A Practical Treatise on Smallpox 6

A Practical Treatise on Smallpox 6

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.