Small-Pox. 

 Within the past eighty years the entire relation of this disease
to the human family has undergone a complete revolution. It is
no longer the dread and scourge of nations, but a comparatively
infrequent and harmless visitor, and we may confidently hope that
when it shall be possible to confer upon all the benefits of vaccin­
ation we may completely eradicate the disease from the human
species. It is interesting to note that the number of cases of
small-pox in civilized communities has been diminished, not by
any decrease in the severity of the disease, but simply because we
have acquired, through vaccination, the power to resist its attacks.
For among the tribes which have not employed vaccination small­
pox is as destructive to­day as it was in Europe before the time of
Jenner; at that time 50,000 persons are said to have died of this
disease in England alone. In 1837 small-pox attacked the Mandan
Indians ; within a year only twenty-seven individuals remained out
of the population of 150,000. In consequence of the general intro
duction of vaccination, small-pox has not only ceased to be the
most formidable of the plagues that afflict humanity, but has even
become one of the rarer of the infectious diseases. Even among
the unvaccinated, the disease is not so fatal as in former years, the
mortality now being­ only about one case in seven or eight. Yet in
consequence of the gravity and evil after-effects of the disease, as
well as of its contagiousness, it is important that every case should
be early recognized; for which reason a somewhat minute description
will be given.

Stage of Invasion.—The disease usually begins with a chill,
and is distinguished from the other eruptive fevers by the extreme
violence of this chill; in some cases a series of chills recur in the  
course of a few hours. This chill, wrhich marks the beginning of
the fever, usually occurs about ten or twelve days after exposure to
contagion. Previous to the chill, there may have been some lassi­
tude, languor, and perhaps wandering pains in different parts of the
body, especially in the abdomen, the small of the back, and the
head. The beginning of the fever is also usually accompanied by
nausea and vomiting ; the tongue is coated, the bowels usually con­
stipated. In children, convulsions are a common occurrence ; in
adults, delirium is not infrequent. There may be also various addi­
tional symptoms, such as retention of urine and partial loss of power
in the limbs. On the other hand, the symptoms may be so mild as
to attract no special attention. The severity of the subsequent
fever, and the extent of the eruption are usually proportional to the
severity of these symptoms in the stage of invasion. In these
cases, in which the patient feels but slightly indisposed before the
appearance of the eruption, he may not be compelled to keep his
bed any time during the attack ; while there are cases in which the
onset is so overwhelming that the patient dies before the eruption
has had time for complete development. On the third day after
the chill, usually—sometimes on the second, fourth, or even sixth
day —an eruption begins to appear, marking the beginning of the
Stage of Xh*uption.—A most striking feature, which marks
very accurately the beginning of the eruption, is the cessation of
fever, which may have been quite intense for two or three days
previously. At the same time that the fever ceases, the symptoms
usually improve : the pains are less severe, the mental disturbances,
if present—delirium, convulsions, etc.,—often cease, and the patient
is more comfortable.

The rash usually appears first upon the face, especially around
the mouth and on the chin; at nearly the same time the neck and
wrists are affected, then the breast and arms. The extension of
the rash over the entire body usually requires two or three days, so
that six or seven days may elapse after the initial chill before the
entire eruption has appeared. The rash at first takes the form of
small red spots, sometimes exhibiting a purplish tint; the center of
these spots becomes hard and somewhat elevated, the rash resem­
bling at this period somewhat the complete eruption of measles—a
resemblance which has occasioned serious errors in diagnosis. At
this time even the inexperienced can usually recognize the nature 
of the malady; for the eruption on the wrists feels very much like
small shot under the skin. Within twenty-four hours it will be
noticed that the tops of these little bodies constituting the rash
are filled with a clear watery liquid, this change usually occurring
first in that part of the rash which first appeared, that is, on the
face, wrists and neck. During the next two days these little drops
of watery fluid increase in size so as to become an eighth of an inch
or more in diameter; but it is not until the fifth day of the eruption
that the characteristic appearance—the feature which distinguishes
the small-pox rash from all others—is visible—the depression in
the center. The top of the vesicle, as the little collection of watery
fluid is called, is nearly flat except that its middle is drawn down­
ward, making an appearance resembling that of the navel; it ià
hence technically termed umbilicated. This is, as has been said, the
most characteristic feature of the small-pox eruption, and the one
which is relied upon for a decision in doubtful cases. In most
instances, it is true, the experienced physician can give a positive
opinion so soon as the shot-like rash appearsupon the wrists; indeed
he may be confident even previous to this time, from the history of
the case, that it will prove to be small-pox. Yet there are instances,
in which the attack is very light, the patient does not feel anything
more than a slight indisposition—and perhaps even attends to his
avocation—in which the rash consists merely of a few scattered
spots. In such cases a positive opinion can rarely be given until
this peculiar feature, the umbilication of the vesicles appears. So,
too, there may be at times doubt as to whether the disease is small­
pox or chicken-pox, for in the latter disease large vesicles resembling
those of small-pox, but not umbilicated, are observed.

If the case be severe and the eruption very profuse, many of
these vesicles may coalesce, running together so as to form blisters
of considerable size. Yet even here the characteristic umbilication
can usually be observed. Up to this time the vesicles have been
clear and transparent, containing only a watery fluid; but about the
sixth day after the first appearance of the first eruption, this watery
fluid contained in the vesicles becomes turbid and white—that is,
suppuration occurs. The vesicles, or pocks, as they may now be
called, become distended with fluid, the central depression or
umbilication disappears, and the pocks become pointed. At the
same time the patient, who has been for several days nearly or quite 
free from fever, becomes again the subject of a fever equal or
exceeding that with which the attack was ushered in.
Before referring in detail to this secondary fever, it should be
remarked that the eruption is not limited to the skin. For, simul­
’taneously with its appearance on the cutaneous surface, it may
be seen also, though to a less extent, on the mucous surface of
the mouth and throat. In these places it does not, it is true, exhibit
exactly the same appearance as on the skin ; the spots are sur­
rounded by a whitish area, and do not exhibit the entire course—
the change into vesicle and pock already described. Instead of
this, there not infrequently occur minute ulcers, even while the
rash on the skin is still in the vesicular stage. In many cases the
eruption is not limited to the mouth and throat, but may extend
also down the wind­pipe to the lungs ; in these instances the breath
is usually extremely offensive. So, too, the other mucous mem­
branes may become the seat of the disease ; that of the eye—called
the conjunctiva—not infrequently suffering from the appearance of
several pocks ; indeed, the ulceration consequent upon these pocks
may destroy the eyesight by rendering the front of the eye white
and opaque. So, too, the mucous membrane of the genital organs,
especially in women, may become the seat of the small-pox erup­
tion. The most dangerous complication arising in connection with
the mucous membranes is the swelling of the larynx, whereby the
air admitted to the lungs is greatly diminished in quantity, and
suffocation may be imminent.

The secondary, or suppurative fever, begins, as already indi­
cated, with the change in the character of the fluid filling the ves­
icles, usually about the sixth day after the appearance of the eruption.
The intensity of this fever is usually proportional to the extent of
the eruption, being insignificant when there are but a few scattered
pocks, but very severe in the cases where the vesicles have coalesced
into blisters—the so-called confluent variety. The general surface
of the skin now gives indication of inflammatory action ; the spaces
between the pox are red ; there is often swelling of the eyelids, and
of the face, perhaps also of the hands and feet. This latter feature,
by the way, is a welcome sign, since it is the general experience
that cases of confluent small-pox, in which no such swelling occurs,
rarely recover. The skin is not only red and swollen, but also
painful ; the mouth and throat are sore from the presence of the
pocks, and a considerable quantity of mucus — so-called salivation — 
is often observed. In severe cases, the symptoms already referred
to as possible during the stage of invasion are frequently noted—
delirium, convulsions, and partial loss of power in the limbs.
On the seventh, eighth or ninth days of the disease the pocks
or pustules become converted into scabs ; they break, and their
contents dry and harden into crusts. Those parts of the skin
which have been thickly studded with pocks may be now almost
entirely concealed by the mass of scabs, so that the face may look
as if covered with a mask. Meanwhile the skin exhales a charac­
teristic, extremely unpleasant odor. The repulsive appearance of
the skin covered with crusts taken in connection with this sickening
odor, combine to render small-pox one of the most loathsome dis­
eases with which we are acquainted. However, in most cases the
patient’s general condition begins to improve so soon as the scab­
bing commences; the fever subsides, the appetite usually improves,
and the distressing mental symptoms may also cease, so that the
convalecsence of the patient may be said to begin with the com­
mencement of the scabbing. In severer cases, however, the
patient’s condition remains serious for some days yet. The fever
persists ; there is considerable annoyance from the ulcers left by
the broken pocks, for it may be expected that the site of each pus­
tule which has broken and discharged its contents, will be an ulcer,
the depth and extent of which varies with the size of the previous
pustule. It is these ulcers in which the unsightly scars or “ pock-
marks “ originate.

An attack of small-pox, therefore, usually lasts, in those who
recover from it, about three weeks, recovery being complete about
four or five weeks after exposure to contagion ; that is, after twelve
days of incubation there are three of invasion, five to seven for the
eruption, four or five for the scabbing process, and six to ten for
the removal of the scabs and the healing of the ulcers. These
various periods, and hence the entire duration of the disease, may
vary somewhat, but the time already indicated may be considered
a fair average. The discolored spots marking the sites of the pocks
may be visible for several weeks subsequent to recovery, especially
when the skin becomes cold. In many of these spots pitting occurs;
in some the skin gradually assumes its natural appearance.
Several accidents may unfavorably complicate the course of
small-pox. The various mucous membranes may be permanently
somewhat affected by the eruptions ; many months may elapse 
before the voice, for instance, is entirely recovered. So, too, bron­
chitis, and even pneumonia (inflammation of the lungs) sometimes
occur. The skin of the face and body is frequently affected with
erysipelas ; vision is sometimes seriously impaired, or even entirely
lost. The inflammation may extend from the throat into the ears,
and thus result in deafness. A serious disease of the kidney may
supervene, and female weaknesses sometimes date from an attack
of small-pox.

Such is the course of ordinary small-pox, yet cases occur in
which, either from the depraved condition of the patient’s consti­
tution at the time of exposure, or from the reception of an unusually
large amount of the contagious matter, the disease exhibits a far
more violent course, and is termed malignant small-pox. In such
cases the vessels contain, not a thin watery fluid, but a reddish,
bloody liquid ; there may be even extravasations of blood (black
and blue spots) into the skin in different parts of the body. These
cases are sometimes called hemorrhagic small-pox. The general
condition of the patient indicates from the start a fatal termination,
which usually occurs within a week. The individual is commonly
delirious or maniacal, completely prostrated, and succumbs before
the formation of pocks is complete.

Cause.—There is, unquestionably, a specific poison or virusy
the entrance of which into the body occasions this disease, though
this virus has not as yet been isolated. So far as we are aware, the
disease is never contracted except by exposure, direct or indirect, to
the emanations of a previous subject of the disease. Many cases, it
is true, are known in which it seems impossible to trace the connec­
tion with other patients suffering from small-pox, since individuals
who have not consciously approached even a dwelling of a small-pox
patient are stricken with the disease. But it is also known that very
slight and indirect exposure is sufficient to convey the specific virus.
It is not necessary to touch an individual already afflicted, nor even
to approach his sick room. It may suffice merely to touch a gar­
ment which has once, even years before, enveloped the person of a
small-pox patient, or which has hung in his vicinity. Indeed, it is
impossible to trace all the possible ways in which contagion may be
conveyed from one case of small-pox to another individual. In large
cities a contagion most frequently occurs by passing afflicted indi­
viduals on the street, by riding in the same street car or carriage, 
even after the small-pox patient has left the vehicle. The disease
may be probably communicated at any time, and during all stages of
its progress, but it is especially contagious during the period of scab­
bing and drying. Even after the surface of the skin is entirely
healed, the patient should not for a time mingle with other individu­
als. The body of one who has died from small-pox is a fruitful
source of contagion, since instances enough are on record in which
individuals have contracted the disease by simply gazing upon the
face of the dead.

The susceptibility to small-pox, as to all other known infectious
diseases, varies extremely in different individuals in different races,
and under the influence of conditions which are as yet unknown.
Some persons are, as is well known, insusceptible to the disease as
well as to vaccination ; others, again, have had small-pox twice, or
even three times. The African and the Indian races are far
more susceptible to its ravages than are the whites. Then, again,
at intervals of a few years, the general susceptibility of the com­
munity seems to be increased so that cases of small-pox become far
more numerous than usual.

A point of considerable interest is the fact that the child in
the womb may experience the disease with its mother, and thereby
acquire, before birth, the usual immunity conferred by one attack of
small-pox. In most cases of small-pox in pregnant women abor­
tion or miscarriage occurs ; yet instances enough are on record in
which healthy children have been born, exhibiting the characteristic
pitting of small-pox, and possessing no susceptibility to the disease
or to vaccination. In other cases again, in which a pregnant
woman has small-pox, the fætus in the womb escapes entirely,
while the most singular fact is that the fætus may experience the
disease, while the mother, through whom the exposure was effected,
escapes, either because of a previous attack or because protected
by vaccination.

While there is no reason for believing that an attack of small­
pox can be or ever has been shortened, or “ aborted,” by artificial
means, yet there is a prevalent belief among physicians that this
process occurs during certain epidemics of small-pox. That is to
say, cases have been known in which individuals presented all the
symptoms indicating the invasion of small-pox, and yet no eruption
occurred ; yet such individuals are thereafter insusceptible to small­
pox and to vaccination alike.

The mortality from small-pox varies, like the susceptibility to
it, with the age of the patient, and with certain unknown conditions
of atmosphere or soil which favor the occurrence of epidemics.
The average among scattered cases—the so-called sporadic cases—
is probably not greater than one in nine or ten; yet in epidemics
and in communities where vaccination has not been extensively
practiced, the mortality may reach a much larger figure. A fatal
result occurs more frequently in the second week of the disease
than at other times; thus Gregory found that of 168 fatal cases
death occurred in ninety-nine during the second week, in thirty-two
during the first, in twenty-one during the third, in nine during the
fourth and in seven during the fifth week. Generally speaking,
the danger may be said to be indicated by the extent of the
eruption.

Treatment.—There is as yet no means known whereby
an attack of small-pox can be cut short or in any other way
interfered with ; the disease once established, must run its
course. Yet small-pox, like the other eruptive fevers and
infectious diseases generally, is self-limited. The patient is
sure of a cure if he can only manage to survive until the natural
termination of the disease occurs. The object of treatment, there­
fore, is simply to sustain and assist the afflicted individual; to sup­
port his strength, allay so far as possible the fever and other annoy­
ing symptoms of the disease. One of the first requisites, therefore,
consists in good nursing and hygiene. The comfort and welfare of
the patient alike will be promoted by a free supply of fresh air; his
fever will be diminished and his pains assuaged by warm baths, or
where this is impracticable, by frequent sponging with warm water;
his thirst may be quenched by the use of cold drinks, ice water, lem­
onade or effervescing drinks. Persistent vomiting is a troublesome
symptom to treat, but may be often controlled by permitting the
patient to hold pieces of ice in the mouth until melted, or by admin7
istering equal parts of lime-water and milk, say a tablespoonful
every two hours. If there be a tendency to constipation, a saline
laxative, such as the citrate of magnesia, may be employed; at the
same time a teaspoonful of sweet spirits of nitre may be given four
or five times a day. If the mouth and throat be sore they may be
frequently washed and gargled with a solution of the chlorate of
potash—one drachm to the ounce of water. If vesicles form in the 
eyes, also, extreme care should be taken to secure perfect cleanliness
by frequent washings with simple water ; yet this complication,
because capable of such serious results, should always be entrusted
to the care of the physician.

One of the most important indications in most cases of small
pox is the necessity for the employment of nourishing, easily-digested
food. The patient has, of course, little or no appetite, and his diges­
tion is further impaired by nausea, and perhaps by the soreness
of his mouth and throat, during the primary fever—the stage of in­
vasion. Reliance may be placed upon milk, broths, and similar sick­
room fare; but during the second week certainly it will be neces­
sary, in the vast majority of cases, to employ alcoholic stimulants
in some shape; whisky-punch is perhaps the best form.
The most important object of treatment, though one which
cannot always be successfully accomplished, is the avoidance
of scars or “ pitting. “ It is scarcely necessary to mention all of
the plans wThich have been devised for the accomplishment of this
end; the fact that so many have been recommended, indicates
that none can always be relied upon for success. In the writer’s
experience, the best plan consists in touching the largest vesicles
with a pointed stick of the nitrate of silver (lunar caustic) on the
second day of their appearance; then poultices of linseed meal or
bread and milk may be applied over the entire face for four or five
days, until the vesicles have become umbilicated; then collodion,
mixed with one-twentieth part of glycerine, may be applied to the
vesicles by means of a earners hair brush, so thick as to make an arti­
ficial skin. This may be renewed every day or two.

While we endeavor faithfully to discharge our duty to the
patient himself, we may not forget the interests of others. It is
scarcely necessary to remark that the individual should be isolated
so far as possible from others, especially that no children should be
permitted to run any risk of contracting the disease. At the very
first manifestation of small-pox, every one who has been or can be
exposed to the contagion, should be at once vaccinated; for since
the stage of incubation of the vaccine matter is several days shorter
than that of the small-pox virus, it is possible, by immediate vac­
cination, to escape the small-pox, even after exposure; and even if
the vaccination be performed too late to prevent the attack of
small-pox, the disease will be nevertheless less severe than would
otherwise have been the case.

  
Then, again, it must not be forgotten that the patient is ­
capable of communicating the disease even during his convalescence —
indeed, after the skin is entirely healed ; and that all the articles of
whatever nature present in the room during his illness may also
convey the disease after months have elapsed. The patient should,
therefore, never be allowed to come into contact with any person
until a week or so after the scabs have all fallen off and the surface
is entirely healed ; not until he has by repeated fumigations and
disinfection destroyed, so far as may be, all the effluvia emanating
from his person. As for the bedding and body linen, the most
effectual method of disinfection is by burning them ; if this be
impossible, they, as well as the carpets and furniture of the room,
should be disinfected by the use of bromine, as will be described
under the head of “ Disinfection.”

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