with the hypodermic injections of morphia. This was done particularly
in cases where the pains were very severe, when the pupils were
disposed to be contracted, or when there was continued profuse
sweating. In addition to this, atropia was continued without morphia
during the intermission in a few cases. The patients proved
susceptible to its influence, and dryness of the mouth with dilatation
of the pupils was readily {430} produced by gr. 1/60 every six hours.
In one case gr. 1/40 every four hours for two days caused delirium,
with the usual symptoms of belladonna action, all of which passed away
quickly after withdrawal of the drug. But in none of these cases was
the relapse influenced in the least.
Other remedies may be used for the relief of the insomnia, which is
always one of the most distressing symptoms. Chloral and bromide of
potassium have been found serviceable in various epidemics, and some
observers have preferred them to opium for the relief of headache and
insomnia. They did not prove reliable in the Philadelphia epidemic of
1869-70. Bromide of potassium, even in large doses, produced scarcely
any effect, and, while in a few cases chloral in doses of gr. xx. gave
positive relief, in the majority of instances 40 grains failed to
cause sleep or relieve suffering. It must not be forgotten also that,
as there is a special tendency to cardiac failure in this affection,
the action of chloral must be closely watched.
In a small series of our cases where muscular pains, hyperæsthesia,
and twitching were marked succus conii was given quite freely, but
without any apparent benefit.
The condition of the stomach required attention in almost every case.
Nausea, vomiting, and epigastric and hypochondriac soreness were the
prominent symptoms. Anorexia was usually complete during pyrexia, and
not rarely patients were admitted to the hospital who asserted that
for one or more days they had not taken any nourishment whatever.
Under such circumstances, and in a disease where the tendency to
prostration and cardiac failure calls for stimulants and food, it is
evident that strict care must be given to the diet. In many cases
skimmed milk with lime-water, meat broths, arrowroot, or gruel, could
be taken in small amounts at short intervals, and retained. But
whenever these are rejected, no attempt should be made to persist in
their use, but koumiss, whey, or chicken-water should be substituted,
and continued until the stomach grows retentive. Equal care must be
paid to the selection of a suitable form of stimulus. It may be proper
to employ a mild and relaxing emetic if the patient be seen at the
onset of the disease and if there is reason to suspect the presence of
indigested food in the stomach, but under any other circumstances
there seems no reason for its use in a disease where vomiting is so
common and gastric irritability one of the most troublesome symptoms.
Nor should purgatives be given save when very positive indications
exist for their use.
Constipation is rarely obstinate; the amount of nourishment taken is
very small; in a considerable proportion of cases there is diarrhoea,
or at least a sensitive state of the bowels; and as a consequence it
is preferable in nearly every case to dispense with laxatives
entirely, and, if the bowels must be opened by assistance, to
administer a simple enema.
When irritability of the stomach is marked, benefit may be derived
from very small doses of calomel frequently repeated, as, for example,
gr. 1/8 or 1/4 every one or two hours. Subnitrate of bismuth may be
used in combination with this or as a substitute for it. In several
instances more prompt relief was obtained from nitrate of silver given
in the dose of gr. 1/12 every three or four hours, dissolved in thin
mucilage of acacia.
Stimulants were remarkably well borne, and their administration in
such form as was acceptable to the stomach was clearly of service,
{431} even from an early period of the disease. As a rule, whiskey was
employed, given in the form of milk punch. By carefully graduating the
amount of alcohol, and when necessary diluting the milk freely with
lime-water, the stomach usually received it well. If circumstances
favored, dry champagne, or brandy or sherry in carbonated water would
often prove preferable. The exhausting nature of the disease, the
marked tendency to cardiac failure, and the inability to digest an
adequate amount of nourishment, all indicate the early use of
stimulants. In cases where a tendency to the development of the
typhoid state existed alcohol was freely given, even to the extent of
sixteen ounces of whiskey in twenty-four hours. Other stimulants were
usually given in these cases, such as carbonate of ammonium,
especially if pulmonary congestion existed; turpentine, especially if
tympany was marked; or Hoffmann's anodyne or spirit of chloroform, if
muscular twitchings, hiccough, or insomnia with wandering delirium
were prominent symptoms. In all cases of severity the use of tonics
and stimulants should be maintained in reduced doses during the
intermission and for some days after the final fall of temperature.
It remains to allude briefly to certain special remedies and to
certain symptoms requiring special treatment. Formerly, much diversity
of opinion existed as to the propriety of venesection or local
depletion in relapsing fever, but Murchison concluded, after a careful
examination of the evidence, that it had not been shown to be of
service; and certainly the disease as it occurred in Philadelphia in
1869-70 presented no indication whatever for even the mildest
depletory measures. This corresponds with the recognized plan of
treatment in all the specific fevers.
Blisters are not so objectionable in relapsing fever as in either
typhus or typhoid, and there are several conditions in which they have
been found decidedly useful. In cases where the headache has
obstinately resisted cold applications, bromide of potassium, and
opiates, a blister to the back of the neck has afforded marked relief,
with no unfavorable result. Again, in cases where the vomiting and
epigastric distress were severe and obstinate the application of a
blister three inches square to the epigastrium is to be recommended.
Chloroform has proved of value for the relief of various symptoms in
relapsing fever. As already stated, it was found the most useful
remedy for the hiccough which was so troublesome in a number of our
cases, and especially in those where jaundice was pronounced. It also
seemed serviceable in controlling the peculiar chills which in varying
degrees of severity were present in a few cases, recurring at about
the same hour on successive days. These rigors or chills were
uninfluenced by very large doses of quinine or other antiperiodics,
but were apparently controlled by full doses of chloroform given in
advance of the expected hour of recurrence.
Jaundice, which, as has been stated, is partly of hæmic origin, but is
probably also due in part to obstruction from catarrhal swelling of
the mucous membrane of the bile-ducts, is not influenced by mineral
acids, and still less should mercurials or purgatives be administered
for its relief. It would seem proper, in cases where this symptom is
marked, to observe special care in diet and the use of stimulants, and
to employ local sedative {432} astringents, such as small doses of
nitrate of silver combined with opium and belladonna.
Muscular soreness, pains, and tremor may call for special treatment on
account of their severity. The only remedy which has proved useful in
relieving the first two of these symptoms is opium, conjoined with the
external use of anodynes. Iodide of potassium fails even in doses as
large as can be borne, and the same is true of muriate of ammonium and
cimicifuga, which we used thoroughly without any effect. In the
muscular pains, however, which torment the patient during
convalescence, the ammoniated tincture of guaiacum was found of
service. Atropia hypodermically and chloroform internally have been
found useful for the relief of severe muscular twitchings.
Upon the whole, therefore, it will be seen that in ordinary cases a
supporting and expectant plan of treatment is all that is required.
Abandoning the idea of forcibly controlling the fever or of preventing
the relapse, care should be given in the first place to the diet and
to judicious stimulation.
Opium or morphia should be used to control pain, excitement, and
insomnia, aided, as far as the latter is concerned, by bromide of
potassium or the cautious use of chloral. Cooling drinks should be
allowed, cool applications made to the head, and the body should be
repeatedly sponged with cooling and disinfecting lotions. If the
stomach is retentive, quinine in moderate doses may be given in acid
solution, alternating with a simple fever mixture; but if nausea and
vomiting are present, the first purpose will be to allay them by the
appropriate measures already discussed.
Epistaxis is a frequent symptom, but usually requires no special
attention. Occasionally it is profuse, and then should be promptly
checked, since serious exhaustion may follow its continuance. If,
therefore, mild astringent applications do not arrest it, recourse
must be had to the tampon saturated with diluted Monsell's solution.
The urine must be closely watched and frequently analyzed in relapsing
fever. In some epidemics serious alterations in this secretion are
rare; in others it is not uncommon for the urine to be scanty, and to
contain albumen or blood. When this latter condition is presented,
especially if at the same time uræmic symptoms exist, dry cups should
be applied over the kidneys, to be followed by the use of dry heat,
and free perspiration should be promoted by hot-air baths or by the
hot wet pack. It is probable that jaborandi given in repeated small
doses, so as to avoid any depressing effect on the heart, will be
found valuable in such cases. Infusion of digitalis, with spirit of
nitrous ether or with acetate of potassium, may also be used with
advantage.
Absolute rest must be insisted on throughout the entire period of
paroxysm and relapse. The records of every epidemic present instances
of sudden death from cardiac syncope following trifling exertions. The
patients should therefore be kept strictly quiet in bed from the
initial rigor until their strength is fully restored after the
relapse. As the danger of collapse is especially great at the time of
the critical fall in temperature, the patient should be closely
watched as the end of the initial paroxysm and of the relapse
approaches. If there is any sudden rise of temperature, with head
symptoms due to hyperpyrexia, large doses {433} of quinine, ice to the
head, cold spraying, or the cold bath must be promptly used. As
sweating begins the body must be covered with a warm blanket and warm
stimulating drinks be administered. If any marked tendency to collapse
is observed, the subcutaneous injection of strychnia or of ether and
digitalis, conjoined with diffusible stimulants internally and hot
applications externally, are to be employed immediately. The special
remedies required for the various complications and sequelæ have
already been sufficiently indicated.
I desire in conclusion to acknowledge the important assistance
received from Drs. Geo. S. Gerhard, Louis Starr, Charles Shaffner, and
R. G. Curtin, who, under the supervision of my colleague, the late Dr.
Edward Rhoads, and myself, recorded the histories of most of the cases
which serve as the basis of this article, and also tabulated them for
statistical purposes.[43]
[Footnote 43: Reference must also be made to the interesting
observations on spirilla published by Mülhaüser in _Virchow's Archiv_
for July 9, 1884, after this article had been printed. His results go
to confirm the view that the spirillum of Obermeier is the essential
cause of relapsing fever.]
{434}
VARIOLA.
BY JAMES NEVINS HYDE, M.D.
Variola is an acute, febrile, contagious, and systemic affection,
preceded by an incubative period, characterized by the evolution of
symptoms in a relatively determinate order, with a cutaneous
efflorescence successively papular, vesicular, and pustular in type,
followed by crusting, and terminating either fatally or by complete
convalescence, with or without sequelæ in the form of multiple,
circumscribed, and superficial cicatrices.
SYNONYMS.--_Lat._, Variola; _Eng._, Small-pox; _Fr._, Petite Vérole;
_Ger._, Pocken; _Ital._, Vajuolo.
HISTORY.--Small-pox is a disease which, there is reason to believe,
was first developed in the earliest ages of which the human family has
record. Originating probably in China, India, and the adjacent
countries of the Asiatic continent, its extension over Europe and
America was, without question, in the line of progress pursued by the
advancing centres of traffic and population. The earliest traces of
its ravages can be dimly recognized in the descriptions of writers in
the middle and latter parts of the sixth century. In the early years
of the tenth century, however, a remarkably accurate picture of the
disease was drawn by Rhazes, a physician of Bagdad. His treatise,
translated by Greenhill for the London Pathological Society,[1] sets
forth the views of an Egyptian physician named Ahron, who wrote in the
sixth century. After these dates the remarkable political and social
changes in Europe, which are to be attributed either directly or
remotely to the Crusades, contributed largely to the opportunities for
the spread of the disease and to the occurrence later of those
decimating epidemics which became veritable scourges. In the last
century the resulting mortality in some of the countries of Europe was
often equal to the entire population of one of their largest cities.
If a modern traveller could find himself transported to the streets of
the city of London as they appeared in the early part of the present
century, it is probable that no peculiarities of architecture, dress,
or behavior would be to him so strikingly conspicuous as the enormous
number of pock-marked visages he would encounter among the people at
every turn. In the face of all cavil and sophistry, medical science
will always count among its greatest triumphs the modifications which
variola has undergone since its preventive treatment was established
upon a satisfactory basis by the discovery of the immortal Jenner.
[Footnote 1: _A Treatise on the Small-pox and Measles_, by Abu Becr
Mohammed Ibn Zacaríyá Arrází, London, 1848.]
{435} The bibliography of the disease is extensive, and the list of
authors contributing to the subject is enriched by the names of such
men as Boerhaave, Van Swieten, Sauvages, Willan, E. Wagner, Johanny
Rendu, Hebra, and, more lately, Kaposi.
ETIOLOGY.--Respecting the etiology of variola, it can scarcely be
affirmed that our knowledge has been greatly extended since the date
of the experiments of Jenner. There is no historical knowledge of its
generation de novo; and the earliest cases of the malady must
therefore be classed with the exceedingly rare instances of
spontaneous cow-pox which have proved such a boon to the
vaccini-culturists. To-day every case of small-pox is justly regarded
as having been directly or indirectly transmitted from one or more
individuals affected with a similar disorder. It is thus recognized as
specifically infectious, contagious, and inoculable, its transmission
occurring, first, without contact, by atmospheric conduction of a
volatile contagious principle of unknown nature; second, with contact
either by (_a_) actual transference of dry or moist infectious
secretions deposited upon a susceptible surface, immediately or
through the medium of garments, bed-clothing, paper money, and similar
material substances; or (_b_) by inoculation of unprotected persons
with the pathological product of an infected organism. There is no
doubt but that the contagious principle displays its greatest
activities in connection with the contents of the lesions undergoing a
change from the vesicular to the pustular phases, though from the
beginning to the end of the disease it is probable that all the
tissues and fluids of the infected body are in various degrees capable
of producing the malady in those who are unprotected. Furthermore,
whether associated or not with an organic substance, the contagium of
the disease is known to preserve the power of reproducing itself for a
period lasting for weeks, months, and even a longer time. A field for
its activities once secured, there is a period of time during which
few if any evidences of its progress are declared, this period being
abruptly terminated by distinct and characteristic symptoms. This is
known as the period of incubation.
The nature of the contagium in small-pox has been the subject of much
speculation, careful investigation, and experiment, the results having
established but few facts of any practical value. There is at present
no proof that any bacteria, vegetable germs, or other minute organisms
foreign to the human body are the essential causes of the disease. It
is certain that in health the human body is completely enveloped in a
volatile medium emanating from the secretions of the glands of the
skin, which can be recognized by some of the keen-scented lower
animals when it is wafted through the air at a distance of several
hundred feet from a single individual. It is reasonable to conclude
that not only in small-pox, but in other contagious and infectious
diseases, these emanations possess a pathological character, and
become capable of transmitting such maladies from diseased to healthy
organisms. Certain also it is that when the subjects of these diseases
are crowded together, as in prisons, hospitals and camps, this
contagious element gathers an unwonted intensity. By far the larger
number of all transmissions of variola occur after inhalation of the
infective medium--in other words, by the avenue of the lungs. It is
probably for the same reason that the disease spreads more widely and
with greater virulence during the cold seasons of the {436} year, in
this latitude especially from December to February--a time when the
ventilation of inhabited dwelling-houses is usually much less perfect
than in warmer weather.
The disease affects individuals of all ages and both sexes, not
sparing the foetus in utero, and, in the case of the latter, occurring
both with and without previous infection of the mother of the unborn
child. Nowhere are its ravages so extensive and followed by such fatal
results as among those who have long been unprotected by previous
vaccination. Among the debilitated, as also among the very young and
the very old, small-pox is liable to be followed by severe
complications and a fatal result. Negroes, possibly in consequence of
tendencies inherited through generations of unvaccinated ancestors,
are particularly prone to the disease. Lastly, there is occasionally
noted an individual idiosyncrasy, in consequence of which either a
remarkable susceptibility to the disease exists or a no less singular
immunity against its encroachment is conferred.
Thus, physicians, much exposed to its influences in the discharge of
their professional duties, are known to be relatively exempt, while
other individuals, few in number it must be admitted, have either had
repeated attacks of the malady itself, or, after each exposure to its
contagious principle, a recurrent illness of variable type. In the
immense majority of all cases, however, one attack confers immunity
upon the sufferer against subsequent invasion of the disease for the
remainder of life. Upon a few occasions I have known variola to occur
in individuals previously affected with cutaneous diseases, especially
the eczematous--a fact which merely suggests that such pre-existing
disorder of the integument conferred no immunity against infection.
SYMPTOMATOLOGY.--The earliest symptoms of small-pox may be
occasionally recognized during the stage of incubation, which, as
described above, embraces a period of from ten to fifteen days, though
these limits are not absolutely fixed, since both shorter and longer
incubative periods have been at times established. During the interval
the patient may appear to enjoy perfect health, or, on the other hand,
suffer from an ill-defined malaise, with anorexia, languor, insomnia,
and allied symptoms. Close observation of the patient thus affected
will often reveal the existence of a peculiar pallor of the face,
accompanied by a skin-color which suggests a slight degree of
sallowness of the complexion. These rather indeterminate symptoms are
naturally most marked toward the completion of the period of
incubation.
The latter terminated, the period of invasion follows, and extends
from the conclusion of the incubative stage to the moment when the
first cutaneous lesions of variola appear upon the surface. The
symptoms which characterize the onset of this period of invasion are
conspicuous and characteristic. There is often a sharp vespertine
rigor or a more or less continuous chilliness, accompanied by
sensations of "creeping" over the surface, lasting even for several
hours. Meantime, the temperature rises to 103° or 105° F., the pulse
running up to 120 or 130 beats per minute. In this febrile condition
there is commonly complaint of a characteristic aching in the head and
back, intense, scarcely intermittent, and so peculiar as to have
frequently furnished a clue to the diagnosis of the approaching
malady. These sensations are quite analogous to the substernal and
other pains which frequently precede the first explosions {437} of
syphilis, and are all, without question, due to the circulation of a
poisoned blood, the influence of which is in this manner confessed by
the nervous system. In the case of infants and young children the
invasion of small-pox is frequently ushered in by delirium and
convulsions--symptoms which are to be explained by the facts just
named.
This complexus of febrile and nervous symptoms, varying somewhat in
intensity and possibly interrupted by sensations of chilliness, may be
recognized as continuing on the second and third days of the period of
invasion. Meantime, there may be noted a dusky hyperæmia of the
pharynx and tonsils, the surface of which may even display elevated
points which develop later into papules. In exceptional instances the
intensity of the poison is such that the system fails to rally before
the violence of the onset, and a fatal result ensues before the
characteristic exanthem appears upon the skin.
On the second and third days of the invasion stage of the disease, if
they are displayed at all, the variolous rashes appear. Too much
attention can scarcely be paid to the importance of their recognition
on the part of the diagnostician. Often indeed have practitioners been
deceived by their occurrence, having been either completely blinded to
the serious nature of the malady in progress, or, as Bartholow[2] has
well shown, having supposed that they were dealing with a concurrence
of variola and scarlatina or rubeola.
[Footnote 2: "The Variolous Diseases," _Med. News_, Mar. 4, 1882, p.
232.]
Hebra was the first to point out the significance of the rash known as
roseola variolosa or erythema variolosa. Occurring at about the dates
named above, it is in a few patients pronounced and vivid, even in
solitary instances rivalling in severity the exanthem which succeeds
it. In others, the majority of all patients in some epidemics, it may
be entirely wanting. The writer has certainly observed its most
typical development in women who were either menstruating or in the
puerperal state. It is said also to be relatively frequent in subjects
of a tender age. Kaposi[3] has recognized it in all its manifestations
at every age.
[Footnote 3: Consult the admirable chapter on variola in his treatise,
_Path. u. Therap. der Hautkrankt_, Wien, 1882.]