physician of our day with respect to variola is its complete removal
from all civilized countries, and indeed from the face of the earth,
by the practice of universal vaccination and revaccination. The
evident modifications which the disease has undergone in late years as
a consequence of the extraordinary attention given to this subject is
an earnest of the future. The day is probably not far distant when the
man, woman, and child unprotected by vaccination will properly be
regarded as an enemy of the human race, and treated accordingly.
Evidences of the most satisfactory character as to successful
vaccination should be imperatively required of all applicants for
admission to schools, academies, colleges, charitable institutions,
public libraries, art-galleries, and places of labor controlled by
incorporated institutions; of all members of conventions,
legislatures, political, religious, and deliberative bodies; of every
purchaser of a ticket for purposes of travel; and of every voter. In
addition, there should be in every district a systematic and
periodical inspection of all persons registered in the census by
persons qualified and competent to perform compulsory vaccination.
This is the scientific treatment of variola.
Respecting the therapeutic management of variola, it must be admitted
that there are no remedies known to exert the slightest influence in
either cutting short the curriculum of the disorder or in checking its
progress in any stage. When vaccination is practised after the disease
is fully developed, the two disorders, vaccinia and variola,
apparently concur, and proceed pari passu to the evolution peculiar to
each. Quinia, the sarracenia purpurea, the salicylate of sodium,
emetics, diaphoretics, purgatives, and other remedies and methods
vaunted as efficacious, have again and again failed to establish the
claims which have been put forth respecting the value of each.
The most important of the considerations to be regarded at the outset
of the management of the small-pox patient relate to his hygienic
surroundings and nursing--considerations which scarcely differ from
those recognized as of general importance in the case of all septic,
contagious, and filth-producing diseases.
The timid, the fearful, and the unprotected are to be at once
dismissed from the bedside, and trustworthy attendants secured who
have received protection by either recent vaccination or a prior
attack of the malady. The sick chamber should be sufficiently large
and capable of the most thorough ventilation by free access of air.
Solar light should be excluded {452} as rigidly and completely as
possible, since it is reasonably certain that its access to the face
has an etiological relation to the pitting of that part, often the
most serious sequel of the affection. It is an interesting fact that
pitting is much less frequently noted on those parts of the body from
which light is excluded by the covering of the clothing. The
temperature of the sick room during the febrile stages of the disorder
should not rise above 70° F. nor be permitted to fall below 60° F.
Between these extremes a variation may be made in accordance with the
sensations of the patient.
During the invasion stage of the disease the patient can rarely
assimilate food, but if this be possible it should be given throughout
the entire course of the disease in the form of animal broths, eggs,
nutritious soups, and milk. Iced and acidulated beverages are often
grateful to the palate, and small lumps of ice should be permitted to
dissolve slowly in the mouth. Lime-water may be required by unusual
gastric irritability. As the disease progresses and the palate and
buccal membrane become painful and sore by reason of the localization
there of pustular and other lesions, various mouth-washes and gargles
may be ordered, such as those containing the chlorate of potassium,
the tincture of myrrh, the tincture of cinchona, or even the milder
demulcent fluids made by the addition of flaxseed, gum acacia, or
powdered elm-bark to water. In almost all such cases the skilled nurse
will accomplish a grateful result by frequently cleansing the mouth of
the sufferer (especially before the deglutition of aliments) by
covering the finger with a soft handkerchief, dipping it in pure hot
water, and then thoroughly and gently cleansing the entire buccal
cavity. The spray of a saturated solution of boracic acid in
rose-water may then be directed over the parts.
Applications of cool and iced water to the skin are commonly grateful,
and, as a rule, are accompanied by no danger to the patient, though in
the early periods of the disease they unquestionably retard the full
evolution of the cutaneous symptoms. For the pain in the back,
therefore, which is often the most urgent symptom of the invasion
stage of the disease, it is usually preferable to make hot
applications. The large rubber bags now in common use, filled with hot
water and from time to time applied to the lumbar region, may be
employed with good effect simultaneously with iced, spirituous, or
camphorated applications to the head.
Numerous indeed have been the topical applications made to the surface
of the skin in the pustular stage of the malady, both with a view to
assuage the soreness and pain and to obviate the tendency to pitting.
The opening of the pustules and the evacuation of their contents
(practicable only in other than confluent forms of the disease) has
been practised from an early date, but is ineffectual from the
standpoint of any practical results thus obtainable. The same may be
said of the subsequent cauterization of the floor of the pustular
chamber, which only adds to the distress experienced by the sufferer
in his skin. Medicated unguents, applied to the skin, containing
mercury, iodine, and other substances, are not known to be followed by
any better results. It may indeed be laid down as a general rule that
fatty applications to pus-producing surfaces where the pathological
product is virulent are apt to undergo decomposition and otherwise act
unfavorably upon the tissues--a fact first pointed out by Ricord in
connection with the treatment of the {453} chancroid. Vaseline, as not
liable to undergo chemical decomposition, is not open to this
objection.
Curschmann, Kaposi, and other authors are in agreement respecting the
value of water-compresses over the surfaces invaded by the eruption--a
method of topical treatment which I desire to fully endorse after
personal observation of its value. Curschmann recommends compresses
dipped in iced, Kaposi those moistened with tepid water. The sensation
experienced by the patient will prove the best guide to the
temperature of this fluid. I prefer a solution containing one drachm
of boracic acid to the pint of water as hot as can be discovered to be
productive of comfort, a drachm or two of glycerine being added to the
solution. The compresses dipped in this (or a carbolated solution, if
the latter is preferred by either physician or patient) should be
assiduously moistened and changed regularly by the attendants just as
long as they can accomplish good. They operate, first, by protecting
the part; second, by keeping it moist; third, by maintaining the
surface temperature at the point most pleasant to the patient; fourth,
by exercising the gentlest degree of equable compression over the
surface. When desired, this may be covered with the Lister protective
material or a piece of oiled silk to prevent evaporation at the
surface.
In Vienna warm baths, administered either by the process of continuous
immersion so generally practised there or by immersion for from two to
three hours of each day, have been found to furnish the greatest
amount of comfort to the patient. The skin is thus speedily relieved
of its tension, the exfoliation of the crusts is hastened, and the
time required for the evolution of the cutaneous lesions, if not
shortened, is at least not retarded by the accidents of exposure to
the desiccating influences of the air--ends which for the patient are
practically one. In this country, and especially in private practice
outside the larger charities with their ampler provision for these
emergencies, nearly the same result may be reached by wrapping the
patient completely in sheets wrung out of water of the temperature
desired.
From first to last in the treatment of variola, all indications should
be made subordinate to that most prominently set forth by the general
character of the symptoms--viz. the conservation by every possible
means of the vigor of the patient. The tax upon all reserves of vital
energy is here so enormous and constant that he will gravely err who
for a moment loses sight of this fact. Hence it is that anodynes,
chloral, opium and its alkaloids, the bromide of potassium, and
similar medicaments, introduced either by the stomach or by hypodermic
injection, are to be jealously reserved for emergencies when it would
seem cruel to withhold the temporary comfort they may impart.
Stimulants are of course to be freely employed whenever they are
indicated by exhaustion as this may be shown by a weak pulse and other
failing functions of the body, but are certainly best reserved for
such emergencies. In general, it may be remarked that the fewer the
medicaments ingested by the stomach, and the larger the restriction of
the labor of this organ to the task of sustaining the nutrition of the
body, the better are the chances of a favorable issue.
It is unnecessary to add that all other indications presented in any
given case are to be met, subject to the conditions indicated above.
Abscesses {454} are to be opened and antiseptically treated; delirious
patients are to be sedulously prevented from doing themselves injury;
daily movements of the bowels are to be secured; while the diarrhoea
of the typhoid state, occasionally resulting from the exhausted
condition of the system when the force of the disease is spent,
demands proper control.
Cleanliness is to be enforced by every judicious measure. The skin of
the patient is to be washed in tepid water and soap as often as
practicable in the course of the disease, and under no circumstances
are applications of ointments, washes, or lotions to be allowed to
collect in strata upon the surface commingled with the pus and crusts
of the disease. At the time of such ablution, and occasionally
oftener, the linen and other garments of the patient are to be
changed. When the crusts are regularly exfoliating from the surface of
the body general warm baths may be ordered, after each of which the
surface of the body may be anointed with vaseline or covered with a
finely-sifted dusting-powder, such as the corn-starch farina sold by
grocers.
Inasmuch as hemorrhagic variola is usually hopeless in character, and
remedilessly fatal, Kaposi's liberal use of opiates may be recommended
when euthanasia is all that can be expected. So long as there is the
narrowest chance of recovery resort may be had to ergot, turpentine
and the mineral acids internally, combined with the external use of
styptics and ice. But little confidence can, however, be placed in
these measures, which will prove entirely ineffective in the great
majority of all cases.
In all fatal cases of variola the duties of the physician are not
ended by the death of the patient. It is for the benefit of the living
that he should require destruction or disinfection and long disuse of
all domestic articles that were employed upon or about the patient.
The lifeless body should be disposed of by cremation, and medical men
should exert their influence in favor of legal enforcement of such a
wholesome practice.
{455}
VACCINIA.
BY FRANK P. FOSTER, M.D.
SYNONYMS.--Vaccina, Variolæ vaccinæ (Jenner), Cow-pox, Cow-pock,
Kine-pox, Kine-pock; _Fr._ Vaccine; _Ger._ Kuhpocken, Schutzpocken,
Impfpocken, Schutzblattern; _It._ Vaccina; _Sp._ Vacuna.
DEFINITION.--An eruptive disease characterized by a cutaneous lesion
closely resembling that of small-pox, going through the stages of
papulation, vesiculation, pustulation, incrustation, and
cicatrization; differing from small-pox in the mildness or almost
total absence of the constitutional symptoms, by being communicable
only by inoculation, and by the fact that the lesions, as a rule, are
developed only at the points of inoculation and in their immediate
neighborhood.
This definition holds good for the great majority of cases, but in
each of its parts we must take account of exceptions. For example, the
lesion does not always follow the regular sequence of changes
described. It may stop short at the stage of papulation, constituting
the so-called raspberry excrescence, which will be further referred to
hereafter; it may pass directly from the stage of vesiculation into
that of incrustation, without any such change in its liquid contents
as can properly be said to form a pustule; desquamation may take the
place of incrustation; and, after an evolution otherwise normal, there
may be no formation of a scar, simply because the destructive effect
of the lesion has not extended deeper than the epidermis. The
constitutional symptoms are sometimes severe, but they are always of
very short duration. The disease is said to have been communicated
otherwise than by inoculation in the case of some of the lower
animals. Thus, Chauveau succeeded in producing some of its phenomena
in the horse by causing the virus to be inhaled in the form of spray.
It is doubtful, however, if it is possible to eliminate all sources of
fallacy in such experiments. Finally, a generalized eruption is
occasionally observed, although with great rarity. In stating these
exceptions no reference is intended to cases in which complications
occur.
NATURE OF THE DISEASE.--Many considerations warrant us in classing
cow-pox among the varioliform diseases--chiefly its general
resemblance to variola, and the fact that individuals who have been
affected by it are thereby more or less fully protected against
small-pox. It has been thought, indeed, that cow-pox was in reality
but a modified form of small-pox; and this idea has been the basis of
one of the theories that have been held as to the origin of vaccinia.
Before enumerating and discussing those theories it will be well to
mention that cow-pox is spoken of as spontaneous, casual, or
inoculated, according to its mode of origin, known or assumed, in
individual instances.
{456} Spontaneous or original cow-pox is the name commonly applied to
the disease as it is met with in the cow in instances in which its
mode of origin is unknown. Strictly interpreted, this expression
implies a belief that the affection is capable of being developed in a
cow independently of contagion or infection--a notion that seems to be
held by many physicians, but not, so far as the writer is aware, by
those whose study of the subject has been such as to lend any
considerable weight to their opinions. Ordinarily, however, the term
spontaneous cow-pox is employed simply as a convenient expression to
denote the disease as it occurs naturally in cows, without implying
any belief or theory as to its mode of origin.
Casual cow-pox is the term applied in cases that have been contracted
by accidental inoculation, whether in the cow or in man. It is
manifest that the so-called spontaneous cases are really casual,
unless we accept the doctrine that infection is not necessary to the
development of the disease.
The term inoculated cow-pox implies that the affection has been
produced by intentional inoculation. Here, again, we are confronted
with an illogical expression, for a disease that is inoculated
accidentally is still inoculated, as much as if it had been conveyed
purposely. It may be said, indeed, that the casual disease is due to
some other form of infection than inoculation, but for such an
assertion there is not a particle of proof.
Passing from this unsatisfactory nomenclature to a consideration of
the theories that have been held as to the nature of cow-pox, we are
first met with that of its being a disease sui generis, like
small-pox, measles, scarlet fever, and the like, and, like them,
originating only by its own specific contagion, not being capable of
development by a modification of any other contagion, however closely
it may thus be counterfeited. This seems the most rational theory of
the nature of cow-pox, but it cannot be demonstrated except by
disproving all opposing theories; and that has not yet been
accomplished.
Another theory is, that cow-pox is really small-pox modified, as the
phrase runs, "by passing through the system of the cow." It has been
thought possible, indeed, to specify in what way the cow's system
could impress such decided changes upon the virulent disease small-pox
as to convert it into the mild affection that we know as vaccinia; in
other words, it has been imagined that the function of lactation
accomplished this remarkable result. This notion may have been due to
the observation that so-called spontaneous cow-pox is met with only in
cows that are in milk. The significance of this fact, however, is
really nothing more than that cows in milk are more exposed to
accidental inoculation than other bovine animals--namely, at the hands
of the milkers. The fact that in such cases the lesions are almost
always confined to the teats and the udder, far from affording any
ground for the notion that there is some mysterious connection between
cow-pox and the function of lactation, is but another proof that the
disease is the result of inoculation. The lesions appear at the points
of inoculation, the teats and the udder being the parts handled by the
milkers. Moreover, there is no difficulty in inoculating young calves
or adult bulls, and the lesions so produced do not vary in a single
particular from those observed in so-called spontaneous cases.
{457} Men have been so carried away with this milk theory, however, as
even to believe that the virus of small-pox might be shorn of its
dangerous properties, so that it would produce only the vaccinal
lesion when inoculated simply by mechanical mixture with milk. During
the late Civil War one of the Confederate Army surgeons actually put
this notion to the test of practice on quite a large scale,
inoculating large numbers of persons with a mixture of small-pox virus
and milk, terming the practice mitigated inoculation. We can scarcely
suppose that he did anything else than variolate these persons, just
as he would have done had he used variolous lymph without the addition
of milk. His experiments show nothing new; they merely furnish a
recent confirmation of the well-known fact, familiar to the old
inoculators, that inoculated small-pox is sometimes exceedingly mild
in a series of cases.
This theory of the variolous origin of cow-pox, and of the
practicability of converting small-pox into cow-pox at will by
"passing it through the system of the cow," has taken deep root in the
minds of men, especially in Great Britain, where the late Mr. Ceely's
experiments and Mr. Badcock's experience seemed to give it some color.
Some years ago, however, the question was investigated most
practically and thoroughly by a commission appointed for the purpose
by one of the medical societies of Lyons, Chauveau being the recorder.
Their conclusion was--and their reasoning seems to the present writer
incontrovertible--that small-pox and cow-pox were wholly distinct from
each other under all circumstances, and that it was impossible to
convert the one into the other. But the doctrines of the English
investigators, reinforced as they were by the ingenious arguments of
the late Dr. Seaton, were not easily to be overturned in their own
country or in America; consequently, the practice of variolating cows
has been resorted to from time to time for the purpose of obtaining a
stock of vaccinal virus of unquestionable authenticity--the so-called
variola vaccine. This practice is utterly fallacious, and it is also
dangerous, since the disease so produced, however mild it may seem to
be, is nothing more nor less than small-pox, with its infectiousness
by effluvium and its liability to prove serious even when carefully
inoculated.
Quite recently the experimental investigation of the question has been
undertaken de novo by a well-known English veterinarian, Mr. Fleming;
and, since his conclusions coincide with those of the Lyonnese
commission, it is to be hoped that we have seen the last of this
rough-and-ready method of improvising a case of genuine cow-pox--a
method that, in the light of our present knowledge, can only be
characterized as downright malpractice.
The third and last theory we have to consider is that which ascribes
the origin of cow-pox to infection from the horse. So far back as
Jenner's time it was conjectured that cow-pox was due to the
accidental conveyance of the virus of the grease (the eaux-aux-jambes
of the French) by reason of the cows being milked by persons who were
also employed in the care of horses affected with that disease. Grease
is an eruptive disease of horses' heels. Doubtless it has often been
confounded with a mere eczematous affection by those who have
repeatedly failed in their persistent attempts to inoculate cows with
it, and, on the other hand, a localized eruption of horse-pox may have
been mistaken for it by those who have {458} supposed themselves to
have succeeded in producing cow-pox by inoculating cows with the virus
of grease, and have consequently given in their adhesion to the grease
theory of the origin of cow-pox. At all events, so far as the writer
is aware, that theory is not now held by any well-informed writer.
Still regarding the horse as the originator of cow-pox, we must turn
our attention to horse-pox (equinia). Several years ago Depaul of
Paris took great pains to establish the fact that horse-pox (an
affection totally distinct from grease) was an eruptive febrile
disease of horses, an exanthem; that the eruption was generalized,
and, being for the most part concealed by the hair, generally
overlooked; and that it was capable of being conveyed by inoculation,
the lesion being indistinguishable from that of cow-pox. He believed
himself to have demonstrated also that it was the contagion of
horse-pox that gave rise to cow-pox in the cow.
Depaul's investigations were very keen and his conclusions were
exceedingly plausible, but they cannot be called convincing,
notwithstanding the fact that Constantin Paul succeeded for a time in
popularizing a stock of horse-pox virus as material for vaccination.
At about the same time the Beaugency case of cow-pox was discovered,
and the perfectly satisfactory use that has been made of that stock
may have thrown Depaul's theories and Paul's practice undeservedly
into the background.
We can only say, in summing up, that the small-pox theory is utterly
untenable, that the horse-pox theory has not been disproved, and that
the theory that regards cow-pox as derived neither from small-pox nor
from horse-pox, but as a disease sui generis, although not proved, is
the most rational of all, and the most in keeping with known facts.