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 airbefore 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.
Vaccinationconsists 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.
In the practical production of vaccine virus calves are vaccinated much as human beings are vaccinated, but over a larger area. Usually the posterior abdomen and the insides of the thighs are covered with superficial linear incisions, and into these incisions the seed virus is rubbed. In the laboratory of the New York City Health Department all operations relating to the vaccination of the animals and to the collection of the virus are carried on in an operating-room provided with a cement floor, glazed brick walls, and equipped with enamelled metal operating furniture, such as would be used in a hospital. The attendants wear sterile gowns and the technique of the operations is aseptic. The seed virus is either humanized virus collected by touching sterile pieces of bone to the serum exuding from ruptured vesicles on the arms of children, or in the great majority of cases bovine glycerinated virus which has been preserved two months or longer.
It is found that the crust of the vesicle, the serum issuing from the vesicle after the crust is removed, the pulp which forms the semi-solid contents and base of the vesicle, and the serum which exudes from the base of the vesicle after the pulp has been removed by a curette, all convey material capable of producing the vaccine vesicle in a susceptible person, and are therefore all different forms of vaccine virus. It has been shown, however, that if any of this material is filtered, so that all the solid particles are removed, the filtrate is inefficient. In other words, the serum is efficient as vaccine virus simply by virtue of the solid particles which it contains. It is also found that the pulp is so rich in the active principle of vaccine virus that it may be mixed with several times its weight of glycerin or other diluent and still maintain its efficiency.
The different sorts of vaccine virus on the market are simply different ways of supplying this material coming from the vesicle. Most material is in one of three forms,—
(a) The pulp diluted with some excipient, such as glycerin, vaseline, or lanolin. The emulsion, made by mixture with glycerin, may be contained in a vial or in a capillary tube, or may rest on some holder, such as an ivory or bone point. In the latter case the point is usually protected by some form of cap. Mixture with vaseline or lanolin makes a paste, which is usually issued in a box. This is in use in parts of Italy and in India.
(b) The serum dried on a holder, as an ivory or bone point or a quill.
(c) The serum mixed with some excipient, usually solid or semi-solid, until it becomes a paste, and furnished like dried serum on a holder.
For a physician the choice among these three forms is governed by considerations of efficiency, safety, and ease of use. All the forms are under certain conditions efficient, but comparative tests show that the emulsion of the pulp issued by different laboratories is much more certainly efficient than the other forms, and the glycerinated emulsion is at present in most general use both abroad and in this country.
It is also true that all forms may be perfectly safe. All forms contain bacteria when prepared, and the majority of these bacteria die within a few weeks or months after preparation. On account of the mildly antiseptic quality of glycerin the bacteria in the glycerinated emulsion usually die sooner than those in the other forms of virus, and so far as bacteria are objectionable in the virus the glycerinated form may therefore be said to be somewhat preferable. It should be added, however, both that glycerinated virus is usually put in the market before the bacteria have disappeared and that the bacteria present in virus issued by well-conducted laboratories are not found to be pathogenic to persons when inoculated by the customary method of vaccination.
The ease of use of any form of virus depends largely upon the custom of the physician. In vaccinating a large number at one time there can be no question that the use of a liquid virus supplied in vials is more rapid than the use of a dried virus, as the latter has to be thoroughly moistened before it can be applied effectively.
Methods of Vaccination.—The usual method of vaccination is to scarify a spot on the skin and to rub the virus on that spot. The choice of place depends partly on æsthetic reasons and partly on convenience. To avoid the formation of an unsightly scar on the arm, the leg may be used instead. If the arm is chosen, the insertion of the deltoid is the place of election on account of the small number of lymphatics there. If the leg is chosen, the area just below the head of the fibula presents the same anatomical advantage; but a spot a short distance above the knee on the outside of the thigh is often thought to offer less opportunity for injury and infection. Choice between the sides depends in an adult on the use to which the vaccinated limb is to be put, and in a baby on the advantage of vaccinating the side which is carried away from the nurse.
The size of the scarification is important. The vesicle is always somewhat larger than the scarification, and the larger the vesicle the greater danger that the surface may be broken, and the more opportunity there is for the introduction of extraneous infection. A spot as large as the head of a medium pin is about as small as can be easily scarified, and vesicles formed on such scarifications are least liable to have inflammatory complications. If, as certain evidence tends to show, a larger area of scar guarantees greater protection, and if a larger area is therefore desired, it is better to vaccinate in two or three small spots than in one large one. It is somewhat difficult to rub the virus from a bone point on a spot of the minute size described, and as this form of virus is usually more dilute than glycerinated virus, a larger area may safely be employed.
The scarification may be made with any sharp instrument, or with the point itself. The only precaution necessary is that the instrument should be free from infection. As a scarifier the ordinary cambric needle presents the advantages that it is usually clean, is easily sterilized, and is so inexpensive that a fresh one can be used for every operation.
It is not necessary that the scarification should draw blood, although blood is not objectionable unless it flows so freely as to wash away the virus, or unless the subject has hæmophilia.
Although with a notably susceptible subject or with especially active virus it may be sufficient simply to smear the virus on the scarified area, it is usually necessary and always advisable to rub in the virus with a wooden slip or with the point firmly and thoroughly.
Other methods of introducing vaccine virus are by puncture, by deep injection, and by the mouth.
In the method by puncture either a grooved lancet or a hollow needle may be used. A shallow puncture is made and the virus is deposited in it. The resulting vesicle is usually small and nearly circular, and generally remains free from infection; but as the hole in which the virus is placed is small, it is possible that the issuing blood may wash it away completely, and the percentage of success with this method of inoculation is not quite so large, even in careful hands, as by the process of scarification with the same virus. Animal experiments with deep injection of virus through a hypodermic syringe and with administration of virus by the mouth show that there is no certainty of successful vaccination by these means, and that when success results there is no proof of it without a subsequent vaccination on the skin to test or to demonstrate the immunity.
Care after Vaccination.—As vaccination is a surgical procedure, it should be conducted aseptically with a sterile instrument on clean skin, and the wound should be guarded against extraneous infection. It is well therefore to put either a sterile gauze cover or a clean shield over the wound as soon as the virus has been sufficiently absorbed, and to leave the protection on until the natural crust has been formed,—i.e., for a few hours. If the guard could be kept in position without motion and also without injurious pressure, it might remain until the process ended with the formation of a scar and the exfoliation of the crust; but practically it is so certain that the guard will be moved that it is wise to remove it and to trust to the protection of a clean muslin or linen cloth attached to the loose sleeve or other undergarment. For a day or two at the time when the inflammation is at its height it may be well again to guard by a shield against injury from a blow or push, but the shield should always be regarded as itself a danger. If by any accident the vaccine pustule becomes infected, it should be treated like any other infected wound,—the crust removed, the ulcer cleansed with antiseptics and dressed surgically. The immunity given by the pock is not at all lessened by this treatment.
Normal Clinical Course.—After primary vaccination in man there is a stage of incubation lasting for from forty-eight to seventy-two hours; a papule then develops, and by the end of the third or fourth day this has begun to show umbilication and a vesicular structure. When fully developed, about the sixth day after vaccination, the vesicle is distended and pearly in color. On the seventh or eighth day the areola develops,—i.e., the skin about the vesicle becomes hard, sensitive, and red, the redness extending a variable distance, not usually more than two inches from the edge of the vesicle. In the course of the next day or two the vesicle loses its pearly appearanceand becomes opaque and often slightly yellow. With the development of the areola and of the pustule the adjacent lymph glands may swell and become somewhat painful; there may also be constitutional derangement,—some fever, pain, anorexia, restlessness, and more or less prostration; there is usually a moderate leucocytosis. About the eleventh or twelfth day the areola begins to fade, the constitutional symptoms to subside, and the pustule to dry up. A dark crust is formed which drops off usually between the eighteenth and twenty-fifth days, leaving a rosy depressed scar on which not infrequently a secondary scab is formed, to be shed a few days later.
Variations in the Clinical Course.—The vesicles may appear on the second day, but it is more frequently delayed until the fourth, fifth, sixth, seventh, or even the eighth day, and cases have been observed in which the delay was even longer.
The areola, which should be bright red, may be purple, and may extend a long distance from the vesicle.
The pustule may be hemorrhagic or may be filled with greenish pus; in this case there is probably a mixed infection.
Sometimes instead of a vesicle there appears a hard elevated nodule, in color like a red raspberry. With this there is usually no areola, and no constitutional symptoms develop. The growth is usually an evidence of poor virus. It may persist for some time before absorption.
The course may be abortive,—i.e., the vesicle does not develop completely; pustulation comes early and the crust is shed and the scar formed before the end of the second week. This course is normal though not invariable in revaccinations.
The scar may be poorly marked, even when the vaccination has run a typical course.
Complications.—The most frequent complications are infections and eruptions. An infection may be, of course, of many sorts. It may be, for example, the streptococcus of erysipelas, or the bacillus of tetanus, but it is oftenest a skin coccus. These infections may be introduced with the virus, with the instrument, or later through wounds in the vesicle or pustule. Erysipelas and tetanus following vaccination are exceedingly rare, and it has never been shown that in a case of tetanus the germ was inoculated at the time of vaccination.
Eruptions are probably usually due to a chemical irritation produced by the development of the vaccinia; they are analogous to the eruptions following the injection of antitoxine and the ingestion of various drugs. They vary in appearance, sometimes resemble the eruption of measles or of scarlet fever, and again are urticarial; they are macular, papular, and vesicular.
When a moist eczema is present there may be auto-inoculation of the pock on the affected area and a general confluent vaccine eruption appear.
Immunity.—The immunity against smallpox, or vaccinia, produced by vaccination is of gradual growth, and is not complete until the period of suppuration, about the beginning of the second week. Natural immunity is said to exist, and is probable, but it is exceedingly rare. Vaccination of a pregnant woman rarely, if ever, confers immunity on the fœtus.
Duration of Immunity.—Sometimes a single vaccination gives immunity for life. Usually, however, susceptibility returns at latest seven to ten years after vaccination, and the second vaccination may give immunity for the rest of the lifetime, or susceptibility may return again and again. Failure of active, properly inserted virus shows only that the person so vaccinated is at that time immune, but conveys absolutely no information about the condition a few months later. The appearance of the scar is not a trustworthy guide as to immunity. Susceptibility to vaccination returns frequently within one year, and has returned in three months from the time of a successful vaccination. Susceptibility to smallpox probably returns, as a rule, later than susceptibility to vaccinia. It is rare that a case even of varioloid occurs within five years of a successful vaccination.
Conclusions.—Every child should be vaccinated at the time of election during the first year of life, and should be revaccinated before beginning school-life with its possibility of exposure. Every person, no matter at what age, should be vaccinated at a time of possible exposure to smallpox unless he has been successfully vaccinated within three months.
VARIOLA ERYTHEMATOSA.(First day of eruption).
VARIOLA ERYTHEMATOSA.(First day of eruption).
VARIOLA PAPULOSA.(Second day).
VARIOLA PAPULOSA.(Second day).
VARIOLA HEMORRHAGICA.(Second day—Fourth day).
VARIOLA HEMORRHAGICA.(Second day—Fourth day).
VARIOLA VESICULOSA.(Fourth day).
VARIOLA VESICULOSA.(Fourth day).
VARIOLA VESICULOSA.(Third day—Fifth day—Sixth day).
VARIOLA VESICULOSA.(Third day—Fifth day—Sixth day).
VARIOLA SEMI-CONFLUENS.(Fifth day—Sixth day).
VARIOLA SEMI-CONFLUENS.(Fifth day—Sixth day).
VARIOLA CONFLUENS.(Seventh day—Eighth day).
VARIOLA CONFLUENS.(Seventh day—Eighth day).
VARIOLA PUSTULOSA.(Ninth day).
VARIOLA PUSTULOSA.(Ninth day).
VARIOLA DISCRETA.(Ninth day).
VARIOLA DISCRETA.(Ninth day).
VARIOLA PUSTULOSA.(Tenth day).
VARIOLA PUSTULOSA.(Tenth day).
VARIOLA PUSTULOSA.(Ninth day—Tenth day—Eleventh day).
VARIOLA PUSTULOSA.(Ninth day—Tenth day—Eleventh day).
VARIOLA PUSTULOSA ET CRUSTOSA.(Tenth day—Twelfth day).
VARIOLA PUSTULOSA ET CRUSTOSA.(Tenth day—Twelfth day).
VARIOLA CRUSTOSA.(Eighteenth day).
VARIOLA CRUSTOSA.(Eighteenth day).
VARIOLA DESICCATA ET SQUAMOSA.(Twentieth day).
VARIOLA DESICCATA ET SQUAMOSA.(Twentieth day).
1. PIGMENTATION AFTER VARIOLA. (30th day).2. VERRUCOUS SCARS. (25th day). 3. CONFLUENT PITTING. (35th day).
1. PIGMENTATION AFTER VARIOLA. (30th day).2. VERRUCOUS SCARS. (25th day). 3. CONFLUENT PITTING. (35th day).
1. VACCINIA. (4th day).2. VACCINIA. (8th day).3. PRIMARY VACCINATION. (8th day).4. VACCINIA. (8th day).5. VACCINATION ULCER.6. VARICELLA. (3d day).
1. VACCINIA. (4th day).2. VACCINIA. (8th day).3. PRIMARY VACCINATION. (8th day).4. VACCINIA. (8th day).5. VACCINATION ULCER.6. VARICELLA. (3d day).
1. VACCINIA. (4th day).2. VACCINIA. (8th day).
1. VACCINIA. (4th day).
2. VACCINIA. (8th day).
3. PRIMARY VACCINATION. (8th day).4. VACCINIA. (8th day).
3. PRIMARY VACCINATION. (8th day).
4. VACCINIA. (8th day).
5. VACCINATION ULCER.6. VARICELLA. (3d day).
5. VACCINATION ULCER.
6. VARICELLA. (3d day).