PROGNOSIS.—The prognosis of variola is wellnigh inseparably associated with the question of protection by vaccination. Variola vera in the unprotected is an exceedingly fatal malady, the death-rate varying in different epidemics according to the severity of each and the ages and hygienic surroundings of the victims of the disease. Certainly, from 15 to 50 per cent. of unprotected individuals affected with the disease occurring in epidemic form in any given community will perish. This number may, however, be enormously increased, as, for example, among a large number of unprotected negroes crowded together in a filthy prison, or when the malady makes a periodical visitation to an insular community where long isolation has begotten a carelessness with respect to vaccination.
With respect to individual cases it may be asserted, first, that an intense series of prodromic symptoms, followed by the appearance of an unusually large number of cutaneous lesions, is often unfavorable. Confluence of the latter adds to the gravity; hemorrhagic and purpuric symptoms are in the highest degree portentous, and commonly indicate a fatal result. Women pregnant or in the puerperal state, infants at the breast, and persons of both sexes at advanced ages, are little able to resist the ravages of the disease. According to Kaposi, women recently delivered prematurely or who have lately suffered from an abortion succumb more often than others of their sex. Chronic alcoholism among male subjects and the cachexia induced by all chronic visceral and systemic disorders are sources of weakness which largely increase the death-list by adding to the heavy strain upon the vital energies. The prognosis is rendered uncertain or unpromising by extensive involvement of the mucous as well as of the cutaneous surfaces, by marked visceral complications, by evidences of shock or exhaustion before the apogee of the exanthem is reached, by grave sequelæ, and even by simple complications of the malady when, instead of entering promptly upon convalescence, the patient lingers for weeks in a typhoid condition. An unfavorable symptom in any case is the sudden cessation of the processes actively pursued upon the surface of the body. The swelling of the integument then suddenly diminishes and the crusts by which it was covered shrivel. The eruption, in brief, seems to undergo what may be described as a collapse. The pulse at such moments usually flutters feebly, and there are other portents of dissolution which the eye of the physician will hardly fail to interpret correctly. The fluids in such instances mechanically drain away from the surface of the body to seek the deeper parts. This is not peculiar to small-pox. Similar phenomena occur even in the case of other than exudative affections of the skin. In pityriasis rubra the patient dies leaving an integument apparently unaffected, and I have seen a patient dead of even multiple sarcoma of the skin when the tumors were reduced fully one-half in bulk as the result of a similar cause.
On the other hand, the practitioner should never forget that even apparently desperate cases of variola rally and are won back to life. That the exudative process should be in full evolution at the surface of the body is, cæteris paribus, certainly so far a good omen. The most hideous, extensive, and stench-emitting crusts have hidden for a time the forms that have for many subsequent years not only known the enjoyment of life, but have made that life of inestimable value to others. The physician in the presence of this most loathsome and formidable disease should never despair.
PROPHYLAXIS AND TREATMENT.—The loftiest end to be reached by the physician of our day with respect to variola is its complete removal from all civilized countries, and indeed from the face of the earth, by the practice of universal vaccination and revaccination. The evident modifications which the disease has undergone in late years as a consequence of the extraordinary attention given to this subject is an earnest of the future. The day is probably not far distant when the man, woman, and child unprotected by vaccination will properly be regarded as an enemy of the human race, and treated accordingly. Evidences of the most satisfactory character as to successful vaccination should be imperatively required of all applicants for admission to schools, academies, colleges, charitable institutions, public libraries, art-galleries, and places of labor controlled by incorporated institutions; of all members of conventions, legislatures, political, religious, and deliberative bodies; of every purchaser of a ticket for purposes of travel; and of every voter. In addition, there should be in every district a systematic and periodical inspection of all persons registered in the census by persons qualified and competent to perform compulsory vaccination. This is the scientific treatment of variola.
Respecting the therapeutic management of variola, it must be admitted that there are no remedies known to exert the slightest influence in either cutting short the curriculum of the disorder or in checking its progress in any stage. When vaccination is practised after the disease is fully developed, the two disorders, vaccinia and variola, apparently concur, and proceed pari passu to the evolution peculiar to each. Quinia, the sarracenia purpurea, the salicylate of sodium, emetics, diaphoretics, purgatives, and other remedies and methods vaunted as efficacious, have again and again failed to establish the claims which have been put forth respecting the value of each.
The most important of the considerations to be regarded at the outset of the management of the small-pox patient relate to his hygienic surroundings and nursing—considerations which scarcely differ from those recognized as of general importance in the case of all septic, contagious, and filth-producing diseases.
The timid, the fearful, and the unprotected are to be at once dismissed from the bedside, and trustworthy attendants secured who have received protection by either recent vaccination or a prior attack of the malady. The sick chamber should be sufficiently large and capable of the most thorough ventilation by free access of air. Solar light should be excluded as rigidly and completely as possible, since it is reasonably certain that its access to the face has an etiological relation to the pitting of that part, often the most serious sequel of the affection. It is an interesting fact that pitting is much less frequently noted on those parts of the body from which light is excluded by the covering of the clothing. The temperature of the sick room during the febrile stages of the disorder should not rise above 70° F. nor be permitted to fall below 60° F. Between these extremes a variation may be made in accordance with the sensations of the patient.
During the invasion stage of the disease the patient can rarely assimilate food, but if this be possible it should be given throughout the entire course of the disease in the form of animal broths, eggs, nutritious soups, and milk. Iced and acidulated beverages are often grateful to the palate, and small lumps of ice should be permitted to dissolve slowly in the mouth. Lime-water may be required by unusual gastric irritability. As the disease progresses and the palate and buccal membrane become painful and sore by reason of the localization there of pustular and other lesions, various mouth-washes and gargles may be ordered, such as those containing the chlorate of potassium, the tincture of myrrh, the tincture of cinchona, or even the milder demulcent fluids made by the addition of flaxseed, gum acacia, or powdered elm-bark to water. In almost all such cases the skilled nurse will accomplish a grateful result by frequently cleansing the mouth of the sufferer (especially before the deglutition of aliments) by covering the finger with a soft handkerchief, dipping it in pure hot water, and then thoroughly and gently cleansing the entire buccal cavity. The spray of a saturated solution of boracic acid in rose-water may then be directed over the parts.
Applications of cool and iced water to the skin are commonly grateful, and, as a rule, are accompanied by no danger to the patient, though in the early periods of the disease they unquestionably retard the full evolution of the cutaneous symptoms. For the pain in the back, therefore, which is often the most urgent symptom of the invasion stage of the disease, it is usually preferable to make hot applications. The large rubber bags now in common use, filled with hot water and from time to time applied to the lumbar region, may be employed with good effect simultaneously with iced, spirituous, or camphorated applications to the head.
Numerous indeed have been the topical applications made to the surface of the skin in the pustular stage of the malady, both with a view to assuage the soreness and pain and to obviate the tendency to pitting. The opening of the pustules and the evacuation of their contents (practicable only in other than confluent forms of the disease) has been practised from an early date, but is ineffectual from the standpoint of any practical results thus obtainable. The same may be said of the subsequent cauterization of the floor of the pustular chamber, which only adds to the distress experienced by the sufferer in his skin. Medicated unguents, applied to the skin, containing mercury, iodine, and other substances, are not known to be followed by any better results. It may indeed be laid down as a general rule that fatty applications to pus-producing surfaces where the pathological product is virulent are apt to undergo decomposition and otherwise act unfavorably upon the tissues—a fact first pointed out by Ricord in connection with the treatment of the chancroid. Vaseline, as not liable to undergo chemical decomposition, is not open to this objection.