TREATMENT.
In the treatment of smallpox the therapeutic measures employed must
necessarily vary with the severity of the disease and the condition of
the patient in its successive stages. No remedy or plan of treatment
will apply to all cases and at all times. As in the other exanthemata,
there are cases of variola in which the disease runs so mild a course
that a little nursing or simple attention to the personal comfort of
the patient is all that is absolutely necessary. Such cases occur
in those who have already had the disease,--for a second attack of
smallpox must always be considered as a possibility, although it is a
more rare occurrence than some writers would lead us to believe. Such
cases also occur and with the greatest frequency in those who have been
rendered more or less immune by a previous vaccination. But mild cases
of smallpox may also occur among the unvaccinated; and in the present
epidemic I have noted a few cases where, in spite of the lack of any
protection from vaccination, the eruption and other symptoms of the
disease were quite as mild as in some cases of so-called varioloid, or
smallpox modified by previous vaccination.
In contrast with these cases which require no special medical
treatment, there are others of marked severity with unexpected
complications which tax the physician’s skill to its utmost capacity.
Still another class of cases, fortunately rare in most epidemics, are
those to which the name of variola maligna has been given, and in which
medical treatment seems to be almost as unnecessary as in the mild
cases, since all attempts to avert a fatal termination have so far
proved utterly futile.
In the successive stages of a typical case of variola a marked
change in the character of the treatment is demanded both by the
peculiarities of the eruption and the accompanying general symptoms.
Instead of considering the various types of variola from a therapeutic
stand-point, therefore, it would seem more practical to discuss in
their natural order those measures which are adapted to the successive
stages of the disease, beginning with the
*Period of Incubation.*--During this period, which extends from the
date of infection to the appearance of the earliest symptoms of the
disease, treatment is rarely demanded, since in the great majority of
cases the outbreak of the disease is a surprise, and in no case can
it be positively known that a patient has smallpox until the initial
symptoms appear, and often not until the characteristic eruption has
developed. In many instances, however, it is quite certain that an
individual has been exposed to the contagion of variola; and when
such a one happens to be unvaccinated, or has not been vaccinated in
recent years, the assumption is strong that the disease may have been
contracted and will manifest itself in due time.
The question as to whether vaccination can have any notable effect
in modifying the course of variola when performed after a person has
been exposed to and has contracted the disease is one concerning which
a considerable difference of opinion is expressed by modern writers.
While some contend that even if vaccination fails to prevent the
development of variola it is quite certain to modify its severity,
others claim that it can be of no more advantage than locking the barn
after a horse has been stolen.
The precise effect which vaccination during the stage of incubation
may exert upon the subsequent course of the disease is very difficult
to determine in one or even a small number of cases, since it is
almost impossible to predict in any given case what the severity of
the disease will be. In the opinion of Curschmann it is very doubtful
whether vaccination can even render the course of smallpox milder. He
states that in many instances where vaccination has been performed
after exposure to smallpox infection the pustules of vaccinia and
variola have been seen developing side by side, the former having
apparently no effect upon the latter. In the opinion of Welsh, on the
other hand, vaccination after infection often modifies the disease,
and not infrequently prevents it altogether. He believes that when
vaccinia has advanced to the stage of the formation of an areola around
the vesicle, about the eighth day, it begins to exert its prophylactic
power against smallpox; and as the period of incubation in variola
is usually twelve days or more, an early vaccination may exert its
protective influence in advance of the time when the variolous eruption
should appear.
Welsh reports one hundred and ninety-four cases of vaccination
performed during the stage of incubation, in which thirty-eight
were perfectly protected against smallpox, sixteen almost perfectly
protected, thirty-one protected to a well-marked degree, thirty
partially protected, and seventy-nine were unprotected.
Of these one hundred and ninety-four cases the death-rate was 12.90
among those vaccinated early in the stage of incubation; it was 40.98
among those vaccinated from one to seven days before the eruption of
smallpox appeared; while among the unvaccinated cases the death-rate
amounted to fifty-eight per cent.
As it is well known that a secondary vaccination runs its course more
rapidly than a primary one, it is evident that if an exposed patient
has been already vaccinated a secondary vaccination is more apt to
exert a protective influence. Since vaccination with humanized virus
is more speedy in its effect than when bovine lymph is used, it is
advisable to employ the former when readily obtainable and to make
several insertions in order to increase the probability of success.
Even a late vaccination in the stage of incubation may be of value,
as it sometimes happens that this period lasts fourteen days or more.
Early in the nineteenth century Waterhouse claimed that two days after
infection vaccination would save the patient.
Good results from the subcutaneous injection of vaccine lymph have also
been claimed by Farley and others, but the efficacy of this method of
treatment appears to have been assumed rather than proven.
The speedy vaccination of all those who have been accidentally exposed
to smallpox infection will do no harm, even if it fails to modify the
disease when contracted. Indeed, it is always advisable, since the
persons exposed, even if not already infected, are liable to contract
the disease through possible subsequent exposure; and in the case of a
threatening epidemic no precaution should be neglected which might tend
to lessen the number of possible cases.
Since no drug nor specific remedy exists which administered during the
period of incubation will abort or modify the subsequent eruption, the
only thing to be done is to prepare the patient by means of a rigid
regimen and all possible hygienic measures to withstand the impending
attack. When the fact of exposure is certain, forewarned should be
forearmed.
*Period of Invasion (Initial Stage).*--At the outbreak of the initial
symptoms of smallpox a correct diagnosis is rarely made, owing to the
fact that headache, lumbar pain, chills, fever, and nausea are not
sufficiently pathognomonic to always suggest the true nature of the
disease. In those cases, however, where it is known that the patient
has been exposed to infection and an attack of variola is consequently
anticipated, the diagnosis is comparatively easy. In such a case the
patient should be put to bed, or at least confined in a large, airy
room, from which all draperies and superfluous articles, capable of
absorbing infectious germs, should be at once removed. The temperature
of the room should be kept as low as possible in summer and should
not exceed 60° to 65° F. in winter. An extra bed or couch should be
provided, to which the patient can make a convenient and agreeable
change later in the course of the disease, especially if it proves to
be of a severe type.
At the outset the bowels should be freely opened by a dose of calomel
and soda, followed in the morning by a saline purgative; and since
constipation is apt to persist in most cases throughout the course of
the disease, it is advisable to administer a little cold citrate of
magnesia or some other agreeable laxative from day to day.
A warm bath should be taken and the skin from head to foot thoroughly
cleansed by vigorous soap friction and the application of an antiseptic
lotion. If the disease proves mild, a daily bath can be taken; or when
this does not seem advisable, the daily sponging of the whole body with
cool water will usually lessen the fever and add greatly to the comfort
of the sufferer. If the patient happens to belong to the class of the
unvaccinated, or has not been vaccinated for many years, and there
exists consequently the prospect of a severe attack, the hair and beard
should be closely clipped. In most cases, however, this procedure can
be left until the eruption has appeared, and if this is moderate in
amount, the cutting of the hair, especially in the case of young girls
and women, may not be necessary.
The diet, which throughout the course of smallpox is a matter of the
greatest importance, should be light and nutritious during this stage,
consisting mainly of milk, broth, or gruel.
The medicinal treatment of smallpox in this stage and throughout
the course of the disease must be mainly symptomatic. Upon careful
nursing and the prompt treatment of the various symptoms as they
present themselves we must depend in great measure for the fortunate
termination in any case. The remedies and special methods which have
been vaunted by some as tending to abort or modify the eruption and
to lessen the severity of the disease, have been tested by others and
found wanting. A specific for variola comparable in its action to
that of mercury in syphilis or quinine in malaria is at the present
time unknown, although, in view of the recent advances in antitoxic
medication, the discovery of such is a hope that may possibly be
realized in the near future.
A high degree of fever in the initial stage of smallpox with intense
headache and backache are symptoms which call loudly for relief,
although they may not betoken a corresponding severity of the disease
in its subsequent stages. Aconite, quinine, phenacetine, and other
antipyretics are remedies which may now be advantageously given, and
the daily cool bath, although it may not have the notable effect
so often observed in typhoid fever, will assist in lowering the
temperature.
If the fever is combined with extreme nervousness, the old and reliable
Dover’s powder will be found of service. In some cases delirium is
present during the initial stage, and occasionally a suicidal tendency
is manifested, which makes it necessary to have a watchful nurse in
constant attendance upon the patient. Potassium bromide in full doses,
chloral, or sulphonal may be advantageously employed as a sedative, but
the most effective remedy is probably the hypodermic injection of the
sulphate of morphine (gr. 1/4).
If the headache, which is almost invariably present, is very severe, an
ice-bag or cold cloth applied to the scalp will afford relief. The fear
which has been entertained by some that such a procedure might tend to
suppress the eruption is utterly groundless. For the lumbar pain, of
which the patient often complains, a hot application will usually feel
more grateful. The custom of applying mustard-plasters to the lower
part of the back is not to be recommended, since the irritation of the
skin which is caused thereby is liable to increase the eruption in
that region and add to the subsequent discomfort of the patient. The
theory that the eruption can be lessened upon the face by increasing
the number of lesions upon some other part of the body has never proved
successful in practice.
The sensation of thirst which is always present, and is often
intolerable, can be alleviated by frequent sips of cold milk or by weak
lemonade, either hot or cold. If there is extreme nausea and vomiting,
as is usually the case with children, small pieces of ice dissolved in
the mouth will relieve it together with the excessive thirst.
*Period of Eruption.*--With the outbreak of the papular eruption of
smallpox, which usually appears upon the face on the third day of
the disease, a notable decrease of the fever occurs with a decided
improvement in the general condition of the patient. In a mild case,
when a diagnosis of variola is not promptly made, the patient often
returns to his business or pursues his or her customary duties with no
thought of the danger to which others are exposed through contact or
association. But the rapid development of the eruption soon leads to
the discovery of its true nature and a realization of the importance of
continued isolation.
During the papular and vesicular stage little or no internal medication
is required, Gayton, an English writer on smallpox, who evidently
shares the popular belief that the main duty of a physician is to give
medicine, remarks that “we may also prescribe a little effervescing
saline, for unless something is given in the form of medicine, the
impression on the sick man’s mind is that you are doing nothing to
assist him.” An intelligent public, in this country at least, is
gradually awakening to the fact that skilful medical treatment cannot
longer be measured by the number and size of the apothecaries’ bottles.
Although the appetite may now return, a restriction of the diet to
simple and nutritious articles of food, such as milk-toast, eggs,
oysters, and jellies, should be enforced.
The daily bath should be continued, and there is no objection to its
being made antiseptic by the addition of carbolic acid or bichloride of
mercury. It is simpler and safer, however, to employ a plain bath and
to disinfect the skin later by sponging with some antiseptic lotion,
such as peroxide of hydrogen or permanganate of potassium. It has been
claimed by some enthusiast, though never demonstrated, that carbolic
soap will abort the disease.
The local treatment of the eruption during the papular and vesicular
stage has been a subject of experimentation for centuries, and the
prevailing opinion at the present time is that little or nothing can
be done to arrest its development. Most of the local applications,
like the mercurial and other plasters of former days, though doubtless
of some value, have proved generally to be more uncomfortable than
beneficial to the patient. Tincture of iodine, pure or diluted, with
an equal part of alcohol, nitrate of silver solution, collodion,
picric acid, and more recently ichthyol, have been advocated by some
and rejected by others after a careful test of their merits. Gayton
recommends the use of the old itch lotion of sulphur and quicklime when
cases present themselves before eruption or during the papular stage.
He claims that if the lotion is rubbed over the whole body every four
or six hours it will prevent the papules from reaching the pustular
stage and thus avert the severe secondary fever. This surprising
statement he bases on the observation of hundreds of cases.
The effect of light upon the development of the smallpox eruption is
a subject of considerable interest, and in recent years it has become
one of therapeutic importance. As long ago as the fourteenth century
John of Gaddesden and other physicians of his time were in the habit
of excluding both light and fresh air from smallpox patients. The
walls and furniture of the sick-room were painted red, on account of a
peculiar virtue supposed to reside in this color, and the unfortunate
occupant was nearly smothered by red curtains hung around his bed.
Ever since that time it has been a common custom to darken the room
of a smallpox patient, partly on account of the photophobia present
during the course of the disease and partly on account of the idea that
sunlight would aggravate the eruption. The fact that the face and hands
are most intensely affected would seem to substantiate this idea, but
the argument fails when we consider that the feet are usually the seat
of an eruption scarcely less profuse.
It was claimed by Black, in 1867, that the complete exclusion
of light from the eruption of smallpox, even when occurring in
unvaccinated persons, effectually prevented pitting of the face.
Barlow, Gallivardin, and others, have expressed a similar belief.
Experimentation by Finsen, Unna, and others having demonstrated that
it was not the heat of the sun but the ultra-violet or chemical rays
which cause solar eczema and pigmentation of the skin, it was suggested
by Finsen that in place of the complete exclusion of light in the
treatment of variola, it was only necessary to eliminate the chemical
rays of sunlight by means of red glass windows or red curtains.
Acting upon this suggestion Lindholm, Svensen, Day, and others, treated
smallpox by this new method, and made most favorable reports of their
results. The red light proved agreeable and soothing to the eyes of
the patients, frequently caused the vesicles to dry without becoming
purulent, and lessened the suppurative fever. The patients, it is
claimed, passed directly from the vesicular stage into convalescence,
and neither pitting nor pigmentation of the skin was observed.
Some less enthusiastic experimenters with the red-light treatment of
variola have been more moderate in their praises, and in some smallpox
hospitals it has been tried and given up.
My own experience with this method is limited to the observation of
a few cases treated at the Riverside Hospital in 1893. Under the
direction of Dr. Cyrus Edson, health commissioner, one ward was fitted
with red glass windows. The cases treated were of a mild type, and
although no deaths occurred, the disease appeared to run its usual
course and the experiment was negative as to results. In reply to a
letter of inquiry, Dr. Edson writes me that “if the results had not
been negative a very careful report would have been made.” For the
advancement of therapeutic knowledge it is indeed unfortunate that
while the enthusiast is always so ready to write, the sceptic or
unsuccessful experimenter is usually inclined to remain silent.
*Period of Suppuration.*--With the transformation of the smallpox
vesicles into pustules a rise of temperature occurs which is commonly
known as the “secondary fever,” and in severe cases the swelling of the
face, hands, and feet usually occasions the most intense suffering.
The chief dangers of this stage arise from the possibility of septic
poisoning and the probability of a greater or less degree of exhaustion.
A nutritious diet is now of the utmost importance, and in severe cases
bouillon, malted milk, or other prepared foods which can be readily
swallowed should be given every two or three hours. If the patient
is in a stupor, he may be awakened in order to receive the necessary
nourishment, but the calm, refreshing sleep which sometimes follows a
period of wakefulness and complete exhaustion should not be disturbed.
Alcoholic stimulants are usually of great service in this stage and may
be given freely, especially at night and in the early morning hours
when the patient’s vitality is at its lowest ebb. In case of delirium,
rectal alimentation will often be found necessary as a substitute for
or a supplement to oral feeding. The rectum should first be thoroughly
cleansed by an enema of soap and water and then from four to six ounces
of milk and brandy or eggnog may be injected.
As the eruption of smallpox attacks the mucous membrane of the mouth,
nose, and throat, as well as the skin, difficulty in swallowing and
considerable discomfort in breathing is often present, especially
during the suppurative stage. If the patient is able to sit up and
gargle, peroxide of hydrogen or some other antiseptic solution
should be used at regular and frequent intervals. In case of extreme
prostration, when any effort by the patient or the mere raising of the
head might lead to syncope or symptoms of collapse, it is advisable
to wash out the patient’s throat and nostrils with a large swab of
absorbent cotton, dipped in a saturated solution of boric acid.
Pyrozone, borolyptol, listerine, and other liquids may be conveniently
used for this purpose diluted with one or two parts of water. Small
pieces of ice or ice-cream given at frequent intervals with a small
coffeespoon will usually be found extremely grateful to the suffering
patient.
For a purulent conjunctivitis which may sometimes result from the
presence of pustules on the lids, the saturated solution of boric acid
should be frequently used in the form of a spray.
When delirium occurs in this stage the patient must be closely watched,
and, if necessary, the limbs may be kept quiet by linen sheets folded
and carried across the bed and fastened at either end. Since chloral
given by the mouth is liable to cause œdema of the glottis, it may be
advantageously administered by the rectum, or in its place the bromides
or a hypodermic injection of sulphate of morphine may be substituted,
although when the patient is suffering at the same time from severe
bronchitis the use of opium is objectionable.
The treatment of the eruption in the suppurative stage is of the
greatest importance so far as the comfort of the patient is concerned.
A host of applications and peculiar methods of treatment have been
recommended and tested in successive epidemics. Many of these have
been found to have no effect save to intensify the patient’s horrible
appearance and to aggravate his discomfort. From time immemorial
attempts have been made to prevent the pitting of the face after the
disease by treatment of the individual lesions. The cauterization of
the pustules with nitrate of silver after evacuation of the pus--the
so-called ectrotic method--has been practised by many in the past,
but the consensus of opinion at the present day seems to be that the
procedure is as useless as it is painful. The ointments, plasters,
pastes, and varnishes which have also been advocated are usually
unpleasant or troublesome to use, and in the pustular stage are not
likely to accomplish any desirable end. At this period it is too
late to consider the possibility of preventing pitting, although the
resulting injury to the skin may be reduced to a minimum by the use of
all local measures which tend to reduce the grade of inflammation.
For the highly inflamed condition of the skin which characterizes
the suppurative stage of smallpox, especially in its confluent form,
cold water is, beyond all doubt, the best antiphlogistic. The cold
compresses advocated years ago by Hebra constitute the simplest method
of local treatment and one which is most grateful and beneficial to
the patient. They exclude the air, macerate and soften the lesions,
and lessen the local inflammation. Although it cannot be claimed that
they modify in any degree the development and course of the eruption,
it is doubtful whether anything better in the way of local treatment
has ever been suggested. Pieces of lint should be dipped in cold water
and applied smoothly to the face and other portions of the body where
the eruption is abundant and the skin inflamed. To prevent their drying
too rapidly a little glycerine may be added to the water and the lint
covered with gutta-percha tissue or oiled silk. Moore recommends
covering the face with a light mask of lint and oiled silk, having
holes for the eyes, nose, and mouth. The lint is wet with a mixture
of glycerin and iced water (fʒi-f℥i). If preferred, a cold solution
of boric acid may be used in place of plain water, and when there is
an excessive and unpleasant odor present, thymol may be added to the
solution. Immermann states that he used for a time sublimate dressings
to the face (1-1000), but found that plain water did quite as much good
and was safer to use.
Next to the face, the hands and feet suffer most from the eruption of
smallpox, and, owing to the fact that the skin is not as lax in the
latter region, particularly upon the fingers and toes, the inflammatory
swelling of these parts is always attended with extreme pain when
pustules are numerous. Under such conditions it may be found advisable,
in place of merely wrapping the hands and feet in lint and oiled silk,
to immerse them in pans or pails of water, or to supply the patient
with mittens and stockings made of vulcanized rubber cloth. Indeed, if
the patient is not in too critical a condition, he may be immersed for
hours in a bath, as recommended by Hebra for the treatment of extensive
burns, pemphigus, and various ulcerating affections involving a large
portion of the body.
*Period of Dessication.*--When the distended, semi-globular pustules
begin to dry, they tend to flatten, and often undergo a secondary
umbilication from the shriveling of the central portion of the pock. In
favorable cases the general condition of the patient improves as the
fever subsides, and a more substantial diet may now be allowed.
The symptom which usually causes most local discomfort at this stage is
the itching which invariably accompanies the drying of the pustules.
This is often intolerable, and much of the pitting left after an attack
of smallpox may be due to the tearing of the crusts from the face and
other parts.
The best application which can now be made to the skin for the double
purpose of softening the crusts and allaying the pruritus is a solution
of carbolic acid in olive oil (five or ten per cent.). When the itching
sensation of the face and hands is intense, it can be greatly relieved
if the nurse will frequently spray these parts with pure chloroform,
or, if the crusts have an unpleasant odor, with a mixture of chloroform
and some antiseptic solution.
In the case of restless or unmanageable children the elbows may be put
in splints so that the finger-nails cannot come in contact with the
face.
*Period of Convalescence.*--When the crusts have dried and fallen
from the face and body and no unpleasant complications still exist,
the patient may be considered as a convalescent. No treatment is
now required except a liberal diet, the daily bath, and a continued
application of carbolized vaseline or some antiseptic oil. When the
discolored cicatrices left after the falling of the crusts appear
elevated and hard, as is frequently the case upon the face and hands
(variola verrucosa), it is customary with some to paint them with
tincture of iodine. A pleasanter and more effective application is a
twenty per cent. solution of resorcin in rose-water.
When the skin has assumed its normal smoothness, and no indication of
the disease remains except the dull purplish-red spots where the crusts
have fallen, the patient may be regarded as well, and, after a careful
disinfection of his body, he may be furnished with fresh or thoroughly
disinfected clothing and discharged from the hospital or sick-room.
In disinfecting a patient prior to his discharge, not only should a
prolonged bath be taken, but the head should be thoroughly shampooed
with carbolic soap, the nails cut and scrubbed with the same, and the
mucous orifices of the body cleansed with peroxide of hydrogen.
*Prophylactic Treatment.*--The prophylactic treatment of smallpox
is of vastly more importance than any therapeutic measure, since it
concerns a community and not merely an individual. In dealing with
smallpox cases many physicians discover only too late that an ounce of
prevention is worth many pounds of cure. When a case of smallpox is
first recognized, or even suspected, the patient should be isolated in
a room from which all unnecessary articles of furniture, especially of
soft texture, have been removed. A sheet moistened with some volatile
disinfectant should be hung before the door, and no one allowed to
enter the room save the nurse and doctor. A change of clothing should
be made outside by the former whenever leaving the room, and a gown
should be ready for the latter to wear at each visit. Upon leaving
the sick-room the physician should carefully disinfect his hands and
remain for some time in the fresh air before making another call. When
the diagnosis is positively made, all who have come in contact with
the patient, unless manifestly immune, should be found and vaccinated
without delay.
During the course of the disease all discharges, such as fæces,
urine, sputa, or vomited matter, should be received in glass or
earthen vessels containing a five per cent. solution of carbolic
acid. Handkerchiefs and soiled rags should be burned or with towels
and soiled sheets placed in a carbolic solution and allowed to remain
for twelve hours. The plates, knives, forks, and spoons used by the
patient should be kept in the sick-room and washed in a disinfectant
solution by the nurse, while any uneaten food should be treated in the
same manner as the patient’s discharges. When the patient has fully
recovered, and, after personal disinfection, has left the sick-room,
this should be thoroughly fumigated. The mattress and bed-coverings
should be burned or, in large cities, sent to the Board of Health for
disinfection. In case of death the corpse should be washed with a
strong bichloride solution or painted with carbolized oil (twenty per
cent.), and buried or cremated as quickly as possible. The clothing
worn by the patient at the beginning of the disease should be destroyed
or disinfected by baking for an hour in an oven at a temperature of
220° F., or steamed for five minutes at a temperature of 212° F.
In disinfecting the sick-room, the furniture, woodwork, and floor
should first be scrubbed with carbolic soap and hot water or a
solution of bichloride of mercury (1-500). The windows, ventilators,
and fireplace should then be tightly closed and the fumes of burning
sulphur or formaldehyde gas used to complete the disinfection. Sublimed
sulphur burned in a moist atmosphere (one pound to every thousand cubic
feet of space) is effective, but is at the same time objectionable on
account of its tendency to bleach or discolor all textile fabrics.
In well-furnished rooms, containing articles liable to be injured by
sulphur or steam, such as wall-paper, paintings, books, etc., it is
advisable to use, whenever possible, a formaldehyde gas-generator,
which can usually be obtained from the local Board of Health.