III. SMALLPOX (Variola)

An accute infectious disease characterized by pronounced skin eruptions. The eruptions have four stages: papule, vesicle, pustule, and crust. When the crust forms, it comes off, leaving a pit in the skin. In confluent types of the disease the scar is most pronounced, sometimes destroying otherwise good features.

Etiology.--Smallpox is considered one of the most virulent of contagious diseases, and it is generally believed that persons exposed are almost invariably attacked, unless protected by vaccination. This is one of the most stupendous exaggerations to be found in medical literature. My experience has been that very few people take it when exposed to it.

I remember quite a number of years ago being connected with a pest-house, where I was appointed physician and spent two hours a day with confluent smallpox for three months, without taking the disease. It is true I had a vaccination scar from childhood, but I have long since given up the opinion that that afforded me any protection. With me in that epidemic was a thirteen-year-old girl, who was caught and held there by the health authorities. She waited upon the sick people, and in all that time did not spend one hour outside of the house except in the small yard. She never had been vaccinated, and she failed to contract the disease. I could give many instances of personal experience where many were exposed without a single development. In this particular epidemic two German nurses took down, in spite of the fact that they had been vaccinated and re-re-vaccinated in the old country, where they do the work "just right."

Age.--The disease is common to all ages, and is very fatal to the extremely old and young. The unborn child may be attacked, but only when the mother develops the disease. It is said that in the case of twins only one may be attacked, thus showing that there is an immunity without vaccination.

Race.--It is said that the aboriginals suffered terribly from smallpox. Why? Because it is a disease of filth. The uncivilized people are just filthy enough to be good subjects for this disease. It is said that, when it was first introduced into America, the Mexicans died by the thousand. They yet suffer very greatly. Only a few years ago I was corresponding with a physician, located in Mexico, whose function was to take care of the miners for a large corporation. He gave me much information in regard to the severity of the disease among the natives. It is said the North American Indians have been decimated by this disease. The negroes are especially susceptible, and the mortality among them is great, being about forty-two per cent, against twenty-nine for whites.

Variation in the Virulence.--Sydenham states that smallpox has its peculiar kinds, taking one form during one series of years and another during another; which means that the severity of the epidemic probably varies with the atmospheric and local conditions. There is no question but that perfect sanitation has almost obliterated this disease, and sooner or later will dispose of it entirely. Of course, when that time comes, in all probability the credit will be given to vaccination; but if we could drop back to the aboriginal condition and do away with sanitation generally, smallpox would return with all its virulence.

Prevalence.--In the United States there has been a steady decrease.

When receiving orthodox treatment, pustules sometimes make their appearance on the tongue and throat and in the rectum. The disease has also been known to pass down the esophagus, and even down into the stomach. In decidedly severe cases of confluent smallpox it would be hard to say what part of the anatomy is not affected. There is no disease so dreadful as the worst types of smallpox. That mortality should be great in this disease is obvious; for the entire surface of the body is involved to such an extent that radiation of heat must be sadly interfered with.

Symptoms.--Smallpox is divided into three forms: discrete, confluent, and the hemorrhagic variety. The discrete form is where the pustules are isolated and do not run together. The confluent form is where the surface is a mass of pustules all run together. The hemorrhagic variety is called black smallpox, because the hemorrhage into the skin turns it black. When receiving proper treatment only the first form develops.

There is a modified smallpox known as varioloid. This is supposed to be modified by vaccination, but I have seen cases of pronounced types of discrete smallpox that had no modification by vaccination, and the patients were not prostrated nor confined to the bed to exceed twenty-four hours. They were around, reading, doing chores, while the pustules were forming and drying up. The semi-confluent and confluent smallpox is a disease to be dreaded; but the force of the disease is undoubtedly being controlled by sanitation. In fact, the disease is one of filth, not only on the outside of the body, but also on the inside of the body. When people learn to live correctly, and domestic and civic sanitation is what it should be, it will be impossible for this disease to get a foothold even in the lightest form.

When a physician is called to see a case of smallpox, the patient may be complaining of headache; certainly a decided backache and bone-ache--in the olden times it was called the "breakbone fever." A never-failing symptom is a feeling of shot under the skin. By passing the hand gently over the forehead, cheeks, or arms--or, in fact, any part of the body--long before the skin is reddening there will be shot-like projections felt just beneath the skin. There is nothing about the early symptoms of smallpox that is so positively diagnostic as those symptoms. Some of these very discrete cases will have one or two pox in the roof of the mouth. The first twenty-four hours there will be heavy aching in the back, and perhaps vomiting and headache. After that, unless it is a case of confluent smallpox, the patient will be comfortable for the remainder of the sickness--that is, if the case if properly nursed and treated.

Desiccation.--The pustules terminate by either breaking and drying up, or drying up without breaking, and forming a crust. This takes place about the third week. In confluent smallpox the crust adheres for a long time. The reason for it is that the inflammation dips deep and leaves a permanent scar.

Complications.--Complications may set up in any of the mucous membranes, the lungs, bowels, or eyes. Pericarditis is a serious complication. Bright's disease may follow. Inflammation of the reproductive organs of both male and female may result. It is not my intention to give anything but a very short sketch of this disease. Those who would like to know its history, complications, variations--in fact, give exhaustive study to the subject--I would recommend to read Osler's "Practice of Medicine." There will be no complications if the patient is treated properly. Complications are made by regular practice.

Treatment.--Patients should be separated as widely as possible. It is very dangerous to bring two cases of confluent smallpox together in what might be called a large room; indeed, a large drawing-room is small enough for one case. Huddling such cases together will cause great mortality. The disease should be treated in tents, and out in the open as much as possible. Some authorities recommend opium to relieve the pain in the back. I think this is the worst kind of malpractice. The hot bath will relieve the pain, put the skin in as comfortable a condition as possible, and certainly will be a safe remedy to relieve all suffering. The baths should be continued long enough to relieve the pain. The bowels should be washed out every night regularly, using two quarts of water.

The patient should be given all the water desired, but positively no food of any kind. By some authorities it is recommended to give barley water, oatmeal water, lemon juice, etc. Until the temperature has been reduced to the normal, the patient should be given plenty of cold water, and nothing else. In case of diarrhea, a small opiate, such as paregoric, has been recommended; but there will be no diarrhea unless the patient is fed. The patient should be kept as clean as possible around the eyes, nose, ears, and the outlets of the body. If the bathing is kept up often enough to give full relief from suffering, this, in addition to applying a little olive oil to the skin, will keep the surface more pliable, and prevent discomfort and stiffness of the skin. In convalescence a patient should be warned not to eat too heartily the first week, After that, if convalescence is fairly rapid, by the second week the patient may eat moderately of all the food given to a well person.