eyes; but as to bleeding at the Nose, it is sometimes very useful by preventing or abating the feverish Heat, and never so dangerous, as such Evacuations from other Parts, which is an Argument that the Frame and Contexture of the Blood is not only shaken and disordered, but dissolved and broken into minute Atoms; and being thus severed, and its Continuity ruined, it is ready to issue through the Glands, and pass thro’ any Strainers of the Body without Opposition, especially those of the Kidneys; and this is a Discovery of the greatest Putrefaction, or a state of Mortification in a great part of the Blood; and therefore the Small-Pox, as well as malignant Fevers, attended with such a Discharge, is generally incurable. It is true, if this Symptom happens at the Entrance of this Distemper, and that in a moderate Degree, it will sometimes gradually abate before the Time of the Suppuration, and the Patient may recover; and the same may be said of black or dark coloured Urine: This very ill Sort, from which some few however make their Escape, come forth upon the Skin on the second Day; but of those on whom the Pustules appear the same Day, that the Illness begins, I do not believe, as I have said, that any recover.

I have now done with accounting for the several Species of Small-Pox, but I must yet add one Sort, according to the Opinion of some, which is indeed very wonderful; and that is a Kind, which is not accompanied by any Spots, Pustules, or Eruptions whatsoever; when the wise Doctor tells the good People that it is the Small-Pox within, and would have appeared outwardly, if Nature had been strong enough to have thrown out the Matter; but she being defective and unequal to the Task, the Small-Pox without appearing destroys the Patient in a very clandestine Manner. This is certainly very surprising; for here is a Disease without Symptoms, which is somewhat extraordinary: The Doctor fancies it had a great Mind to have been the Small-Pox, but being disappointed of that Intention it kill’d the Patient in such a malicious and secret Way as no Body knew what did hurt him: But can any Man know this would have been the Small-Pox? why might it not more probably have been a very malignant Fever, that took off the Patient in so few Days? Besides, if it be considered, that Nature pushes out the word and most fatal Sort of Small-Pox in Spots or Pustules, even on the first or second Day; so hasty is she to expel the malignant and pernicious Matter; and why should it have such Patience as to linger three or four Days without casting out in Spots this pretended unappearing Small-Pox is unaccountable. Let this be tried in parallel Cases; how odly would it sound to say that a Patient died of a St. Anthony's Fire, that never scorched, or so much as appeared on any Member of the Body, or that he had a Boil, or Phlegmon, or a Scorbutick Inflammation, that never redened, swelled or pained any Part whatsoever, or a Cutaneous Disease, by which however the Skin was never in the least affected? Having now given an Account of the Nature of the Small-Pox and its proper Characters, and divided it into its several Species, and laid down the peculiar Properties, that discriminate and distinguish one Sort from another; I come to discourse upon the most proper and effectual Method of Cure in this great Distemper.

Sect. III.

Of the Method of Cure.

Capital I page 70 A Treatise upon the Small-Pox.jpg
N the most favourable Sort of the Distinct Small-Pox, which are few in Number and mild in Quality, Nature her self, as I have before observed, is able to cure the Distemper, and needs not call the Physician in Aid; as on the other Hand the most Malignant Confluent Kind will hear no Reason, but puts all Methods and Medicines out of Countenance; and in these deplorable Instances the Physician will shew his Judgment and Honesty by declaring that the Case is above the Reach of Skill and Remedies, and inconsistent with Hopes of Recovery, which is more fair and honourable than for the securing of his Reputation and keeping up an Opinion of his Skill and judgment, to act a double Part by telling the Patient, and a few Friends within Doors, that he will certainly live, and all without Doors, that he will certainly die. It is then in the intermediate Degrees that the Doctor’s Province lyes, and in those dubious, and sometimes very difficult Cases, by a skilful and judicious Conduct, he may be very beneficial to Mankind, whilst many Times he relieves the Patient by a proper and skilful Method, who would have perished, if left alone to assisted Nature, to an ignorant and injudicious Practiser, and much more to the Care and Wisdom of a confident Nurse, often more destructive than the Disease it self; for Nature has many Ways to struggle and shift for Life, would these rash or weak Pretenders to Knowledge stand by, and let her have fair Play.

When any Person is attacked with the Symptoms that usually precede the Small-Pox, viz. a great Heat, a swift and labouring Pulse, Pains in the Back, Vomiting, Sickness, and Head-ach, it is advisable he should be let Blood to ten or twelve Ounces, or more, if the Pulse are strong and the Patient young, and of a vigorous and florid Constitution: a gentle Vomit, and a lenitive Glyster are likewise very proper, if there is Room and Time to administer these Remedies.

If it proves the severest Kind of the Distinct Small-Pox, where, tho' the Pustules continue separate, they are however very numerous, and therefore require great Labour from the active Principles to digest and bring them to Perfection, which must be attended with great Heat, especially when they come to Suppuration, the greatest Danger will be left the Patient should be overset by the prevailing Fever; and therefore all proper Means should be used to guard against it, and for this End the cold Regimen is here to be preferred before Cordials and Alexipharmack Remedies.

When proper Evacuations previous to the Eruption have been prescrib'd, there is little to be done for four Days after it; for the Fever, during that Time, is most commonly mitigated, and the Heat suspended till about the eighth Day, when the Maturation beginning the Fever rises to a higher Degree, and then in this last Stage of the worst Distinct Sort, cooling and diluting Means and Medicines, such as Juices of Lemons and Oranges, Spirit of Vitriol, in common Drink, ought to be administred more plentifully to suppress and reduce the excessive Heat, or, at least, to prevent the Growth of it: And in this Season likewise quieting Remedies, of which Diacodium, or Syrup de Meconio, are found to be the most friendly and successful, may be given in a greater Degree, or more frequently, especially at the Time of their Turning, when Nature is at her greatest Plunge, and obliged to exert her utmost Vigour for making a decisive Effort; at this Time an Ounce of the Syrup before mentioned given early in the Evening, and repeated six Hours after, will be proper and beneficial; and if five or six Drops of Spirit of Vitriol be added to it, it will yet be more advantageous, since those Drops will make it more effectual for abating the immoderate Heat, as well as render it more agreeable to the Stomach.

During this Stage, when the Small-Pox are coming out, or only riling and enlarging their Bulk, Medicines of no Kind are demanded, and Cordials are forbidden for fear of inflaming the Blood, and agitating the Spirits, and so disposing them to a severe and dangerous Fever, while the Pustules are in ripening: But in this calmer Season, when the violent Symptoms, which usher in the Eruptions, are removed, and those that are concomitant to the Digestion or Suppuration do not yet appear. Nature is to be trusted with doing her own Work, and the Blood is only to be attempered and diluted with cooling Liquors to prevent excessive Heat: But if obstinate Wakefulness should afflict the Patient, an Ounce of Diacodium should be given at Night, and repeated if there be a Demand for it; and if a Looseness happens ten drops of Liquid Laudanum, or a spoonful of Diacodium should be given in any convenient Liquor after every such Evacuation. When the Heads of the Pustules begin to whiten, and fill with the digested Matter, and the Heat grows more intense, then an Ounce of Diacodium, with five Drops of the Spirit of Vitriol, and two Ounces of Barly Cinnamon Water, will make a proper Draught to be administred every Night. The Juices, mentioned before, of Oranges and Lemons should be squeezed into all the Patients Drink, and sometimes Spirit of Vitriol, to the Quantity of five or six Drops should be given in the same Manner interchangeably with those acid Juices. If at the latter End the Patient should be dispirited, and the Pulse gow weak and depressed, which however seldom happens, then moderate Cordials are demanded, and will be very useful, such as Diascordium, Confection of Allkermes, Contrayerva-Stone, Gascoign’s Powder, &c. to the Quantity of half a Dram, which should be repeated as the Exigencies of the Patient require. It is true, that those Medicines only have hitherto been accounted Cordials, that being of a warm and generous Nature, revive the fainting and languid Spirits, but if it be considered, that when the Oppression and Disorder of the Spirits proceeds from a high and swift Motion and excessive Heat of the Blood, those Remedies also may be truly stiled Cordials, that by reducing the exorbitant Heat, and bridling the Celerity of the Pulse, bring them down to their due and healthful Standard, as well as those that raise them when they are too weak and much below that regular State; for these Remedies do as much relieve Nature when it deviates from its due Proportion of Heat and Motion, by being rais’d too high, as the warm and active ones succour and befriend it, when it is beaten down, and the Heat and Motion are below Standard; and therefore the cooling and diluting Means, that restrain the Effervescence of the Blood, and the Fury of the Fever, are as truly cordial and as much Friends to Nature in this Situation, as on the other Hand generous and Alexipharmack Remedies can be by railing and inlivening inlivening the Spirits, when they are in an opposite languishing State; and therefore the warm and cool Medicines are equally Cordials, that is they succour Nature alike in different Exigencies.

As to the Method of Cure in the Confluent Kind, it has been of late Years much disputed whether the cold or hot Regimen, as they are called, is the most proper and beneficial. It is true, that our most celebrated Physicians before Dr. Sydenham universally declared for the last; but that Doctor having taken a Resolution at his first entring upon the Practice of Physick, as he himself assured me in Conversation, to act directly contrary in all Cases to the common Method then in Fashion among the most eminent Physicians, (and he told me his Reasons for it) in Conformity to the Design did in the Management of this Disease, as well as others, oppose the common Method of the Physicians of the Court and City; for whereas they set themselves with the utmost Vigour to subdue the Malignity and Putrefaction, which, in their Judgment, tainted and dissolved the Blood in this Kind of Small-Pox, by the use of the most generous and active Medicines, such as Venice Treacle, Virginian Snake-root, Contrayerva, Zedoary, Saffron, Volatile Salt of Hartshorn, Powder of Viper’s Flesh, and the like; Dr. Sydenham being, as said above, determined to oppose their whole Scheme of Practice, fell upon the cold Regimen, and discharged all the Train of warm Alexipharmack Remedies, such as above enumerated, and instituted a Method of Practice Reverse to this; for he opened not only the Curtains round the Bed, but often the Windows likewise to let in fresh Air to the Room, took the sick Persons out of Bed, and plied them constantly with diluting and attempering, or with acid and cooling Remedies: In the mean Time he often thro' the several Stages of the Distemper, prescribed six Drams, or an Ounce of Syrup of white Poppies to be taken in the Evening, or at the Beginning of the Night, and to be repeated, and the Dose to be increased as great Wakefulness and Inquietude should demand; and this Method has much obtained since his Time.

To compromise the Controversy between the contending Parties, and to set the Matter in a true Light, it must be considered, as I have explained my self in the former Part of this Discourse, and that of malignant Fevers, that there is so great a Solution and Disruption of some Parts of the Blood, sometimes in a lower, sometimes in a higher Degree, as makes them incapable of being reunited and consolidated again with the sound Parts from which they are broken off; but they must be digested and expelled, or Nature must sink and fall in the Attempt; and in this Disposition of the Blood consists what we call Corruption, or Putrefaction, and which for its Conformity in all its Properties to a Gangreen in the solid Parts, I call a state of Mortification, as I have often said before.

Now it is very evident, that in such a State, two Intentions of the greatest Importance are to be persued; one is to encourage and invigorate the active Principles of the Blood, and enable them to subdue and concoct the putrid Materials, and exclude them from their Fellowship: The other is to contract and bind up the loose Structure and Frame of the Blood, and hinder the Dissolution and Rupture of the Parts, and so prevent the Progress of the Putrefaction; which will likewise be a prevalent Means to reduce the excessive Heat that arises from the Conflict between the sound and active Parts, and those that are corrupt and putrefied: Now upon this it will appear, that the contending Parties are both in the right, and both in the wrong. Those that insist upon the hot Method, act very reasonably, in prescribing proper Remedies to reinforce Nature, and assist the operative found Parts of the Blood; that by this Means they may be more prevalent and successful in digesting and expelling the putrid and malignant Matter of the Disease; and by these generous Recruits, and timely Succours, they answer the first important Intention abovementioned. And the Patrons of the cold Regimen, by plying the Patient with astringent, cooling, and diluting medies, serve the other Exigence of Nature, by contracting and strengthening the Contexture of the Blood, and preserving the Integrity and Continuity of its Parts; by which Means a Check is given to the farther Solution and Secession of them from each other; by which Means likewise, the excessive Heat is mitigated and restrained. Thus far they are both in the Right: But then they are both defective and erroneous, while the Gentlemen of the hot Regimen depend wholly, or chiefly at least, on their warm and active Cordials, opposed to Putrefaction; and the others rely too much, if not entirely, on the cooling Method. I know it will be said, that cooling Medicines, such as Juice of Lemons, and Spirit of Vitriol, are very prevalent Medicines against Putrefaction; and I allow that they are so, in their Manner of Operation, which I have explained before; that is, by confining and binding closer the sound Parts of the Blood, and so keeping them together, and preventing their farther Separation, in which Putrefaction consists: But when many Parts are already corrupted, dissolved, and thrown out of the Structure of the Blood, and cannot be re-united so as to recover their former Texture and Cohesion, it is the Province of active, generous, and enlivening Remedies, in this Juncture, to assist Nature in digesting and sending out into the Skin these ruined and mortified Particles, which cannot be performed by cold and astringent Medicines, that will rather suppress and abate the Vigour of the active Principles, and so far reduce the vital Heat, as to disable it to discharge the great Office and Duty of Concoction and Exclusion; and therefore in my Judgment, the Gentlemen of the hot Method, and those of the cold, are singly, but half Physicians for the Confluent Small-Pox, and both united and blended together, would make a compleat Practiser: One that consolidates the hot and cold Method, and unites in his Prescriptions cooling, astringent, and diluting Remedies, with warm and generous Cordials, in equal, or different Proportions, as the Relief of Nature requires, that is, as the Pulse are more to be quicken'd, animated, and inspirited; or on the other Hand, to be reduced, and brought to a lower State, which likewise is the Case of malignant Fevers. And having thus laid the Ground-work, I proceed to the Method of Cure in this Disease, which is so dangerous, and often destructive, especially to Persons of higher Rank; and had the Method of Cure, that I shall lay down, been observed, I believe this Fury had not made such Havock, nor have triumphed in such a terrible Manner, with her Spoils and Graves about her, as of late she has done; because I have seen many Patients under the most formidable and threatning Symptoms of the high Confluent Kind, evidently rescued by this compounded, or complex Method, from the very Jaws of Death, as hereafter I shall relate, without any Prejudice, or any Respect of Persons, but from a sincere and impartial Intention of being beneficial to Mankind.

The Method of Cure, in the Confluent Kind.

At the first Attack of the Disease, the Patient ought to be let Blood to a considerable Quantity, twelve or fourteen Ounces, especially if the Person is of a robust and florid Constitution; and the Physician should not be discouraged from giving this Advice, notwithstanding the Pulse should be at first weak and low, for that often proceeds from the Oppression of the active Parts of the Blood, which being too much agitated and expanded by the feverish Ferment, labours for room to extend its Current, that it may move along the Veins with greater freedom: And therefore, when by bleeding it is ventilated and made easy in its Circulation, the Pulse are so far from being weakened and lower’d, that they rather rise and beat with more strength and regularity. Nor should he forbear advising the Patient to be let Blood, though some Scattering Eruptions should appear upon the Skin, for fear the Small-Pox should be checked, or retarded in their coming out; which is the Reason alledged against this Practice; for this is merely imaginary, and upon frequent Experience, I know the contrary to be true; and indeed, it is very agreeable to Reason, that when the Blood-Vessels are in a good Measure cased from the Violence and Confusion that they feel from the immoderate Dominion of the inflammatory Parts, and the excessive Heat of the whole Mass, by which it gains more space and liberty of Circulation, it should better perform its Duty in concocting, and calling out of its Bosom the Matter of the Disease; and besides, should it be supposed, that the letting of Blood in the Season I contend for, did indeed bridle and keep back the Small-Pox from crowding out so hastily, as otherwise they would do, would that be any detriment to the Patient? No, on the contrary, it would be very beneficial, for as I have observed before, no Person suffers by the coming out of the Small-Pox too late, though Multitudes do by their coming out too soon; for then they break forth before Nature has had sufficient Time to labour, and digest the Matter, too hastily expelled. Hence it appears, what a mischievous Custom, as I observed before, prevailed formerly among Persons of better Fashion, and still continues among the People of meaner Condition, especially among the ignorant Inhabitants of the Country, to administer strong Wine, and hot Cordials, such as Saffron, Venice Treacle, Methridate, Diascordium, and other Medicines of the like active Quality, with Intention to help Nature to drive out the Pustules, which is to stimulate, and push her on to throw off the crude and unconcocted Matter before its Time, which she was too apt and ready to do before, for her present Ease, but to her greater Danger afterwards. This is so pernicious a Practice in the first Stage of this great Distemper, that all Men should be made acquainted with it; and here it is certain, that the cold Method is infinitely to be preferred before the hot, for here to prescribe Orvietans, Sir Walter Rawleigh's Confection, generous Treacles, and Cordial Powders, is to employ Oyl to quench an Inflammation, and for composing Strife, and Sedition begun in the Blood; to send in auxiliary Incendiaries, which will succour and animate the licentious and ungovernable Parts, and thereby propagate the Disorder and Confusion, intended to be controlled and appealed. And this Method of letting Blood very early, even after some Pustules begin to appear, is the more justifiable, if we reflect, that when one bleeding before the Eruption has not relieved the Patient, but afterwards, the Heat of the Fever is very exorbitant, and the Pulse continue to run swift and high, a second has been experienced to be beneficial and successful; but this does by no Means warrant the Physician to order his Patient to be let Blood at the height, or about the Conclusion of the Disease, upon Pretence of reducing the Fever: For in the first Case, that is, in the first Stage of the Distemper, Nature is strong and spiritful; and therefore not able only to bear Evacuations, and particularly bleeding, but does likewise require it for her necessary Service, to cool the Blood, and gain Ease by the Discharge of noxious Humours; but in the latter End, Nature is tired and exhausted, and ready, for want of Strength and Vigour, to lye down under her oppressive Burthen; and the Doctor, that would now think to raise her Power and Activity by expensive Evacuations, must have a peculiar Turn of Thought, much out of the common Way of reasoning; but of this hereafter, when I shall discourse of this Subject in its proper Place.

Twelve Hours after the Patient has been let Blood, a Vomit may be usefully prescribed, to evacuate the noxious Humours of the Stomach, that may hinder the Operation of Remedies, or by being absorbed by the Blood, may joyn with the Matter of the Disease, and encrease the Putrefaction, as well as to agitate and shake the Frame of the Nerves, and express from the Glands their putrid Contents. The Form of the vomitive Medicine may be this as follows: Take of the vomitive Indian Root half a Drachm; of Oxymel Scilliticum an Ounce, or six Drachms; of Milk-Water, or that of Carduus, three Ounces; make it into a Draught, and let the Patient, to promote its Operation, after half an Hour, drink plentifully of the Infusion of Carduus Leaves in spring Water boiling hot, when it becomes cool enough for drinking: But if the sick Person vomits freely of himself, then Dilution, with two Quarts of the Infusion I have mentioned, will be sufficient. If by Means of the Oxymel, the Draught works likewise downwards, then a Clyster will be unnecessary, otherwise after twelve Hours, that Remedy should be administred, to empty and cool the Bowels, and especially if it be considered, that the Patient is likely to continue bound many Days after. The Materials of the Clyster may be Milk and brown coarse Sugar; which I prefer to other Forms, because it is the most cooling, and therefore most refreshing in an inflammatory State of the Blood.

Sometimes about the Time of the Eruption, the Urine is of a dark Coffee-like Colour, which happens either from the high Degree of Putrefaction, as it often falls out in malignant Fevers; or from some grumous extravasted Drops of Blood coagulated in the Parts where they are lodged, which is often a Symptom likewise of the Stone. And sometimes, in this Stage of the Distemper, the Urine becomes bloody, which is one of the most fatal Symptoms that attend it; and it is very seldom, if ever, cured, if it happens in the middle, or later end of the Disease: The Cause of this terrible Symptom is the great Disruption and Solution of many Parts of the Blood, as I have been often obliged to repeat, which being broke into minute Atoms, have lost their Connexion with the Mass, and with one another; and being now only contiguous and not united, they pass easily through the Pores and Meshes of the Strainers, which while they kept their Coherence and Continuity, by Reason of their disproportioned Size and Figure they were unable to do; and in this high Degree of Corruption, there is such a Separation and Comminution of the Parts, that they rush through many other Emunctories and Sluices of the Body, as well as the Glands of the Kidneys, as I have before observed. But if this Evacuation happens at the Beginning, it does not certainly presage Death; for sometimes I have seen the Patient, notwithstanding, recover: And the Physician should take Care, not hastily to pronounce this a deplorable Case, especially if the Patient is one of the fair Sex: The best Method to be observed in this Case, in which letting of Blood is forbidden, in my Judgment is that, which restrains, binds up, and holds together, the Parts of the Blood, and so preserves their Integrity and Coherence; for it is the Loss of that, as I have explained, that occasions this bloody Evacuation; and the following Remedies, which have a greater Proportion of cooling and astringent Ingredients, may for this End be prescribed.

Take of Conserve of red Roses vitriolated half a Drachm, of Bole-Armoniack, and Dragon’s Blood, each six Grains, of Sal-Prunella, Grains twelve, of Cochineal, and Saffron, each five Grains, make it into a Bolus, with Syrup of Rasberries, Citron, or Lemons; to be taken every six Hours, drinking a Draught of Sack-Whey after it, or four or five Spoonfuls of a moderate Cordial-Julep; or the Bolus may be this following.

Take of Diascordium, or of Sir Walter Rawleigh's Cordial, or Confection of Alkermes, half a Drachm; of Dragon’s Blood, Powder of red Coral, each half a Scruple; Sal-Prunella, fifteen Grains; make it into a Bolus, with Syrup of Rasberries, or Lemons; five or six Drops of Spirit of Vitriol, may be taken three or four Times a Day in small Beer, and in Water mixt with a fourth part of Claret, or Florence Wine; the Juice of Orange, or Lemons, is very proper and beneficial, taken frequently in the Patient’s common Drink, and still at Night, an Ounce of Diacodium should be given during the Continuance of this Symptom. If the Physician finds the Strength and Spirit of the Patient much diminished, and his Pulse below Natures Standard; he ought to prescribe warmer Cordial Juleps, or allow him now and then a little burnt Claret, or add to the astringent Boluses four or five Grains of Saffron, or half a Scruple of Virginian Snake-Root, or Contrayerva Stone; but if these are not required, the main Intention of preventing bloody Urine will be the better answered.

It often falls out, that a Looseness attends this Distemper, sometimes before, and sometimes after the Eruption; that which happens before is not of such dangerous Consequence; for after it is moderated, or removed by Diacodium, or liquid Laudanum, it will disappear, when the Pustules arise; but that which happens after the Eruption is of greater Moment, and should be restrained by taking an Ounce of Diacodium at Night; and if that does not prevail, then the Patient may take three Spoonfuls of the following Mixture after each Stool.

Take of Mint-water and Early Cinnamon-water each five Spoonfuls, Diascordium three Drachms, of Liquid Laudanum a Drachm, make it a Mixture; add of Plague-water an Ounce and half. And if bloody Stools should happen, the same Method is to be observed, which I laid down for the Removal of bloody Urine, only in this Case astringent Glysters should often be administred; such as this following.

Take of the Decoction of burnt Hartshorn, or Sheep’s Head Broth half a Pint, add to it a Drachm of Venice Treacle, and as much Diascordium, and two or three Grains of crude Opium dissolved; or this,

Take of Flowers of Pomegranates and red Roses each a Pugil, of Pomegranate Bark and Oak-Bark each two Drachms, of the Root of Tormentil and Comfry each three Drachms; boil all in a Pint of Water to half a Pint, strain it, and add to it two Drachms of Diascordium and an Ounce of Diacodium.

The Pustules that appear on the second or third Day, do not ordinarily compleat their Eruption under three Days, and sometimes not in less than four; they appear at first in small red Spots, like Flea-Bites, yet a little rising above the Skin, by which they are distinguished from petechial or scarlat Marks, which accompany Malignant Fevers: Sometimes they come out distinct, and but little less in Size, than those of the mild kind, but afterwards when they grow bigger, and are joined daily with new Recruits, they run together and become the Confluent Sort. Sometimes the Pustules are so small, that scarcely any Space or Interval is discernible between them, but they imitate a general Inflammation of the Skin, with some Roughness and Inequality like a St. Anthony's Fire, all over the Neck, and Breast, and Face, as I have said: before, and sometimes they appear at first in a middle State between those I have recited, that is, not so large as the first, nor so small and numerous as the last; the first of these Sorts is dangerous, the second more so, but the last is incurable, and usually come forth on the first, or early, on the second Day.

In the first Stage, which ends at the Eruption of the red Spots, I have already declar’d my Judgment, that Evacuations only take Place, and that warm Cordials are not to be admitted; and I have discoursed likewise on the extraordinary Symptoms, that sometimes happen in this Season of the Small-Pox, and have mentioned what are the most proper Means to have Recourse to in such Exigencies; and now I proceed to the second Stage, which begins soon after the first Eruption, and ends at the Beginning of the Maturation. During all this Division of Time, while the Pustules are in their Growth, and every eight Hours make some discernible Advances towards Ripeness, the Patient is to be treated only with temperate Cordials, and pooling and diluting Remedies, if Nature goes on regularly in her own Work; for the Physician, who is but her Servant, and whose Province it is to succour and assist her in Danger and Distress by endeavouring to reduce her to her right Way when she deviates from it, that is, by raising her Pulse, that best discovers her Condition, when they are too low and depressed, or by bringing them down when too high and vigorous, is obliged to stand almost neutral, and not by impertinent, and often hurtful Administrations to interrupt Natures regular Operations, and incumber her with a foreign Weight of unreasonable or dubious Remedies, when she is scarce equal to her own Burthen: And this is often the Case when an unskilful and unapprehensive Physician, or a confident Nurse, who know not when Nature is in the right or in the wrong, and when she keeps her due Path or goes astray, and who not understanding the Connexion of the Means with the Ends, are always obtruding their Remedies upon the Patient, tho’ they have not in View any particular good Purpose, at which they aim; but in a general and mechanical Way they prescribe such Medicines as are in Fashion, and often given, tho’ perhaps in different Circumstances, by the leading Gentlemen of the Profession.

But because it very frequently happens, that the active and governing Principles of the Blood are unable by their own native Strength to subdue this powerful Enemy, the Assistance of the Physician is demanded where his Skill and Abilities will be fully tried. It often happens that in this second Stage of the Disease, the Glands of the Throat called the Tonsills are much inflam’d and hinder the Deglutition or Swallowing of Food and Liquors for the Patient’s Support, and sometimes to that Degree that they entirely stop the Passage of the Gullet, which will admit no Descent of Aliments to the Stomach; and sometimes this Suffering is protracted beyond two Days successive, and should this Symptom continue much longer it would evidently prove fatal: But I never saw any Person suffocated or starved by this Swelling and Inflammation of the Throat; for by the Assistance of softning, cooling and astringent Gargarisms and Injections of the same Kind by the Syringe, and in more difficult Cases by opening the Veins under the Tongue, or by the Course of Nature in such Inflammations, and the subsiding of the Swellings themselves, after such a Period of Time, the Symptoms have been always removed, and the Sufferer relieved. At the Beginning of this Stage the Eyes are frequently so far inflam'd, as appears by their red and fiery Aspect or Coruscation, that plentiful Drops of watry Serum, as so many impassionate Tears, flow down the Cheeks. This requires no particular Application, for it will disappear of it self, as the Distemper advances; only for the Ease of the Pain and Anguish, the distilled Water of Plantain, Roses or Elder Flowers, may be applied warm to the Eye-lids.

In this Season it often falls out, that the Patient is seized with an obstinate Wakefulness, a Suspension of Reason, and an ungovernable Frenzy; and as Diascordium and Laudanum are of great use in the Small-Pox, so here the Quantity usually given may be increased a third Part, or given twice a Day, Morning and Night: But it is injudicious to raise it to a much higher Degree; for during this Symptom it is often unavailing, which will take its Course in Despite of all Opiate Medicines. The most proper and successful Method is to ply the Patient with the cooling and diluting Medicines above-mentioned, and above all to take him out of Bed and set him in a Chair for a Quarter of an Hour, or a little more, and at his Return to Bed, to give him immediately a quieting Draught; this I have often seen happily attempted.

As for Blisters I cannot approve of them in this Case, and for this Reason, that that Remedy will quicken and stimulate the Blood and Animal Spirits, expand their Structure, and accelerate their Motion; and therefore in a Lethargick Paralytick or Apoplectick State, and in other Distempers where the Blood is sluggish, and the Spirits are loaded with a Collection of crude Humours, they are very beneficial, and the Reason is manifest: But in the Case before us the Spirits are already too much expanded, even to Fury; and therefore cannot be relieved by Remedies, that will stretch them farther, and spur them on the swifter Motion: They do not now want a Spur to quicken, but a Bridle to restrain them; not Medicines to widen and enlarge, but to reduce and contract them; and I have seen the Event answer this Reasoning, for when Blisters have been applied in obstinate wakefulness, when the Heat of the Blood was excessive, and the Pulse swift, they have not produced a Minute’s Sleep; on the contrary, the next Day the Wakefulness was improv'd to a downright Delirium, approaching to a Frenzy: This, I say, I have observed in inflammatory and likewise in malignant Fevers, when attended with a great Abundance of miliary Eruptions.

In this State short and difficult Breathing many Times afflicts the Patient, as well as at the latter End of the Distemper, and always presages great Danger. As Pectoral Medicines ought to be given in this Case, and such Cordials as fainting Nature demands for her Service, to enable the Spirits to go thro' their Labour, and perform their Duty in contracting and dilating the Bread for keeping up the vital Flame; so this Symptom is often happily relieved by a gentle Vomit, which may some Days after be repeated, if the same Circumstances require it; and so if the Face lyes flat and does not begin to swell the ninth Day, according to the usual Manner, the like Vomit administred will much contribute to its Extension and Elevation. But I do not look upon it as reasonable, to administer a Vomit either before such short Breathing happens, merely for preventing what may never come to pass, nor to promote the swelling of the Face, till it be seen that Nature is defective in its Duty, and being unable to perform her Task requires the Help of Medicines. It will be Time enough for the Physician to advance with his Auxiliary Remedies when Nature is actually wanting to her self, and is pushed too hard by the Enemy, and not to fall on rashly before file has given the Word and demands Assistance. The Vomit to be given in either of the forementioned Cases may consist of the vomitive foreign Root and Oxymel of Squills, the Form of which, and the Manner of taking it, has been set down in the Page before.

At the Beginning of this Stage a sore Throat and a rough Hoarseness often afflict the Patient; the last of which by shewing the Dryness and Contraction of the Strainers, and thereby their Incapacity of doing their Duty, is a dangerous Symptom, and is to be treated with soft Gargarisms, Pectoral Decoctions, Mucilages, and plentiful drinking of Emulsions, or other soft convenient Liquors to temper the Blood and dilute the Serum, that it may become thin, and apt to pass the Glands with Freedom.

Sometimes in this Season an irritating vexatious Cough persecutes the Patient, and for the suppressing of it nothing is more effectual than Diacodium by it self, or mixed with Oil of sweet Almonds as in the Form following.

Take of new Oil of sweet Almonds and Diacodium, each two Ounces, of Liquid Laudanum twenty Drops, of Saffron twelve Grains, and with a small Quantity of fine Sugar mix it into a Linctus, and let the Patient take a Spoonful frequently, if the Cough require it. At this Time Emulsions, and the common pectoral Decoction should be freely given, if no Apprehensions of a Looseness forbid it.

Sometimes a Looseness falls out in this Season; for, when after Nature has exerted all her Force to concoct and drive out all the putred Principles of the Disease, and notwithstanding has been unable to accomplish her Design, but still Part of the malignant Matter is unsubdued and remains in the Blood, she strives to free her self of these putred Remains by expelling them by the Glands of the Guts, whence arises the Looseness, for which the Method of Cure has been set down before; for when she cannot by her utmost Efforts exclude all the poisonous Matter to the Surface of the Body, she labours to effect it by other Strainers, not only those of the Guts, but likewise those of the Mouth and Kidneys; and this leads me to the important Symptom that arises at the latter End of the Space of Time between the Eruption and Maturation, that is, a copious Spitting or Salivation, which I have before mentioned, when I enumerated the Symptoms of this Distemper. After the governing and operative Principles of the Blood have determined to the Skin the greatest Part of the Matter of this Disease, a considerable Portion is left behind, which mingling with the Serum, or watry Part of the Blood, is thrown off by Nature to relieve her Oppression into the Salival Glands, and other Strainers of the Mouth. By this Nature is relieved almost as much as by the Expulsion of the noxious Matter to the Skin, provided the Salivation be thin and copious, and continue several Days. But if the Juices separated by these Strainers are thick at first, and excluded with Labour and Difficulty, and especially if attended with a Hoarsness of the Throat; then a Prognostick may be given, that it is like to go ill with the Patient, and that his Life is in great Danger: For as when that Portion of the malignant Materials designed by Nature to be lodged in the Face and Superficies of the Body, are either not wholly thrown out, or if cast out, do not attain a due Maturity, the Patient is in great Hazard from that Part that remains unexpelled; so when the other Part of the noxious or putred Materials, which by Nature's Intention, but imperfect Effort, by Reason of the Narrowness and Driness of the Strainers, are not sufficiently discharged by the Mouth, the malignant Remains in the Blood will, with the utmost Difficulty, any other Way be exterminated, but will grow thicker and more viscous, and stick fast in the Glands, till the Patient is almost suffocated and strangled; and that which continues unexcluded will, by increasing the Fever, oppress the Spirits, and often prove fatal. To assist Nature in this Distress, by keeping the Juices thin, and so preventing their viscous and clammy Quality, that they may with more Ease pass the Salival Glands, plentiful Dilution by all proper Liquors is very necessary, Gargarisms and soft Decoctions frequently injected by the Syringe into the Mouth, that may affect the Throat and free the Strainers from the thick Humours adhering to them, are very profitable; and if short laborious Breathing likewise accompany this Symptom, then the Vomit before-mentioned will be demanded; and at the same Time, to succour and support the Spirits in their Labour, more generous Cordials should be used, that the crude Matter in the Blood may be digested, and the Growth of the Putrefaction resisted.

From the Beginning of the Maturation, to the Conclusion of this great Distemper, commences the third Stage of its Progress. The swelling of the Face proceeding from the inflammatory State of the Pustules, near the Time of their Separation, as I have before described at large, begins most commonly on the ninth Day from its Invasion; but if it appears before, as it sometimes does, it is a discouraging Sight, for then it is evident, that Nature is oppressed by the great Corruption of the Blood, and to deliver her self from her Enemy, proceeds too hastily in her Operations, and would come to a State of Maturation by untimely Advances, as the Case is when unable at the Beginning of the Disease to endure the Fury of the putred Matter, she excludes it on the first or second Day, while it is yet crude and undigested; which unseasonable Effort is attended with the greatest Danger. If the swelling of the Face does not appear at its proper Time, the Vomit before described is very proper to bring it on, and at this Time more active and cordial Medicines are to be administred, and the cooling and astringent ought to bear a less Proportion, because Nature now much spent and weakened by her long Labour and Conflict, requires Relief and Assistance from more generous Remedies, to enable her to digest the crude Pustules, and sustain the hard Task of Suppuration. The Cordials then may be such as follow.

Take of Sir Walter Rawleigh's Confection, half a Drachm, of Saffron, Cochineal, and Volatile Salt of Hartshorn, each five Grains; make it into a Bolus with Syrup of Rasberries, to be taken once in six Hours, drinking after it four or five Spoonfuls of the following Julap.

Take of Milk-Water and Black Cherry-Water, each five Ounces, of Treacle-Water and Plague-Water, each an Ounce and an half, of Syrup of Lemons an Ounce and an half; make it into a julap. Or this;

Take of Diascordium half a Drachm, of Saffron four Grains, of Powder of the Flesh of Vepers half a Scruple, of Virginian Snake-root six Grains, of Sal-Prunellæ half a Scruple; make it into a Bolus with the Syrup of Rasberries or Lemons, to be taken as the other.

In the mean Time the cooling and astringent Medicines ought to be interposed for the Reasons above given; such as juice of Lemons, the Spirit of Vitriol, and plentiful Dilution, which is a great Article in this Distemper, as it is in all inflammatory Fevers, ought to be encouraged. If the Face swells gradually to a good Height, if the Confluent Pustules appear for the greatest part round, and fill themselves by Degrees with white thick Matter; it is highly probable, that on the eleventh Day, or the next following, Nature will triumph over her Adversary, and that the Patient will be then in a State of Safety.

It is on the eleventh Day, when the swelling of the Face begins regularly to diminish and subside, that the Hands begin to rise, where the Course of Suppuration is more backward, because the Eruptions there came forth after those of the Face: But the Decrease of the swelling of the Face is not, in my Judgment, in any wise the Cause of that in the Hands, as I have before demonstrated: But if the Face sinks before the eleventh Day, Nature is forced by the great Putrefaction to take irregular Steps, which presages Danger to the Patient; for the longer his Face continues swelled, the safer his Condition is: Though before the eleventh Day, the Heads of several of the Pustules should not be round, but pitted or dented in; yet if the Sides fill themselves with digested Matter, it will suffice for the Purpose of Nature, and the Patient may escape; and often those depressed Heads will rise again: But if they are not only dented in, but are likewise black and dark, and that in a considerable Number; it discovers great Malignancy and Corruption, and is likely to be fatal. If a great part of the Pustules rise, and are enlarged only by means of a thin limpid Water contained in them, and so appear like small Blisters; it is an Argument that the putrid Parts contained in them are crude, and not digested into laudable Matter, whence a fatal, or at lead a doubtful Issue, may evidently be collected; and in both these Cases, alexipharmick Remedies, that promote Concoction, by animating and confirming the active parts of the Blood, are chiefly to be insisted on; such as I have before laid down, and which may be encreased in their Quantity, in such Difficulties; and at the same Time, Cordials joined with moderate, acid and cooling Roots, in Decoctions, may be used, and drank warm, after each Bolus, to the Quantity of a quarter of a Pint: As this for Instance;

Take of Root of Scorzonera two Ounces, of Root of Butter-bur an Ounce, Eringo-Root candied six Drachms, of Root of Dandelion, Asparagus, sweet Fennel, and Couch-Grass, each half an Ounce; of Seeds of Rhue and sweet Fennel, each a Drachm; boyl all in a sufficient Quantity of spring Water to a Quart; add to it, when strained, of Treacle-Water two Ounces, of Plague-Water an Ounce and half, of the Syrup of the five opening Roots three Ounces. In this Decoction are united warm and Cordial Ingredients, with attempering and cooling ones, to answer the two great Intentions, at first laid down; that is, the binding up, and confirming the Parts of the Blood, and securing their Connexion and Coherence, to prevent the Progress of the Putrefaction and at the same Time to invigorate and empower the sound and active Parts to subdue, concoct, and expel those that are already putrefied: and therefore such Decoctions may be very useful through all the Stages of this Distemper.

Sometimes in this Season of the Disease a copious Separation of the Serum by the Strainers of the Kidneys proves very advantageous to the Patient; for a plentiful, pale and almost limpid Urine, carries off in its Current, a considerable Quantity of the noxious Matter, with which it was charged; for this is another Effort of Nature, to throw off by the Glands of the Kidneys, the residue of the putrid Materials, which she was not able to exclude by the Glands of the Skin, or those of the Mouth, and she often attempts this last Shift with Success. To promote this Separation the Decoction above preferred and generous and enlivening Medicines blended together are most proper and beneficial. I know that some eminent Physicians have recommended in this Case Pulvis Bufonum calcinated; but I must acknowledge, that upon Tryal, I never knew it produced any considerable Effect, and therefore it is not to be relied on. About the tenth Day at Night, when Nature will be most alarmed, the Guards ought to be doubled, and an Ounce of Diacodium is to be given in the Evening, and early the next Morning; and so on the eleventh Night, if the Fever and Inquietude require it. On the ninth, tenth, or eleventh Day, if the Fever is high, and the Heat scarce sufferable, a Clyster of Milk and Sugar, should be administred; as it ought to be every other Day from the Eruption, to suppress the Fury of the inflammatory Parts, and prevent the Fever from getting too great a Head; and by that Means, the critical Province on the eleventh Day is best provided for, and the Physician in his Medicines and Method, from the first, is always to have an Eye to the decisive Time, called the Turning of the Small-Pox, that he may preserve the Blood in that Disposition, which will most favour the determining Struggle.

As to Blisters, though before I would not allow the Application of them, for the Reasons there given, yet about this Season, they may in my Opinion be used with Advantage; not as they cause Evacuation, for that is inconsiderable; but as they stimulate the Blood, and agitate the Spirits, and by that Means quicken and assist them in the Labour of Digestion; and so they operate as proper Cordials, doing the same Office by external Application, which others perform, when given inwardly. But it often happens, that the Case is not judged and determined on the eleventh Day at Night; it is frequently as said before, protracted longer to the thirteenth, fifteenth, seventeenth, one and twentieth Day, and sometimes, tho’ seldome, much farther: And while the Decision is thus suspended, all that the Physician has to do, is to order Clysters to be often injected; to apply Vesicatories, so as to keep two always at work, to continue each Night the quieting Draughts, to support Nature by generous and operative Succours and wait her Steps for a favourable Issue.

If it be demanded, whether in such Cases, purging Medicines ought to be administred to carry off the Putrefaction, and so bring the Contest to a happy Conclusion; I answer, I can by no means approve of that Practice: I have formerly made Tryal of it, but I must acknowledge, I never once saw any good Event. The purging Remedies, instead of carrying off the putrid Humours, diminish the Patient’s Strength; and Nature before almost exhausted, being more enfeebled by this unseasonable Evacuation, always sunk beneath her Burthen; and I have known that other Physicians have had no better Success, and it would be wonderful if they should; for while the malignant Matter is crude and indigested, no evacuating Medicine can disengage and free the Blood from it. It may waste the Spirits by putting them upon insuperable Tasks, and weaken the Patient by expelling the wholsome, instead of noxious Humours, but cannot separate from the Mass the poisonous matter, till it is disposed and prepared by Digestion, for such a Separation, according to the established Maxim, cocta non cruda sunt Medicanda. Besides, if purging Medicines were availing at this Time, and could carry off the unconcocted Parts, they might have done it as well at any Season of the Distemper from the very Beginning; for then the only Obstruction to their Success, was the crude and undigested State of the malignant Matter of the Pustules: And should it be said, that at the latter End, the Putrefaction is not so great as before, much of it having been spent during the Maturation, though defective: I answer, that if it be allowed that the putrid Parts are much fewer than before, it must be allowed too, that Nature is much weaker, and that the Spirits are much wasted and destroyed in the long and sharp Conflict, and therefore the Case will still be equal. Besides, though the Number of the malignant Particles is not so great as at first, yet let them be of what Number the Objector pleases, they are crude and unconcocted, and therefore uncapable of Expulsion; for it is not their greater or less Number, that makes them more or less fit for Exclusion, but their Incapacity consists in their being undigested: and therefore to give purging Medicines to carry off Humours from the Blood, which are not prepared and disposed for Separation, is, in my Opinion an unreasonable Practice. It is in vain to bring a few strained Observations, and drest Narratives, to establish any Practice, that opposes common Sense, and the Experience of skilful Physicians by any Examples or Histories produced to favour a novel Doctrine, and serve an Hypothesis. If Physicians would have Patience and wait on Nature’s Steps, and not run before and precipitate her Operations and disturb her Intentions, I am very confident they would see more recover this Way, than they pretend are restored by purging Medicines. Nature her self often works out her own Deliverance when guided and led, and not driven: She will turn, and wind, and shift in many surprising Ways to save Life, and escape the Enemy. At first she drives to free her self from the putrid Matter of the Disease, by excluding and lodging it in the Skin; and when this does not prove a sufficient Separation, but still many corrupt or mortified Parts remain in the Blood, to supply the Defeat of the first Expulsion, she opens the Sluices of the Mouth, and lets through a Torrent of Serum by Salivation; but if this Attempt is not so successful as to expel the whole Putrefaction, she has recourse to the Strainers of the Kidneys, and by them excludes the putrid Remains in plenty of Urine; and even after this, sometimes her work is still unfinished, and the Blood is not entirely depurated, but remains in part impure and unrefined; and then Nature is put to hard and uncommon Shifts to extricate her self from her Difficulties, by excluding the poisonous Particles not yet separated from the Blood by all her former Endeavours and this she does sometimes by raising a St. Anthony's Fire to consume and purge them off; sometimes by as friendly Stools, and sometimes, though then the Danger is over, by Boils in several parts of the Body; and thus by sundry Hazards, unwearied Labour, and a Series of various Evacuations Nature at length becomes secure, and triumphs over her vanquished Adversary.

The Struggle is indeed sometimes long protracted by the Continuance of the Fever, even in a dangerous Degree, after the Pustules of the Face are turned to a brown Scab, or one dry, hard and unequal Crust; and if we enquire into the Cause, that feeds and supports this Fever, some affirm that the Continuance of it is owing to the crude Matter that lies under the crusty Superficies of the Face, and some undigested Patches disperst in the Limbs, or Trunk of the Body, which constantly supply the Blood with new Putrefaction; but notwithstanding these Pustules not perfectly ripe may perhaps communicate from without some noxious Fuel to the inward Flame, yet let it be considered that the Pustules, though some of them are not fully mature, are however long before so far cast out of the animal Regimen, that their Communication with the Blood seems entirly cut off, as that of a dry Scab, and therefore will cause no Fever.

I have known that purulent Matter has lain twenty Days and more under the hard Pustules, which has been prest from them in great Plenty by the Patient’s Finger, without producing the least Fever; and therefore, I believe, that the Fever, which continues so long after the Face is dry, and in a great Measure cleared, is derived from the poisonous Parts in the Blood, not yet concocted and subdued, and so not prepared for Separation; and I am the more confirmed in this Opinion, when I reflect on this, which I have often observed; that a bad Fever has remained, even after the Face, and Body, have been sometimes almost, and sometimes wholly cleared of the ripened Pustules.

What I have said against purging in the third and last Stage of the Small-Pox, may be urged against Evacuation by bleeding, with the like Evidence of Reason and Experience: As for Experience, I must testify, I never knew that Method succeed: I have formerly heard of one or two that recovered, notwithstanding they were let Blood at the End of the second Stage; but I cannot say, that Operation did contribute to it; and how the Diminution of the Blood, and thereby of the Strength and Activity of the Spirits, should be availing in this Case, is, I must acknowledge, too difficult for me to conceive. If it be said, the Blood is in a great Flame, and the excessive Heat is ready to stifle and overset the Patient; to reduce that Heat, recourse may be had to Clysters, to the taking of the Patient out of Bed, and diluting Liquors; and the active and cordial Medicines may now be given in greater Proportion to enable Nature to digest the putrid Parts, with which she is still opprest; and this will be the best Means to reduce the inordinate Heat, as the painful Inflammation of a Boil is abated, and the Fire extinguished, when the Matter is fully ripened.

I have now expressed my Sentiments on the Nature of this great Disease, divided it into its several Kinds, or Species, and laid down the Method of its Cure: As I have often tried this Method when alone, through the Series of many Years, and have found it successful above any other Way; so in Conjunction with other Physicians, chiefly with Sir J. Shadwell, his Majesty’s first Physician, a Gentleman of extensive Knowledge and Skill in his Profession, and particularly an able and judicious Practitioner in the Small-Pox, it has been persued with great, and sometimes very surprising Success; while Numbers, who seemed to be in deplorable Circumstances, and sinking under the most threatning Symptoms, have been wonderfully relieved, and rescued from the very Jaws of Death.

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