A Practical Treatise on Smallpox 7

A Practical Treatise on Smallpox 7

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.

 

 

 

 

CHAPTER IV.

 

VACCINATION.

 

 

Vaccination consists in the inoculation of virus taken from the pock

produced by vaccinia.

 

*Vaccine Virus.*--Virus has been taken from vaccine vesicles on almost

all animals susceptible to vaccinia, but throughout the greater part of

the last century the material used in the vaccination of human subjects

was taken generally from a vaccine vesicle on the arm of a previously

unvaccinated healthy child. Such virus when collected at the proper

time was found to take with great regularity, and vesicles resulting

from its use were uniformly well developed and typical. Humanized

virus was, however, open to the objection that it could communicate

disease if the child were not perfectly healthy, and as a matter of

fact it did communicate syphilis in a certain number of instances.

The possibility of this infection was so serious an objection to the

use of virus from this source that in the last quarter of the century

calf virus, recommended and used in Italy many years before, was

gradually substituted for human virus, and at the present time the

use of animal virus is general in Europe and in the United States. In

the production of virus, calves are for commercial reasons generally

preferred to other animals. Calves take typically, and a large amount

of virus can be collected from them, whereas all other animals either

are comparatively expensive, or take poorly, or are able to furnish but little virus. Cows also are more expensive, are less easily handled,and develop vaccine vesicles less typically.