Whichever method is chosen the room should remain sealed for at least 8
hours. Even at the end of this time care must be exercised in entering the
apartment and in so doing one should wrap the face in a wet towel, pass quickly
THE INFECTIOUS DISEASES.
to a window and open it, allowing the gas to escape and the fresh air to
Since the discovery of vaccination by Jenner in the last decade of the i8th
century we have had at our disposal a practically absolute preventive of
smallpox and since that time the disease has become a rarity in districts in
which the procedure has been systematically instituted. Consequently too
great insistence cannot be laid upon the necessity for the routine performance
of the operation. All children should be vaccinated at from 3 to 5 months
of ago, every 7 years thereafter and in the intervals whenever smallpox is
prevalent; at such times one should never be satisfied with one unsuccessful
attempt. While vaccination does not always protect, the disease as it occurs
in those who have undergone the operation is very rarely severe.
Treatment. Since no means exists of shortening the disease when once
infection has taken place the treatment is to be directed at the control of the
symptoms and the prevention of permanent scarring. At the onset the patient
should be isolated and put to bed in an airy room, the temperature of which
should be kept constantly at about 65° F. (18.5° C.) and the bowels should
be opened by repeated fractional doses of calomel or other mild laxative, to be
followed by a saline, if necessary. The symptoms of the first stage which
need special attention are the pain, the vomiting, the diarrhoea and the cerebral
manifestations. The pain may be relieved by the administration of acetpheneti-
dine, acetanilide or salipyrine, usually in combination with caffeine to prevent
heart weakness. Morphine may become necessary in severe instances.
The ice cap to the head and the application of analgesic liniments such as
the following, I^ camphors, chloralis, mentholis, aa B i, may prove beneficial.
The vomiting may be controlled by swallowing small pieces of cracked ice, by
minute doses of phenol, hydrocyanic acid or cocaine or by frequent sips of
iced champagne, and the diarrhoea by means of bismuth naphtholate or iodo-
phenolphthaleinate (dose of either gr. v to viiss — 0.33 to 0.5); bismuth
subsalicylate or subgallate in connection with small doses of opium may also
be employed to relieve this condition. The nervous symptoms may be
rendered less distressing by potassium or sodium bromide or hydrated chloral,
any of which may be given per rectum as well as by mouth. Sulphonmethane
is also useful and in the extreme instances the employment of morphine
or opium in small doses may be necessary.
Cool sponging, tepid tub baths and the ice helmet are also useful in the
treatment of the cerebral manifestations.
The temperature is seldom high enough to cause alarm but if necessary
it may be reduced by the application of the ice coil over the precordium or
by cool sponging. Rarely is cardiac weakness an early symptom but should
this be the case stimulants such as caffeine, alcohol or strychnine may be
The dryness of the mouth will be alleviated and the activity of the skin and
kidneys will be favored by frequent cold drinks which should be offered at
The eruptive period. During this stage the problem confronting us con-
sists of two parts, the treatment of the cutaneous manifestations and that
of the constitutional condition. In the former the chief object is to prevent
permanent scarring and numerous methods have been employed with this
end in view. Of these the simplest and one of the most eflEicacious is to cover
the skin with a thin gauze compress which is kept moist with cold i to 5000
to 10,000 mercury bichloride or i to 200 or 300 phenol solution and is
covered with oil-silk. For the face a suitable mask can be made. The
phenol has the especial advantage of neutralizing the unpleasant odor
of the disease. The wet compresses have a certain analgesic effect and are
grateful to the patient. CUpping of the hair is necessary if the eruption
involves the scalp to any extent. Of other means of treating the skin the
employment of wet dressings of weak thymol or potassium permanganate
solutions may be mentioned. Many more drastic applications have been
advocated, such as touching the eruptive points with pure phenol, painting
with silver nitrate solution or ^ strength iodine tincture and even opening the
pusfliles and touching them with stick silver nitrate, but none of these is
likely to yield better results than the simple cold wet compress.
Dusting powders have a place in the treatment of the eruption especially
in its early stages. Of these boric acid, bismuth subgallate, talcum, or a
mixture of phenol i part and lycopodium powder and zinc oxide of each 16
parts are to be recommended. Scrub-baths given daily are said to prevent
pitting since they hinder the formation of the vesicles and pustules; they
are, however, a drastic measure. Continuous warm baths have also been
advocated. The administration of xylol — 100 to 120 drops (6.66 to 8.0)
in divided doses every 24 hours is said to diminish the mortality, to lessen
the characteristic odor of the disease and to tend to arrest the suppurative
stage, thus influencing the occurrence of pitting.
The variolous manifestations in the nose, mouth and throat require the
external application of cold and moisture and attention to the cleanliness of
the nasal and buccal cavities. Antiseptic sprays and mouth washes such as
Dobell's solution or diluted liquor antisepticus are useful here and astringenl
washes such as dilute solution of potassium chlorate or iron perchloride may
be employed. The discomfort attendant upon the appearance of the erup-
tion in the mouth may be alleviated by means of sucking bits of ice and by
emollient and demulcent drinks such as thin oatmeal gruel and teas of
arrow-root or marsh-mallow. If ulcers appear they may be touched with
a 20 percent, silver viteUin (argyrol) solution. Localized collections of pus in
the pharynx or tonsils should be immediately opened and drained.
240 THE INFECTIOUS DISEASES.
The conjunctival eruption should be carefully treated by means of contin-
uous compresses of cold boric acid solution (| saturated) and by instillations
of a few drops of a lo percent, argyrol or of a i to 500 methylthionine hydro-
chloride solution. Silver nitrate solution may be used but is painful and no
more efl&cacious than the silver viteUin. If the eyehds tend to become gummed
together this may be prevented by anointing their margins with vaseline,
either plain or containing 5 percent, of boric acid.
After the crusts have formed the patient should be advised to let them fall
spontaneously for if they are removed before they are wholly loosened the
pitting is apt to be more pronounced. Children should be prevented from
scratching by bandaging their hands loosely in gauze. The itching during
the period of crust formation may be relieved by means of the dusting powders
suggested upon the previous page or by warm baths to which bran may be
added and the scales may be protected from irritation by means of light
dressings of carboHzed vaseline or vaseline containing 5 percent, of boric acid.
If the scabs become detached for any reason before the skin beneath has wholly
healed the suppurating surface should be cleansed with a mild antiseptic
solution and dressed, until the skin has reformed, with borated vaseline.
Exuberant granulation tissue should be touched with stick silver nitrate and
The treatment of the constitutional condition during the stage of pustula-
tion offers "several problems. The strength of the patient must be maintained
by proper and sufficient nourishment and the pyasmic condition necessitates
the employment of measvires such as are indicated in suppurative states due
to other causes. Here alcohol in the form of brandy or whiskey, 2 to 4 ounces
(60.0 to 120.0), and infusum cinchonas in large doses are highly recommended.
The former may be given either diluted with water or in the form of a milk
punch with egg; to the latter a few drops of dilute hydrochloric acid and
spirit of nitrous aether may be added with advantage. The fever seldom
needs especial treatment but should it be alarmingly high the application of
an ice coil to the precordium will usually result in a considerable reduction.
The coal tar antipyretics should be employed with great caution if at all. The
condition of the heart should be carefully watched and should stimulation
be required in addition to the alcohol, strychnine and caffeine may be given
in appropriate doses and should there be evidence of collapse hypodermatic
injections of camphor dissolved in olive oil or aether become necessary. Ner-
vous symptoms may be controlled by the bromides and chloral which may
be given by rectum or by mouth as indicated. The dose of the latter must
be such as to be in no danger of causing heart weakness. Tepid baths are
also useful in relieving the nervous hyperexcitability.
The administration of antistreptococcus serum has been suggested as a means
of combating this stage of the disease and not without reason since the pres-
ence of the streptococcus in the contents of the pustules is common. This
procedure is especially indicated in patients with grave septic symptoms; 15
drachms (60.0) may be given in 3 doses 24 hours apart or in profoundly toxic
instances this quantity may be given in one day. Attempts at controlling
haemorrhages may be made by giving ergot hypodermaticaUy or better by the
internal or rectal administration of calcium chloride. The latter exerts a dis-
tinct influence in increasing the coagulability of the blood and may also be
given in hsemorrhagic forms of the eruption. Its dose is 20 grains (1.33) 3
times a day.
The treatment of the complications is little different from that of similai
conditions occurring independently. OEdema of the glottis may demand
scarification, intubation or tracheotomy. Pneumonia should be prevented
by careful management of its precursor, bronchitis, and by frequent turning
of the patient upon his side to prevent hypostatic congestion of the bases of
the lungs. Pharyngeal suppuration and furunculosis necessitate appropriate
The treatment of smallpox by means of red light has recently been advo-
cated, especially by Finsen, who considers the omission of this method to be
little less than criminal. The idea is not new, having been exploited by John
of Gaddesden in the 14th century. According to Finsen, who excludes the
ordinary daylight by means of panes of red glass, daylight and particularly
its chemical rays have an injurious effect upon the course of the disease since
the suppuration of the vesicles is brought about by exposure to unchanged
sunlight. Upon the infection per se the Hght seems to exert no action. The
avoidance of suppuration, however, is most important, since the stage of pus
formation is the most dangerous epoch in the disease and many fatalities
result primarily from the suppuration. The method must be properly and
systematically employed, but if pus formation has already taken place or is
about to begin the red light will not abort it. Finsen considers that in ordinary
epidemics this treatment will reduce the death rate by one-half. Many other
observers have used the light treatment with good results while still others
are much less enthusiastic in its advocation.
Various other methods of treatment have been recommended with enthu-
siasm, among which may be mentioned that by means of intestinal antiseptics
such as the phenolsulphonates, phenyl salicylate (salol), mercury bichloride,
etc., and that of Talamon who applies a spray to the skin composed of mercury
bichloride and tartaric acid, of each 15 grains (i.o), alcohol (go percent.) one
and a quarter drachms (5.0) and aether to make an ounce and a half (45 -o)-
With this the skin is sprayed for i minute 3 or 4 times a day, the eyes being
protected. The surface is first washed with soap suds, rinsed with boric acid
solution and dried with cotton. The treatment is begun with the appearance
of the rash, and after spraying, the face is covered with 50 percent, mercury
242 THE INFECTIOUS DISEASES.
bichloride glycerite. After 4 days the spray is used less often and after i
week it is discontinued, the glycerite dressing being continued. The same
observer has recommended in the confluent type of the disease baths of
mercury bichloride solution lasting 45 minutes to i hour, internal stimulation
being employed at the same time.
The serum treatment of smallpox has thus far given no results which
render its use justifiable. Further advance in the elaboration of an efficient
serum therapy may be made in the future.
The convalescence usuaUy necessitates the employment of tonics and of
easily Higestible and nutritious food.
The diet of smallpox should be carefully regulated. During the initial
fever only fluids should be allowed but in the remission before the stage of
pustulation semi-solids such as gruels, soft-boiled eggs, meat jellies, etc., may
be given. At the onset of the stage of pustulation the patient must return to
fluids; it is at this time particularly necessary to maintain his strength, conse-
quently the diet should be as concentrated and nutritious as possible.
Synonyms. Cow Pox; Vaccine Disease.
Definition. An infectious disease characterized by an eruption and pro-
duced in man by inoculation with the contents of the vesicle of cow pox.
Individuals who have been successfully inoculated are, with a very few excep-
tions immune from smallpox, and even if able to contract the disease such
subjects are affected with its mildest form, varioloid.
Whether vaccine disease is a separate disease or is the variola of the human
being as manifested in the cow is a moot point, opposite views being held
by different observers; one point is certainly evident, however, to the un-
prejudiced, and this is that could vaccination be systematically and thoroughly
carried out smallpox would become an unknown disease. Unfortunately
certain fanatics oppose the compulsory performance of the operation and
until these experience a change of heart and compulsory inoculation is in-
stitituted cases of variola wiU be seen from time to time and where a proper
soil is offered epidemics will occur.
That inoculation with cow pox was a sure preventive of smallpox was
discovered and proven by Edward Jenner, of Gloucestershire, England, in
While in all probability vaccine lymph contains a specific micro-organism
which is responsible for the train of symptoms which foUows inoculation,
no such body has yet been successfully isolated although much research upon
this subject has been carried out. Various bacteria and amcjeboid bodies
have been found in the lymph but none of these has been proven to be the
essential cause of the disease, vaccinia.
In inducing vaccinia in the human being and rendering him subsequently
immune to smallpox infection two varieties of virus are employed, the human-
ized and the calf lymph. The former is the pus from the pustule of a vacci-
nated human being, the latter is the contents of the pustule of the cow or
calf. The latter is chiefly used at present and is preferable since the human-
ized virus is capable of transmitting syphiHs to the inoculated person should
the individual from whom the virus has been taken be unfortunate enough
to be infected with specific disease. While the possibility of the transmission
of tuberculosis in the same way has been considered it has never been proven.
The operation of vaccination is performed as follows: The site selected is,
in the case of boys, the outer side of the arm at the junction of its upper and
middle thirds. In vaccinating girls in the upper walks of life it is preferable
to use the outer side of the calf. The skin over the part chosen should be
steriHzed by washing with soap and water, alcohol and i to 5000 mercury
bichloride solution, wiped with sterile water and allowed to dry. Then with
a needle which has been steriHzed by heating in a gas flame a surface one-
eighth to one-fourth of an inch in diameter is lightly scratched, care being
taken not to draw blood, but merely to remove the upper layers of the integu-
ment. A slight exudation of serum wiU follow this procedure and into this
the vaccine should be rubbed for several moments. The surface should be
allowed to dry and then dressed lightly with a compress of sterile gauze.
The various shields sold to cover vaccination wounds should not be used.
Different makers supply dried vaccine upon quiUs or ivory points, which may
be used instead of the needle to abrade the skin. When from a reputable
firm these may be employed. The health boards of certain cities furnish calf
lymph put up in glass tubes and packed with a needle, a bit of wood and full
directions for the performance of the operation.
The symptoms following vaccination. Shortly after the inoculation there
is a slight inflammatory reaction at the site of the abrasion which lasts but a
short time. If the procedure is successful and the vaccination takes, after a
period of incubation, occupying usuaUy 3 days, a small red papule appears,
by the 5 th to the 7 th day this becomes an umbilicated vesicle surrounded by a
pink areola and containing a viscid transparent fluid; by the loth day the areola
is more pronounced and the fluid has become purulent. The skin surround-
ing the pustule is often indurated and tender. From this time the inflammation
gradually subsides, the contents of the pustule begins to dry, about the 14th
day a brownish crust forms which becomes flnaUy hard and dry and falls
about the 21st day, leaving a roundish depressed scar which is red at first but
finally becomes whiter than the surrounding skin.
In many instances constitutional symptoms accompany the evolution of
the vaccinal pustule. These vary from slight malaise and irritabflity with
rise of temperature about the 3d day to marked prostration with a febrile
244 THE INFECTIOUS DISEASES.
movement lasting from i to 2 weeks; with this there are headache, gastric
disturbances, restlessness, etc. The number of white blood cells is increased
and enlargement and tenderness of the axillary or inguinal glands, depending
upon the site of the inoculation, occur.
The duration of the immunity conferred by vaccination varies in different
individuals but it is best to revaccinate every 7 years and at other times whenever
smallpox appears epidemically. After from 10 to 15 years a second vaccination
is usually successful but the appearance of the pustiile and the constitutional
phenomena are less characteristic. Even in first inoculations the typical
result niay not be attained. In such instances the operation should be per-
formed again and repeated if necessary until success crowns the effort.
Generalized vaccinia is rare but may manifest itself as a pustular rash on
different parts of the body, appearing on the eighth to the tenth day; the
pustules are most abundant upon the vaccinated limb and may continue to
appear for several weeks. The disease may prove fatal in children.
Complications of vaccination. Cellulitis may occmr, especially in debili-
tated children as a result of contamination at the time of operation or sub-
sequently and may necessitate the employment of radical surgical measures.
Erysipelas is a serious complication and great care should be used in vaccina-
ting if the disease is prevalent. If the disease exists in the family of the
subject about to be vaccinated the operation should, if possible, be post-
poned. During the evolution of the pustule various skin eruptions may
appear and in certain instances dormant disease such as tuberculosis and
hereditary syphilis have manifested themselves.
The occurrence of tetanus as a complication has been noted in a number
of cases most of which were inoculated with lymph from one particular pro-
ducer. The possibility of such contamination should render us especially
careful to use lymph from reputable sources only.
The treatment of vaccinia is wholly symptomatic. Mild cases need no
treatment whatever. Those in which the constitutional manifestations are
unusually severe should be kept in bed and on a fluid diet during the febrile
movement. The bowels should be kept open and the kidneys and skin
active. The local condition and the glandular swellings should be treated
in accordance with proper surgical methods and for the complications the
means ordinarily applicable should be employed.
Definition. A painful constitutional disease, acute or chronic, due to an
abnormal quantity of the antecedents of uric acid in the blood, resulting in
various symptoms, of which joint inflammation is the most prominent and
characteristic, together with the deposition of urates in the neighborhood
of the articulation.
To Wallaston's discovery in 1779 that the deposits at and around the joints
were composed of urates we date our knowledge of this disease and its pathol-
.etiology. In many individuals there is an hereditary tendency but the
disease may also be earned. In more than half the cases a family history
The disease is more frequent in males than in females and it is through the
male line that the hereditary tendency is more likely to be transmitted. Gout
is seldom seen in young subjects and usually shows itself after the age of forty.
The stigmata, however, of the gouty diathesis may be detected as early as
puberty. The most common causes of acquired gout are excessive eating,
particularly of meats, and intemperate drinking, combined with sedentary
habits, yet these factors are by no means essential to its occurrence. It is
also true that not all who possess the hereditary tendency suffer for the indis-
cretions of their forbears, for proper mode of living may act as a preventive.
Over-drinking is a chief factor in the production of gout, but the form in
which the alcohol is ingested has a certain influence on the incidence of the
disease. Heavy ales and beers such as those brewed in England are more
likely to bring on gout than are the lighter malt liquors produced in America
and Germany. Whiskey is less to be avoided in this connection than heavy
wines, such as port. It is probable that the excessive carbohydrate content
of these beverages is the causative factor of the disorder, resulting, as it does,
in the products of gastric acid fermentation, which, upon absorption render
the blood less alkaline and less solvent of uric acid.
Lead poisoning may excite an attack of gout, possibly as suggested by
Haig, because it may reduce the alkalinity of the blood.
Local traumatism to a joint, or even pressure from footwear may bring on
246 CONSTITUTIONAL DISEASES.
an attack in the injured part. The reason of the predisposition of the disease
to attack the great toe joint is unknown.
Pathogenesis. With regard to the pathogeny of gout there is much differ-
ence of opinion, but most authorities unite in beUeving iiric acid to some ex-
tent a causative factor. Whether this substance causes the train of symptoms
known as "gouty" by its increased production in the body, by its diminished
excretion or both, is not certainly known. We are not unanimous in thinking
that the sodium biurate which forms the tophus is the cause or the result of
the pathologic process, but Sir William Roberts' theory that uric acid
normally does not as such circulate in the blood, but only as a soluble quad-
riurate of some base, is probably correct. In normal urine, uric acid is always
present in the form of sodium, potassium or ammonium quadriurate. These
are unstable salts and in the presence of the normal sodium chloride solution
of blood or lymph become converted into the more stable and less soluble
biurates. In health the quadriurates are too soon removed to become converted.
Evidently, therefore, in gout, something delays excretion long enough for
them to be changed into biurates, and this takes place in those tissues, such
as the synovial fluid, the cartilage and the fibrous tissues, which contain the
greatest proportion of sodium salts. The tophi, therefore, occur first where
there is plentiful synovial fluid, then in the cartilages, then in the fibrous