Dm STOKES on the Prevention of Pitting in Small Pox. 111

/kaT. X I I I . ~ On the Prevention of Pitting qf the Face in Con~fluent ,Small-Pox. By WILLIA~ STOKES, M.D., Regius Professor of Physic in the University of Dublin, &c.

DURING the last few years the increased frequency of severe cases of small-pox has given opportunities of testing the com- parative merits of the various modes adopted to prevent disfi- gurement of" the face in this disease. These modes may be thus enumerated : A

1. The puncture of the pustules when matured. 2. The application of' nitrate of silver. 3.-The application of oil, or of the linimentum ca&is. 4. The covering the f~ce With a solution of gutta percha~

with collodion, or with glycerine. 1. As to the first of these modes of treatment, I have no

doubt that it tends to lessen the amount of pitting. But it does not appear so applicable to the worst forms of the confluent disease, as to those in which the pustules, though numerous, remain discrete for a longer period than in the severer cases. It is a slow process, but is not very painful, especially if the punctures be made at the right time, and is, I have no doubt, a mode of treatment which may be properly adopted in many instances. I think that, for its successful employment, we should have a benign type of the disease; that the pustules should appear and advance together; and that the amount of inflammation of the skin should not be great. In a case in which I performed puncturing with the greatest care, the crusts remained on the face for a considerable time; pitting was not quite prevented; and the depressions, though ex~ tremely slight, were numerous and continued obvious for many years.

2. /ks to the application of caustic, I have no personal experience, but i have no doubt that the conditions for its successful employment would be nearly those which have been mentioned as essential to the proper use of the first mode of treatment.

3. In employing oil, or the linimentum calcis, I prefer the latter, but I do not believe that either can be looked on as of much value. In some cases the heat of the face is so great as to produce rapid drying of any application that may be made. In one very severe case, the oil treatment was diligently pursued, and continued from the first appearance of the pustules until an advanced period of the disease. I t was, however, repeat- edly observed, that certainly within an hour after the free use of the oil, all traces of the application had disappeared, leaving

112 DR. STOKES on the Prevention of Pittlng of the F, zee

the parts hard, hot, and dry, and without any alleviation of local suffering. In this case, a great amount of pitting, espe- cially of the nose and cheeks, resulted. I t is worthy of remark that the patient, a young lady, had been carefully and success- fully vaccinated when an inti~nt.

It. is. probable that if the linimentum calcis has any advan- tage, it is owing to the water which it contains, and which acts as a temporary bath or stupe to the part.

4. During the past five years I have used gutta percha and collodion in a considerable number of cases. These, however, were not by any means examples of the worst form of the dis- ease. In most of them the crust came of[" in large flakes or patches, composed obviously of the dried exudations and the covering material, and leaving the skin uninjured. To render this treatment effective, at least so tkr as the exclusion of the air is concerned, it is necessary to renew the application at in- tervals of from twelve to twenty-four hours; "for the covering seems to be repeatedly broken up by the advance of the erup- tion and the swelling of the parts. Some patients are greatly distressed by the feeling of constriction caused by the coating of gutta percha or collodion, and in general the treatment in question appears unadvisable where there is much vascularity, heat, or swelling.

I was first led to adopt this treatment in consequence of the proposal of the late Dr. Graves to produce an artificial cuticle in dealing with various forms of skin disease; see the Dublin Quarterly Journal, August 1, 1852, where may be tbund re- ports of two cases of confluent small-pox, in which the solution of gutta percha in chloroform was employed successfully; in both these cases the pain and itching were relieved, and the face continued moist.

They were both of a typhoid character, wine having to be administered freely, and did not, by any means, exhibit the amount of vaseularity, heat, and swelling, observable in cases of a more sthenic type.

Dr. Graves advises that the treatment should not be used in the earlier stages of the disease. I believe that this point is not yet to be held as quite settled. I t is not proved that the repression of the eruption over a limited space is in chiei" dan- gerous; and, as we shall just now see, whatever lessens the vascularity of the skin bet%re the pock shows itself tends to lessen its amount.

I have not employed glycerine, but learn from my fi'iend, Professor Banks, that he has lately employed a combination of glycerine with lapis calaminaris. He speaks highly of its

in Co~fluent Small-Pox. 113

efficacy as an application to the face. I have no doubt that it will be found a mode of treatment most useful in a large number of cases. Its use is begun from the first periods, and continued until the scabs fall off.

I believe that in reference to the probability of pitting in small-pox, we must take largely into account the character of the disease. I f we look at two cases of confluent small- p~x, in which the amount of eruption and of confluence are similar, or nearly so, yet with opposite characters of fever, is will be found that the chance of pitting is much greater in the sthenlc than in the asthenio or typhoid case. It has happened more than once in the Meath Hospital, that in cases in which, from the condition of the surface after extreme confluence, there was every reason to hope that there would be no pitting, the patient had sunk on the twelfth or four- teenth day. From the rarity of the high inflammatory or sthenic variola during the last ten years, I believe that there are few affections more illustrative of the change in the vital character of disease, so well illustrated by Graves, Alison, and Christlson, than that of small-pox. Indeed, most of our hospital cases, for years past, have been of the asthenic type. They showed extreme weakness, a livid hue of the skin, a tardy and irregular advance of the pustules, and an early tendency to confluence. The pulse was rapid and com- pres3ible, and the action of the heart, though feeble, was jerking and excited. In the fatal cases the lungs seemed to be deeply engaged, and at about the middle stage of the disease many of the pustules on the legs and feet took on a deep purplish or !ivid hue, their appearance approaching to that of the vesicles in gangrenous erysipelas.

Looking at the frequency of pitting on the face, as compared with that of' other parts of the surface, it is not easy to account tbr it, unless by referring to the fact that, while the rest of the surface is kept covered, and so not only comparatively*ex- .eluded fi'om the action of the air, but in a state of humidity, the integuments of the face remain in a dry and heated state--first, from the action of the external air, and next, from the increased vascular action. Hard and hot scabs are formed, and the ul- cerative process makes its way downwards to a greater or less .degree. Some have held that the liability of the face to mark- lngs was to be explained by anatomical considerations. How- ever this may be, it.will be found that in cases in which from an early period certain portions of the face have been kept pro- tected fi'om the action of the air, and in a permanently moist state, pitting does not occur. This .may be seen in cases of

voL. xxix. ~o. 57, ~. s.

114 Da. STOKES On the Prevention of Pitting of the Face

sthenic confluent small-p., ox, where,, with the view of preventin g the adhesion of the eyetids, poultices have been used over the eyes. In such cases it will be often found that every part of the face is marked, except those over which the little poultices had extended.

The application of poultices over the face appears to me to be the surest mode of preventing the consequent disfigure- ment. We should commence their use at the earliest period,and continue it to an advanced stage of the affection. In most cases they may be applied even over the nose, so as to cover the nostrils; for these passages are generally so obstructed as to be for the time useless to the patient. I f the nostrils can be kept pervious by injections, the poultices need not be applied over their orifices.

I f the chances of marking are in proportion to the activity of the cutaneous irritation, we may hold that this method should fulfil three important indications of treatment--

1. The exclusion of air. 2. The moderation of the local irritation; and 3. The keeping the parts in a permanentl, y moist state, so

as to prevent the drying and hardening of the scabs. The value of this treatment, however, will, I feel convinced,

be best seen in the inflammatory or sthenic form of the dis- ease. The best poultice will be that formed of linseed meal, which should be spread on a soft material, such as French wadding, and covered with the gutta-percha paper or oiled silk. I have never had occasion to repent the adoption of this practice. In a case lately treated in this way in the Meath Hospital the result was very satisfactory, so fkr as the preven- tion of pitting over a large portion of the face was concerned. I say a large portion, for on the cheeks thick scabs remained strongly adherent for two months from the first invasion of the disease ; they are gradually, however, falling off, leaving the skin uninjured. I have never before seen such tardiness in the falling off of the scabs; and it is a question how far this condition was brought about by the treatment adopted.

The character of this case was typhoid. The eruption came out tardily, and was not well developed until after sti- mulants had been used; these, too, had to be employed libe- rally, and for a long period of time.

A remarkable appearance is to be seen in this case when portions of the loosened scab are detached. Long filamentous processes, very similar in appearance to asbestos, are found run- ning from the inner surface of the scab into the skin. I do not think that in this case there will be any pitting, but the

in Confluent Small-Poe'. 115

slowness in the detachment &the scab of the cheeks is most re- markable. Alkaline lotions have had little or no effect, and we have lately found the balsam of eopaiba, mixed with oil, to be very useful.

In connexion with this subject, I may mention two clinical observations of value : -

Some years since, when the" type of small-pox was not so decidedly asthenic, a young woman, who had been always strong and healthy up to the time of her illness, was admitted into the fever wards: She had been two or three days ill, and complained of symptoms which were supposed to be those of an early stage of fever, of an active type. The skin was hot knd dry, the pulse strong.and full, and the tongue loaded. She had, in addition, a degree of headach much more se- vere than is ordinarily observed in the commencement of fever. I t was, in fact, so intense, that I thought it necessary to use leeches to the forehead in considerable numbers- -a practice never adopted by us in the ordinary headach of fever, in which relief is given by three or four leeches, or by warm stupes to the head. In this case about twenty leeches were applied, a great deal of blood was drawn, and much relief fol. lowed ; but the fever continued, and within the next two days small-pox vesicles appeared on the neck and bosom. The case went on, and proved a most severe example of confluent pock over the trunk and limbs, but on the face not more than two or three aborted pustules made their appearance.

Here the pustular eruption of the face was apparently checked by an early modification of the local vascular action. I t is a question how far this view may be held to apply to the following case, already noticed by Dr. Graves in his paper on the treatment of skin diseases : - -

A man, who had been under treatment in our surgical wards for a chronic disease of the knee-joint, became affected with fever, followed by the appearance of variola of a severe type. He was transferred to the medical wards, and went through the stages of the disease in its confluent form. His knee had been strapped with mercurial plaster, and at the period of retrocession and the falling of the scabs, the dressings came off. We then observed this singular appearance : above and below the knee, and ending and commencing at a line exactly corresponding to that of the strapping, the integuments were covered with blackened scabs, while the knee remained completely f~ee of any sign of eruption, and silvery white, con- trasting strangely with the condition of the parts above and below it.

I 2

116 DR. STOZES on the Prevention of Pitting in Small-Pox.

This case occurred many years ago, and has an additional interest, as bearing on the proposal of M. Briquet to prevent the markings in small-pox by the use of a plaster, in which the principal ingredient is mercurial ointment.

I attribute the results in our case, and in those of M. Briquet, less to any specific action of mercury, than to the in- fluence of pressure on the vessels of the skin ~.

The practical conclusions which I am disposed to arrive at on this matter are as follows : m

1. That the chances of marking are much greater in the sthenic or inflammatory, than in the asthenie or typhoid con- fluent small-pox.

2. That, considering the change in the character of disease, both essential and local, observed during late years, we may explain the greater frequency "of marking in former times.

3. That in the typhoid forms of the disease the treatment of the surfkce by an artificial covering, such as gutta pereha, or by glycerine, will often prove satisfactory.

4. That in the more active or non-typhoid forms, the use of constant poulticing, and of every other method that will lessen local inflammation, seems to be the best mode of prevent- ing the disfigurement of the face.

"See Gazette M~dicale, 1851.