A Practical Treatise on Smallpox

by George Henry Fox

CHAPTER III.

TREATMENT.

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. Such cases occur in those who have already had the disease,—for a second attack of smallpox must always be considered as a possibility, although it is a more rare occurrence than some writers would lead us to believe. Such cases also occur and with the greatest frequency in those who have been rendered more or less immune by a previous vaccination. But mild cases of smallpox may also occur among the unvaccinated; and in the present epidemic I have noted a few cases where, in spite of the lack of any protection from vaccination, the eruption and other symptoms of the disease were quite as mild as in some cases of so-called varioloid, or smallpox modified by previous vaccination.

In contrast with these cases which require no special medical treatment, there are others of marked severity with unexpected complications which tax the physician’s skill to its utmost capacity. Still another class of cases, fortunately rare in most epidemics, are those to which the name of variola maligna has been given, and in which medical treatment seems to be almost as unnecessary as in the mild cases, since all attempts to avert a fatal termination have so far proved utterly futile.

In the successive stages of a typical case of variola a marked change in the character of the treatment is demanded both by the peculiarities of the eruption and the accompanying general symptoms. Instead of considering the various types of variola from a therapeutic stand-point, therefore, it would seem more practical to discuss in their natural order those measures which are adapted to the successive stages of the disease, beginning with the

Period of Incubation.—During this period, which extends from the date of infection to the appearance of the earliest symptoms of the disease, treatment is rarely demanded, since in the great majority of cases the outbreak of the disease is a surprise, and in no case can it be positively known that a patient has smallpox until the initial symptoms appear, and often not until the characteristic eruption has developed. In many instances, however, it is quite certain that an individual has been exposed to the contagion of variola; and when such a one happens to be unvaccinated, or has not been vaccinated in recent years, the assumption is strong that the disease may have been contracted and will manifest itself in due time.

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.

The precise effect which vaccination during the stage of incubation may exert upon the subsequent course of the disease is very difficult to determine in one or even a small number of cases, since it is almost impossible to predict in any given case what the severity of the disease will be. In the opinion of Curschmann it is very doubtful whether vaccination can even render the course of smallpox milder. He states that in many instances where vaccination has been performed after exposure to smallpox infection the pustules of vaccinia and variola have been seen developing side by side, the former having apparently no effect upon the latter. In the opinion of Welsh, on the other hand, vaccination after infection often modifies the disease, and not infrequently prevents it altogether. 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.

Welsh reports one hundred and ninety-four cases of vaccination performed during the stage of incubation, in which thirty-eight were perfectly protected against smallpox, sixteen almost perfectly protected, thirty-one protected to a well-marked degree, thirty partially protected, and seventy-nine were unprotected.

Of these one hundred and ninety-four cases the death-rate was 12.90 among those vaccinated early in the stage of incubation; it was 40.98 among those vaccinated from one to seven days before the eruption of smallpox appeared; while among the unvaccinated cases the death-rate amounted to fifty-eight per cent.