THE SURGICAL TREATMENT OF SMALLPOX.

BY LAUREL B. SANDALL, M. D., AU SABLE, MICHIGAN.

CAPTAIN AND ASSISTANT SURGEon of UNITED STATES VOLUNTEERS.

DURING my first eight years in medicine I had the good fortune to see but one case of smallpox. This was a mild case in the early stage in a free clinic in Chicago. When the doctor enterd the small clinic room and with a look of horror on his face diagnosed the disease smallpox the most of us students lost our thirst for medical knowledge and almost clambered over each other to reach the zero weather outside, hoping to be purified by the cold and ozone-laden atmosphere.

With little knowledge of smallpox and no other contact with it, in the fall of 1899 while on the advance with American forces along the railroad north of Manila, I received my first exprience in treating this disease.

Among the natives of the Philippines, smallpox is nearly always present, smouldering along with sporadic cases during the dry season, only to break out afresh with thousands of cases during the rainy months. In central and northern Luzon a large portion of the entire population is pock-marked, many having partial or total loss of one or both eyes from this cause. In the Southern (Visayan) Islands, especially Samar and Leyte, there are fewer people who bear evidence of the disease, but during recent years it has been very prevalent there.

The way in which the natives live favors disease of all kinds. They huddle together in a one- or two-roomed hut, wherein at night the entire floor is covered with sleeping humanity, on thin mats. In the average families all the members eat with their fingers from a general supply and drink from a cup made from a cocoanut shell, which is never washed during its years of use. The floor of these houses, made of split bamboo placed an inch apart, is four to six feet from the ground. Under this the family caribou (native ox) is tied at night for safety from ladrones, and here the pigs are penned, either tied by a string through the ear or running at large. The pigs are the scavengers of the country and live on the offal and waste from cooking, dishwashing, et cetera, including excrements, all dropped through the floor. It is necessary to see the filth surrounding a native house to fully appreciate how the inmates live. To an occidental, the only question arising is why they do not all die from contagious and infectious diseases. They pay no more attention to smallpox than to measles, will hide their patients and practice every means of deception that could occur to an oriental mind, to keep the health officers from discovering one of their friends afflicted with the disease.

During three years' campaigning and garrison duty on five different islands, I was stationed in but one town wherein I did not know smallpox to be present. The mortality among the natives was appalling and the fatalities among the Americans that came under my observation and treatment so great that I was led to seek any mode of treatment which might give promise of a lower death rate. After eighteen

months' experience I decided upon the one which is the basis of this article.

In May and June, 1901, I was in charge of three isolated posts. The natives were dying by scores daily, and the only American stricken with the disease in this section under my care died on the eighth day of discrete smallpox, the case being milder in every particular and the number of pustules much smaller than in the one cited below. The government furnished virus for free vaccination of all natives, and over ten thousand were vaccinated at these three posts in a few weeks.

I wish to speak first of an initial rash. I saw several hundred cases of smallpox in different stages, and in every case seen before the second rise of fever and before the shotty rash appeared, this particular rash was present-easily seen on the white skin of the Caucasian, less prominent but always discernible on the darker skin of the native Filippino. Beside the diffuse, macular or measly rash, there was always present a deep-pink, blood-red or purplish pin-head-sized eruption, seemingly "set" into the skin, consisting sometimes of only half a dozen such spots scattered over the chest, abdomen, groin or inner side of the thigh, sometimes of a hundred or more on a patch the size of the palm of the hand. In some instances no other rash but this was discovered before the shotty rash appeared. This rash was so indicative and constant that after a few months' experience, I was always able to make a diagnosis from it when found. One patient in particular, a soldier on whom only a few spots appeared on the chest, had been sent to the typhoid fever ward where I was then on duty. On the recognition of this rash alone, no other being present, diagnosis of smallpox was made, against the protests of all who saw him. Eight days later he died, the case having been a severe one of discrete smallpox.

Sunday morning, June 16, 1901, a corporal of Company K, First Infantry, was reported at sick call almost delirious with a temperature of 104° Fahrenheit. He had been feeling badly only two days, complaining of severe headache and aching of the bones, not localized in the back. Upon casual examination of the arms and chest, nothing was noted. When stripped for the temperature bath, several of the pin-head-sized blood-red spots referred to above, were found in the left infraclavicular region and a patch of perhaps fifty, purplish in color, in the left groin. Smallpox was diagnosed immediately. Two tents were erected on the beach, one for the patient and one for nurses. One of the soldiers in Company K, who was an immune, kindly volunteered to nurse his comrade; and as an assistant we secured a native Filippino of the Twenty-first Company of native scouts, also an immune.

Being chagrined and mortified at the death rate of my previous experience with smallpox; being away from medical advice and books and remembering that the absorption of poison from the pus is the direct cause of death, I reasoned that to prevent or remove the pus must be the indication for treatment. Pursuing this indication in a crude way led me unknowingly to the surgical treatment of smallpox.

For two days the patient's condition was little changed. On the night of the second day, his temperature was practicly normal and through the succeeding stages never went above 100° Fahrenheit. The shotty rash appeared on the face, arms, chest, and on the margin of the scalp, and by the fourth day covered the entire body, the spots on the face becoming vesicular.

GENERAL TREATMENT.-Aside from headache powders the first few days and occasionally a slight purgative, little or no internal medi⚫cation was used. Antiseptic baths were given over the entire body twice a day, and the face and hands were almost continually bathed.

SURGICAL TREATMENT.-Needles, knives, and scissors were given the attendants and hundreds of little swabs were made by twisting absorbent cotton on the ends of toothpicks. An antiseptic solution of bichlorid or of carbolic acid (the only ones at my disposal) was constantly kept at the bedside. A solution of bichlorid one to five thousand was first used and gradually increased to one to one thousand. Carbolic acid was used one to one hundred at first and later one to forty. As soon as the first spots became vesicles they were opened, the contents wiped away, and then one of the little swabs dipped into the antiseptic solution was with a slight twisting motion thoroughly applied to the vesicle floor. As the rash developed rapidly, it was found impossible for the two attendants to open all the vesicles before they became pustules, but special attention was paid to the face and hands. The patient would lie for hours, often asleep, with the two attendants working at the pustules as described above, and always expressed relief from the work rather than fatigue or discomfort. One part of the body would be exposed at a time and the largest pustules opened first. I do not think that there were twenty drops of pus in all the spots on the body at any one time, and as stated above the temperature never went above 100° Fahrenheit; yet he had many more spots on his body than other patients that I had seen pass into delirium and die on the seventh or eighth day. A very few small pits remained about his nose and some on his arms and chest. The eyes were highly injected, swollen and very painful; in fact that was the only symptom of which he complained. Recovery was complete and the loss of flesh scarcely noticeable.

In this case and in thirty or more subsequent ones, the effect of the different modes of opening the pustules was closely observed, and it was found that those from which the entire top was removed healed the quickest; when simply opened they sometimes closed again and refilled. In opening the pustules there is no pain and seldom any blood, even if the entire top is removed. It is practicly the same as opening a blister or vesicle of any variety.

The assortment of instruments was limited, but I would recommend an instrument resembling a curved keratome, and would remove the whole cover or top of the pustule. An intelligent native made for me crude instruments resembling this for use among the Filippinos and in the native smallpox hospitals.

If it is conceded that the presence of pus in the skin is the direct cause of death in smallpox, it is likewise conceded that its prevention or its removal when present is the rational treatment. The spots opened in the vesicular stage often heal without pus, and the pustules, opened and evacuated, heal more rapidly and prevent the absorption of the poison into the system. It is remarkable with what rapidity a person of mediocre intelligence will open and cleanse the pustules. It is tedious and requires a great deal of help, but it shortens the disease and that it saves life cannot be questioned. It also prevents or lessens pitting, which in some instances would be of great value.

The expense should not be a bar when results are so plainly within reach and the saving of life so easily and surely within the hands of the attending surgeons. If the pus in the thousands of pustules were collected in one abscess, no surgeon would hesitate to evacuate it immediately, and the fact of it being scattered over the entire surface of the body does not to my mind change the indication of treatment, the mode being merely a matter of detail.

SUMMARY.

Begin the antiseptic baths as soon as the patient is seen, keeping the skin as nearly aseptic as possible.

As soon as the first spots become vesicular open them by removing the top. Remove all the contents and apply a swab saturated with some antiseptic solution, reaching the entire surface of the vesicle floor.

Treat pustules in the same way after they have formed, endeavoring to keep the skin free from pus. If this is done there is little secondary fever.

The vesicles once thoroughly opened and destroyed do not proceed to pus formation but heal directly, thus obviating the possibility of absorption of the poison.

TRANSACTIONS.

CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.

STATED MEETING, FEBRUARY, 25, 1903.

THE PRESIDENT, CHARLES B. NANCREDE, M. D., IN THE CHAIR.
REPORTED BY JOSHUA G. R. MANWARING, M. D., SECRETARY.

REPORTS OF CASES.

A CASE OF PARALYSIS AGITANS.

DOCTOR PATTON: This woman is thirty-one years old. She has been married and divorced. There is nothing particularly interesting in her family history except that she proceeds from a very nervous family. There is no history of serious disease-syphilis, consumption or any other infectious ailment. She has never been well, has experienced nearly all the diseases of childhood, having had typhoid, whooping

cough and measles all in one year. Her periods were very painful at puberty. After she was married she had a leucorrheal discharge. About four years ago her present affection began with a tremor in the right hand. The fingers were not involved and the tremor was from side to side. Later she experienced pain in the right wrist. ` The tremor then extended to the fingers and they are now held in the postition of holding a pen. Later the tremor involved the right leg, and then the left hand, left arm and left leg. The muscular rigidity is shown by the position in which she holds her head forward. The patient says she is much weaker than when the disease seized her. The only change in her condition is a constant progression. This tremor is a rather coarse tremor, about four or five to the second, and is not of the intention variety. She can control it and in this it differs from the tremor of multiple sclerosis. It is a typic case of paralysis agitans. The history is entirely free from any etiologic factor. Paralysis agitans usually appears in patients past middle age, although it began in this patient when she was only twenty-seven years old. The treatment of this case is hyoscine hydrobromate, one one-hundredths of a grain night and morning, elixir of iron, quinin and strychnin, static spark and breeze. The tremor seems to be controlled a great deal by the hyoscine hydrobromate.

DISCUSSION.

DOCTOR SOLIS: In relation to the point regarding age. In the last six years we have had four cases of about the age of thirty, so that we find many patients whose ages are below those which the books give. In no instance was there any family history of the disease. This woman had a great emotional strain. A few months after her marriage she was under depressing circumstances and the disorder followed this period. Emotional disturbance is nearly always a factor in paralysis agitans and this patient displayed that very decidedly. Her husband abused and threatened her and this disorder followed soon thereafter. There is not much known of the pathology of this disease. The latest investigators classify it as a disorder of the motor cortex. There is some change in the blood supply. None of the patients recover. They become progressively worse. I have not known of a single case that recovered. The condition may last thirty years.

HYSTERIC ATTACKS.

DOCTOR SOLIS: The case I wish to report is that of a young girl, aged nineteen years. The family history is absolutely negative. The patient had all the usual diseases of childhood, with no sequelæ. She attended school until seventeen years of age, when the present affection began. This consists of attacks in which the patient makes an outcry, becomes unconscious, froths at the mouth, bites her tongue and undergoes a series of tonic and clonic muscular contractions. The first attack occurred at 3 o'clock in the morning. Then the other attacks followed. at varying intervals from four to three and two weeks, finally occurring