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.

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. Even a late vaccination in the stage of incubation may be of value, as it sometimes happens that this period lasts fourteen days or more. Early in the nineteenth century Waterhouse claimed that two days after infection vaccination would save the patient.

Good results from the subcutaneous injection of vaccine lymph have also been claimed by Farley and others, but the efficacy of this method of treatment appears to have been assumed rather than proven.

The speedy vaccination of all those who have been accidentally exposed to smallpox infection will do no harm, even if it fails to modify the disease when contracted. Indeed, it is always advisable, since the persons exposed, even if not already infected, are liable to contract the disease through possible subsequent exposure; and in the case of a threatening epidemic no precaution should be neglected which might tend to lessen the number of possible cases.

Since no drug nor specific remedy exists which administered during the period of incubation will abort or modify the subsequent eruption, the only thing to be done is to prepare the patient by means of a rigid regimen and all possible hygienic measures to withstand the impending attack. When the fact of exposure is certain, forewarned should be forearmed.

Period of Invasion (Initial Stage).—At the outbreak of the initial symptoms of smallpox a correct diagnosis is rarely made, owing to the fact that headache, lumbar pain, chills, fever, and nausea are not sufficiently pathognomonic to always suggest the true nature of the disease. In those cases, however, where it is known that the patient has been exposed to infection and an attack of variola is consequently anticipated, the diagnosis is comparatively easy. In such a case the patient should be put to bed, or at least confined in a large, airy room, from which all draperies and superfluous articles, capable of absorbing infectious germs, should be at once removed. The temperature of the room should be kept as low as possible in summer and should not exceed 60° to 65°F. in winter. An extra bed or couch should be provided, to which the patient can make a convenient and agreeable change later in the course of the disease, especially if it proves to be of a severe type.

At the outset the bowels should be freely opened by a dose of calomel and soda, followed in the morning by a saline purgative; and since constipation is apt to persist in most cases throughout the course of the disease, it is advisable to administer a little cold citrate of magnesia or some other agreeable laxative from day to day.

A warm bath should be taken and the skin from head to foot thoroughly cleansed by vigorous soap friction and the application of an antiseptic lotion. If the disease proves mild, a daily bath can be taken; or when this does not seem advisable, the daily sponging of the whole body with cool water will usually lessen the fever and add greatly to the comfort of the sufferer. If the patient happens to belong to the class of the unvaccinated, or has not been vaccinated for many years, and there exists consequently the prospect of a severe attack, the hair and beard should be closely clipped. In most cases, however, this procedure can be left until the eruption has appeared, and if this is moderate in amount, the cutting of the hair, especially in the case of young girls and women, may not be necessary.

The diet, which throughout the course of smallpox is a matter of the greatest importance, should be light and nutritious during this stage, consisting mainly of milk, broth, or gruel.

The medicinal treatment of smallpox in this stage and throughout the course of the disease must be mainly symptomatic. Upon careful nursing and the prompt treatment of the various symptoms as they present themselves we must depend in great measure for the fortunate termination in any case. The remedies and special methods which have been vaunted by some as tending to abort or modify the eruption and to lessen the severity of the disease, have been tested by others and found wanting. A specific for variola comparable in its action to that of mercury in syphilis or quinine in malaria is at the present time unknown, although, in view of the recent advances in antitoxic medication, the discovery of such is a hope that may possibly be realized in the near future.

A high degree of fever in the initial stage of smallpox with intense headache and backache are symptoms which call loudly for relief, although they may not betoken a corresponding severity of the disease in its subsequent stages. Aconite, quinine, phenacetine, and other antipyretics are remedies which may now be advantageously given, and the daily cool bath, although it may not have the notable effect so often observed in typhoid fever, will assist in lowering the temperature.

If the fever is combined with extreme nervousness, the old and reliable Dover’s powder will be found of service. In some cases delirium is present during the initial stage, and occasionally a suicidal tendency is manifested, which makes it necessary to have a watchful nurse in constant attendance upon the patient. Potassium bromide in full doses, chloral, or sulphonal may be advantageously employed as a sedative, but the most effective remedy is probably the hypodermic injection of the sulphate of morphine (gr. 1/4).

If the headache, which is almost invariably present, is very severe, an ice-bag or cold cloth applied to the scalp will afford relief. The fear which has been entertained by some that such a procedure might tend to suppress the eruption is utterly groundless. 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.

The sensation of thirst which is always present, and is often intolerable, can be alleviated by frequent sips of cold milk or by weak lemonade, either hot or cold. If there is extreme nausea and vomiting, as is usually the case with children, small pieces of ice dissolved in the mouth will relieve it together with the excessive thirst.

Period of Eruption.—With the outbreak of the papular eruption of smallpox, which usually appears upon the face on the third day of the disease, a notable decrease of the fever occurs with a decided improvement in the general condition of the patient. In a mild case, when a diagnosis of variola is not promptly made, the patient often returns to his business or pursues his or her customary duties with no thought of the danger to which others are exposed through contact or association. But the rapid development of the eruption soon leads to the discovery of its true nature and a realization of the importance of continued isolation.

During the papular and vesicular stage little or no internal medication is required, Gayton, an English writer on smallpox, who evidently shares the popular belief that the main duty of a physician is to give medicine, remarks that “we may also prescribe a little effervescing saline, for unless something is given in the form of medicine, the impression on the sick man’s mind is that you are doing nothing to assist him.” An intelligent public, in this country at least, is gradually awakening to the fact that skilful medical treatment cannot longer be measured by the number and size of the apothecaries’ bottles.

Although the appetite may now return, a restriction of the diet to simple and nutritious articles of food, such as milk-toast, eggs, oysters, and jellies, should be enforced.

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. It has been claimed by some enthusiast, though never demonstrated, that carbolic soap will abort the disease.

The local treatment of the eruption during the papular and vesicular stage has been a subject of experimentation for centuries, and the prevailing opinion at the present time is that little or nothing can be done to arrest its development. Most of the local applications, like the mercurial and other plasters of former days, though doubtless of some value, have proved generally to be more uncomfortable than beneficial to the patient. Tincture of iodine, pure or diluted, with an equal part of alcohol, nitrate of silver solution, collodion, picric acid, and more recently ichthyol, have been advocated by some and rejected by others after a careful test of their merits. Gayton recommends the use of the old itch lotion of sulphur and quicklime when cases present themselves before eruption or during the papular stage. He claims that if the lotion is rubbed over the whole body every four or six hours it will prevent the papules from reaching the pustular stage and thus avert the severe secondary fever. This surprising statement he bases on the observation of hundreds of cases.

The effect of light upon the development of the smallpox eruption is a subject of considerable interest, and in recent years it has become one of therapeutic importance. As long ago as the fourteenth century John of Gaddesden and other physicians of his time were in the habit of excluding both light and fresh air from smallpox patients. The walls and furniture of the sick-room were painted red, on account of a peculiar virtue supposed to reside in this color, and the unfortunate occupant was nearly smothered by red curtains hung around his bed. Ever since that time it has been a common custom to darken the room of a smallpox patient, partly on account of the photophobia present during the course of the disease and partly on account of the idea that sunlight would aggravate the eruption. The fact that the face and hands are most intensely affected would seem to substantiate this idea, but the argument fails when we consider that the feet are usually the seat of an eruption scarcely less profuse.

It was claimed by Black, in 1867, that the complete exclusion of light from the eruption of smallpox, even when occurring in unvaccinated persons, effectually prevented pitting of the face. Barlow, Gallivardin, and others, have expressed a similar belief. Experimentation by Finsen, Unna, and others having demonstrated that it was not the heat of the sun but the ultra-violet or chemical rays which cause solar eczema and pigmentation of the skin, it was suggested by Finsen that in place of the complete exclusion of light in the treatment of variola, it was only necessary to eliminate the chemical rays of sunlight by means of red glass windows or red curtains.

Acting upon this suggestion Lindholm, Svensen, Day, and others, treated smallpox by this new method, and made most favorable reports of their results. The red light proved agreeable and soothing to the eyes of the patients, frequently caused the vesicles to dry without becoming purulent, and lessened the suppurative fever. The patients, it is claimed, passed directly from the vesicular stage into convalescence, and neither pitting nor pigmentation of the skin was observed.

Some less enthusiastic experimenters with the red-light treatment of variola have been more moderate in their praises, and in some smallpox hospitals it has been tried and given up.

My own experience with this method is limited to the observation of a few cases treated at the Riverside Hospital in 1893. Under the direction of Dr. Cyrus Edson, health commissioner, one ward was fitted with red glass windows. The cases treated were of a mild type, and although no deaths occurred, the disease appeared to run its usual course and the experiment was negative as to results. In reply to a letter of inquiry, Dr. Edson writes me that “if the results had not been negative a very careful report would have been made.” For the advancement of therapeutic knowledge it is indeed unfortunate that while the enthusiast is always so ready to write, the sceptic or unsuccessful experimenter is usually inclined to remain silent.

Period of Suppuration.—With the transformation of the smallpox vesicles into pustules a rise of temperature occurs which is commonly known as the “secondary fever,” and in severe cases the swelling of the face, hands, and feet usually occasions the most intense suffering. The chief dangers of this stage arise from the possibility of septic poisoning and the probability of a greater or less degree of exhaustion.

A nutritious diet is now of the utmost importance, and in severe cases bouillon, malted milk, or other prepared foods which can be readily swallowed should be given every two or three hours. If the patient is in a stupor, he may be awakened in order to receive the necessary nourishment, but the calm, refreshing sleep which sometimes follows a period of wakefulness and complete exhaustion should not be disturbed. Alcoholic stimulants are usually of great service in this stage and may be given freely, especially at night and in the early morning hours when the patient’s vitality is at its lowest ebb. In case of delirium, rectal alimentation will often be found necessary as a substitute for or a supplement to oral feeding. The rectum should first be thoroughly cleansed by an enema of soap and water and then from four to six ounces of milk and brandy or eggnog may be injected.

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. In case of extreme prostration, when any effort by the patient or the mere raising of the head might lead to syncope or symptoms of collapse, it is advisable to wash out the patient’s throat and nostrils with a large swab of absorbent cotton, dipped in a saturated solution of boric acid. Pyrozone, borolyptol, listerine, and other liquids may be conveniently used for this purpose diluted with one or two parts of water. Small pieces of ice or ice-cream given at frequent intervals with a small coffeespoon will usually be found extremely grateful to the suffering patient.

For a purulent conjunctivitis which may sometimes result from the presence of pustules on the lids, the saturated solution of boric acid should be frequently used in the form of a spray.

When delirium occurs in this stage the patient must be closely watched, and, if necessary, the limbs may be kept quiet by linen sheets folded and carried across the bed and fastened at either end. Since chloral given by the mouth is liable to cause oedema of the glottis, it may be advantageously administered by the rectum, or in its place the bromides or a hypodermic injection of sulphate of morphine may be substituted, although when the patient is suffering at the same time from severe bronchitis the use of opium is objectionable.

The treatment of the eruption in the suppurative stage is of the greatest importance so far as the comfort of the patient is concerned. A host of applications and peculiar methods of treatment have been recommended and tested in successive epidemics. Many of these have been found to have no effect save to intensify the patient’s horrible appearance and to aggravate his discomfort. From time immemorial attempts have been made to prevent the pitting of the face after the disease by treatment of the individual lesions. The cauterization of the pustules with nitrate of silver after evacuation of the pus—the so-called ectrotic method—has been practised by many in the past, but the consensus of opinion at the present day seems to be that the procedure is as useless as it is painful. The ointments, plasters, pastes, and varnishes which have also been advocated are usually unpleasant or troublesome to use, and in the pustular stage are not likely to accomplish any desirable end. At this period it is too late to consider the possibility of preventing pitting, although the resulting injury to the skin may be reduced to a minimum by the use of all local measures which tend to reduce the grade of inflammation.

For the highly inflamed condition of the skin which characterizes the suppurative stage of smallpox, especially in its confluent form, cold water is, beyond all doubt, the best antiphlogistic. The cold compresses advocated years ago by Hebra constitute the simplest method of local treatment and one which is most grateful and beneficial to the patient. They exclude the air, macerate and soften the lesions, and lessen the local inflammation. Although it cannot be claimed that they modify in any degree the development and course of the eruption, it is doubtful whether anything better in the way of local treatment has ever been suggested. Pieces of lint should be dipped in cold water and applied smoothly to the face and other portions of the body where the eruption is abundant and the skin inflamed. To prevent their drying too rapidly a little glycerine may be added to the water and the lint covered with gutta-percha tissue or oiled silk. Moore recommends covering the face with a light mask of lint and oiled silk, having holes for the eyes, nose, and mouth. The lint is wet with a mixture of glycerin and iced water (f?i-f?i). If preferred, a cold solution of boric acid may be used in place of plain water, and when there is an excessive and unpleasant odor present, thymol may be added to the solution. Immermann states that he used for a time sublimate dressings to the face (1–1000), but found that plain water did quite as much good and was safer to use.

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. Indeed, if the patient is not in too critical a condition, he may be immersed for hours in a bath, as recommended by Hebra for the treatment of extensive burns, pemphigus, and various ulcerating affections involving a large portion of the body.

Period of Dessication.—When the distended, semi-globular pustules begin to dry, they tend to flatten, and often undergo a secondary umbilication from the shriveling of the central portion of the pock. In favorable cases the general condition of the patient improves as the fever subsides, and a more substantial diet may now be allowed.

The symptom which usually causes most local discomfort at this stage is the itching which invariably accompanies the drying of the pustules. This is often intolerable, and much of the pitting left after an attack of smallpox may be due to the tearing of the crusts from the face and other parts.

The best application which can now be made to the skin for the double purpose of softening the crusts and allaying the pruritus is a solution of carbolic acid in olive oil (five or ten per cent.). When the itching sensation of the face and hands is intense, it can be greatly relieved if the nurse will frequently spray these parts with pure chloroform, or, if the crusts have an unpleasant odor, with a mixture of chloroform and some antiseptic solution.

In the case of restless or unmanageable children the elbows may be put in splints so that the finger-nails cannot come in contact with the face.

Period of Convalescence.—When the crusts have dried and fallen from the face and body and no unpleasant complications still exist, the patient may be considered as a convalescent. No treatment is now required except a liberal diet, the daily bath, and a continued application of carbolized vaseline or some antiseptic oil. When the discolored cicatrices left after the falling of the crusts appear elevated and hard, as is frequently the case upon the face and hands (variola verrucosa), it is customary with some to paint them with tincture of iodine. A pleasanter and more effective application is a twenty per cent. solution of resorcin in rose-water.

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.

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. When a case of smallpox is first recognized, or even suspected, the patient should be isolated in a room from which all unnecessary articles of furniture, especially of soft texture, have been removed. A sheet moistened with some volatile disinfectant should be hung before the door, and no one allowed to enter the room save the nurse and doctor. A change of clothing should be made outside by the former whenever leaving the room, and a gown should be ready for the latter to wear at each visit. Upon leaving the sick-room the physician should carefully disinfect his hands and remain for some time in the fresh air before making another call. When the diagnosis is positively made, all who have come in contact with the patient, unless manifestly immune, should be found and vaccinated without delay.

During the course of the disease all discharges, such as fÆces, urine, sputa, or vomited matter, should be received in glass or earthen vessels containing a five per cent. solution of carbolic acid. Handkerchiefs and soiled rags should be burned or with towels and soiled sheets placed in a carbolic solution and allowed to remain for twelve hours. The plates, knives, forks, and spoons used by the patient should be kept in the sick-room and washed in a disinfectant solution by the nurse, while any uneaten food should be treated in the same manner as the patient’s discharges. When the patient has fully recovered, and, after personal disinfection, has left the sick-room, this should be thoroughly fumigated. The mattress and bed-coverings should be burned or, in large cities, sent to the Board of Health for disinfection. In case of death the corpse should be washed with a strong bichloride solution or painted with carbolized oil (twenty per cent.), and buried or cremated as quickly as possible. The clothing worn by the patient at the beginning of the disease should be destroyed or disinfected by baking for an hour in an oven at a temperature of 220°F., or steamed for five minutes at a temperature of 212°F.

In disinfecting the sick-room, the furniture, woodwork, and floor should first be scrubbed with carbolic soap and hot water or a solution of bichloride of mercury (1–500). The windows, ventilators, and fireplace should then be tightly closed and the fumes of burning sulphur or formaldehyde gas used to complete the disinfection. Sublimed sulphur burned in a moist atmosphere (one pound to every thousand cubic feet of space) is effective, but is at the same time objectionable on account of its tendency to bleach or discolor all textile fabrics. In well-furnished rooms, containing articles liable to be injured by sulphur or steam, such as wall-paper, paintings, books, etc., it is advisable to use, whenever possible, a formaldehyde gas-generator, which can usually be obtained from the local Board of Health.