George Henry Fox

“ In the mild confluent form the disease is similar to the discrete form only that several lesions coalesce. In the severe confluent form the coalescence is extensive and large blisters are formed. The swelling about them is intense, and with the extensive sepsis the patient rarely survives. The swelling of the face and extremities is sometimes enormous, and the suffering is so severe as to make death a welcome visitor.
Confluent smallpox runs a course similar to that of the other forms, except that it is not as rapid as the third and is usually more severe than the first. ”

“ 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. ”

“ 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. ”

“ Cerebro-spinal Meningitis.—In cerebro-spinal meningitis, in which an erythematous or purpuric rash appears, the difficulties of diagnosis are often such as tax the skill of the most expert clinician. It is important to remember that the rash of cerebro-spinal meningitis usually develops gradually or in successive crops, and that its distribution over the cutaneous surface is irregular, while the eruption of smallpox makes its complete appearance within the space of a few hours and is localized chiefly on the face and extremities. ”

“ The very decided tendency to grouping of lesions upon the face and about the wrists so characteristic of smallpox does not occur in varicella, in which the vesicles may appear even more extensively on the trunk than upon the face. In varicella the palms and the soles, except in infants, are almost never affected; while in smallpox these regions are practically never exempt. It is true that in the extraordinarily mild cases of smallpox, such as have constituted the majority of cases during the past two years throughout the West, lesions may or may not be present on the palms and soles ”

“ In the treatment of smallpox the therapeutic measures employed must necessarily vary with the severity of the disease and the condition of the patient in its successive stages. No remedy or plan of treatment will apply to all cases and at all times. As in the other exanthemata, there are cases of variola in which the disease runs so mild a course that a little nursing or simple attention to the personal comfort of the patient is all that is absolutely necessary. ”

“ 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. ”

“ 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. ”

“ As it is well known that a secondary vaccination runs its course more rapidly than a primary one, it is evident that if an exposed patient has been already vaccinated a secondary vaccination is more apt to exert a protective influence. Since vaccination with humanized virus is more speedy in its effect than when bovine lymph is used, it is advisable to employ the former when readily obtainable and to make several insertions in order to increase the probability of success. ”

“ It is during the stage of pustulation that the surrounding skin becomes swollen and œdematous, with an area of redness about the pustules giving the appearance of a bull’s eye. It is also during the pustular stage that the constitutional symptoms become more intense and the fever rises in proportion to the severity of the attack. The pustules are fully matured about the eighth day of the eruption.
During the pustular stage the affection of the mucous membranes reaches its height. The eyelids, lips, and nose are often tremendously swollen. The tongue swells and deglutition becomes impossible. ”

“ 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. ”

“ Period of Invasion.—The disease is usually ushered in by fever, with a distinct chill or chilly sensations, headache, neuralgia, and a general malaise. Frequently the first symptom is a distressing backache. This is located in the lumbar region, but it may be as high up as the lower angle of the scapula, or it may be sacral and extend down into the thighs. The backache is an important symptom when present, but it is not always on hand to help one out in the diagnosis. The backache of smallpox is not peculiar or distinctive, but it is its severity which attracts attention. ”

“ The question as to whether vaccination can have any notable effect in modifying the course of variola when performed after a person has been exposed to and has contracted the disease is one concerning which a considerable difference of opinion is expressed by modern writers. While some contend that even if vaccination fails to prevent the development of variola it is quite certain to modify its severity, others claim that it can be of no more advantage than locking the barn after a horse has been stolen. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ He believes that when vaccinia has advanced to the stage of the formation of an areola around the vesicle, about the eighth day, it begins to exert its prophylactic power against smallpox; and as the period of incubation in variola is usually twelve days or more, an early vaccination may exert its protective influence in advance of the time when the variolous eruption should appear. ”

“ 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. ”

“ 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 is during this stage that, owing to the softening of its membranous covering, the pustule is broken by the movements of the patient or the contact of rough bed-linen. The pustules of the face are usually the first ones broken, and an ulceration frequently occurs which destroys the true skin and results in a pit or scar. Pustules do not rupture spontaneously and discharge their contents. Dessication lasts usually from five to twenty days, the exposed parts being the first to dry and shed their crusts. ”

“ 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. ”

“ 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. ”

“ On December 7 an eruption appeared. On December 8 the patient presented the following appearance: Face uniformly red, or of a dusky hue, and swollen; on close examination a faintly papular condition was apparent. Over chest, abdomen, and extremities was found a profuse papular eruption, of a very dusky or violet-colored hue. On the abdomen some of the papules had coalesced. Papules were noticeable on the hands and feet, particularly on the palms. On the inner surface of the thighs the entire skin presented the appearance of a scarlatinous eruption, although darker in color. ”