Produced by Thiers Halliwell, Bryan Ness and the Online Distributed Proofreading Team at http://www.pgdp.net (This file was produced from images generously made available by The Internet Archive/American Libraries.) Transcriberâs notes: In this plain text transcription, paired underscores denote _italicised text_ and paired asterisks denote *bold text*. A short table of contents has been inserted to assist readers. The following spelling errors have been corrected silently: pathognomic â> pathognomonic accidently â> accidentally coalesence â> coalescence hematomesis â> hematemesis hemorraghic â> hemorrhagic uniformily â> uniformly A PRACTICAL TREATISE ON SMALLPOX _ILLUSTRATED BY COLORED PHOTOGRAPHS FROM LIFE_ BY GEORGE HENRY FOX, A.M., M.D. CONSULTING DERMATOLOGIST TO THE HEALTH DEPARTMENT OF NEW YORK CITY WITH THE COLLABORATION OF S.Â D. HUBBARD, M.D., S. POLLITZER, M.D., AND J.Â H. HUDDLESTON, M.D. Technical Book Co. Domestic and Foreign Directories, Telegraphic Codes, Maps, Foreign and Domestic Periodicals, Technical Books MILLS BUILDING SAN FRANCISCO Telephone Garfield 19 Copyright, 1902 By GEORGE HENRY FOX PRINTED BY J.Â B. LIPPINCOTT COMPANY, PHILADELPHIA, U.Â S.Â A. CONTENTS Chapter Page I Symptoms and course 1 II Diagnosis 9 III Treatment 15 IV Vaccination 26 LIST OF ILLUSTRATIONS. NOTE.--The names of the colored plates are in capitals. The letters H., P., and F. in brackets indicate that the cases were photographed by Hubbard, Pollitzer, or Fox. PLATE I. VARIOLA ERYTHEMATOSA. (First Day.) This shows the earliest eruption upon back and buttocks. The photograph was taken about seven hours after its first appearance. The patient was sent to Riverside Hospital, where she developed hemorrhagic smallpox, and died on the fourth day. [H.] II. VARIOLA PAPULOSA. (Second Day.) Showing numerous incipient papules upon the face. Those upon the forehead were the first to appear and are most prominent. The cheeks present a characteristic leathery appearance. [H.] III. Variola Hemorrhagica. Showing upon the face and cheeks a form of the disease commonly known as âblack smallpox.â Figs. 1 and 2 were photographed on the second day and show a profuse and dark eruption. The swelling and disfigurement of the face present a most striking appearance. Figs. 3 and 4 were photographed on the fourth day, when the patient was in a moribund condition. [H.] IV. VARIOLA VESICULOSA. (Fourth Day.) A case of moderate severity, with well-developed vesicles and characteristic grouping of lesions upon the face. [P.] V. Variola Vesiculosa. Fig. 1 shows a mixed eruption of papules and vesicles upon the right thigh. (Third day.) This condition is exceptional in Variola, though quite common in Varicella. [F.] Fig.Â 2 shows well developed umbilicated vesicles upon the forearm. (Fifth day.) [H.] Fig.Â 3 shows a hemorrhagic effusion into the vesicles on the thigh and leg, a condition far less serious than the purpuric eruption of malignant variola. [P.] VI. VARIOLA SEMI-CONFLUENS. (Fifth Day, Sixth Day.) These illustrations show a partly confluent character which the eruption frequently presents, even in mild cases, and especially upon the legs. The influence of pressure in developing a more profuse eruption may be noted above the ankles, where shoes were laced, and below the knees, where garters were worn. [F.] VII. VARIOLA CONFLUENS. (Seventh Day, Eighth Day.) Fig. 1 shows umbilicated pustules with an intense Ådema of the foot, considerably increasing its size and causing much pain. Fig.Â 2 shows the epidermis raised in a large, irregular patch by the confluence of pustules. [F.] VIII. Variola Pustulosa. (Ninth Day.) Fig. 1 shows an eruption discrete upon the trunk and even upon the hand, while confluent upon the forearm. [H.] Fig.Â 2 shows a vaccine pustule coexisting with variolous pustules. The vaccination took place before the disease began, but too late to exert a decided prophylactic effect. [P.] Fig.Â 3 shows an eruption of large, flaccid pustules with swelling of the foot. [P.] Fig.Â 4 shows an eruption of discrete, tense, hemispherical pustules. [F.] IX. VARIOLA DISCRETA. (Ninth Day.) A typical case of mild smallpox occurring after vaccination and sometimes called Variola modificata or Varioloid. [P.] X. VARIOLA PUSTULOSA. (Tenth Day.) A severe case, showing the characteristic aggregation of lesions on the face and extremities. [P.] XI. VARIOLA PUSTULOSA. (Ninth Day, Tenth Day, Eleventh Day.) These illustrations show the pustular lesions in the stages of complete distention, when they present a rounded appearance, and of incipient desiccation, when they appear flattened and with a central depression or âsecondary umbilication.â [P., F., F.] XII. Variola Pustulosa et Crustosa. (Tenth Day, Twelfth Day.) In Fig. 1 an occlusion of the nasal passages is indicated by the lips parted in respiration. [P.] Fig.Â 2. shows a palmar condition which, in the adult, is found only in smallpox. [P.] Fig.Â 3 shows the desiccation of the facial eruption in advance of other regions. [P.] Fig.Â 4 shows a mild discrete case in which a diagnosis of acne had been made. [F.] Fig.Â 5 shows the eruption in the stage of desiccation. [F.] XIII. VARIOLA CRUSTOSA. (Eighteenth Day.) Showing a few thick crusts remaining upon the face with numerous dull red spots from which the crusts have fallen. [F.] XIV. VARIOLA DESICCATA ET SQUAMOSA. (Twentieth Day.) Figs. 1 and 3 show the dried pustules remaining in the thickened skin of palm and sole after the crusts have fallen elsewhere. [F., P.] Fig. 2 shows the superficial desquamation which follows the falling of the crusts, producing rings of partly detached epidermis. [F.] XV. Fig. 1 shows a peculiar pigmentation sometimes left after the eruption. The central portion, being darker, produces a âbullâs-eyeâ appearance. [F.] Fig.Â 2 shows the hypertrophic condition of the scars which occurs in certain cases in place of the usual pitting, and which tends to disappear in time. [H.] Fig.Â 3 shows severe pitting, a partial loss of hair and eyebrows, and destruction of one eye. [H.] XVI. Fig. 1 shows the typical appearance of a successful revaccination. (Fourth day.) [F.] Fig.Â 4 shows a small, well-formed vaccination pustule at its height. (Eighth day.) [F.] Fig.Â 2 shows a large, irregular pustule resulting from scarification of an area of unnecessary extent. (Eighth day.) [F.] Fig.Â 5 shows an ulcer resulting from infection of the vaccination lesion. [F.] Fig.Â 3 shows a primary vaccination at its height (eighth day) with a characteristic areola. [F.] Fig.Â 6, a case of Varicella on the third day. [F.] PREFACE. Whenever a physician is called to a case of suspected smallpox, he confronts a grave responsibility. If young or without special experience, he is apt to feel a sore need of assistance, and, although a book can never take the place of an experienced consultant, it is the object of the present work to render him as much aid as possible. The text aims to be practical rather than elaborate. The plates are reproductions of photographs from life, some of which have been obtained under great difficulty. While many articles on variola have been illustrated by a few photographs of cases, mostly of the pustular type, this work is believed to be the first which has presented illustrations of the smallpox eruption in each of its successive stages. It is sincerely hoped that the reader will find it of service in familiarizing him with the peculiar features of the disease. GEORGE HENRY FOX. SMALLPOX. CHAPTER I. SYMPTOMS AND COURSE. Variola, or smallpox, is an acute, contagious disease, characterized by an eruption upon both the skin and mucous membrane, with constitutional symptoms of greater or less severity. The eruption presents successively a macular, papular, vesicular, and pustular stage, the pustules finally drying into crusts, which fall and leave the skin temporarily discolored. Where ulceration has occurred it is permanently scarred or pitted. The lesions of the mucous membrane appear upon those parts more or less exposed to the air,--the mouth and eyes, for example,--but in exceptional cases they may be found throughout the entire intestinal tract, and in the uterus and bladder. These lesions do not run a course similar to those observed upon the skin, but appear as red macules, which rapidly change into ulcerations, covered with a whitish pellicle. The ulcers are imbedded in the substance of the mucous membrane and are not as superficial as in cancrum oris. The constitutional symptoms are most prominent during the periods of invasion and pustulation. There are various clinical forms of smallpox, which may be conveniently described as (1) discrete, (2) confluent, and (3) hemorrhagic, or malignant; and then, according to intensity, as (_a_) very mild, (_b_) mild, and (_c_) severe. The few purpuric spots seen in the severe discrete and the confluent forms are not of great significance, as they are generally due to a peculiar diathesis, and as a rule the patient recovers. The malignant form is almost invariably fatal. The term discrete implies that the lesions are separate and distinct, not coalescent. If the lesions coalesce and form patches of various shapes and sizes, the eruption is called confluent. For the purpose of differentiating the various forms above mentioned, it is convenient to first trace a normal, unmodified case of smallpox from the initial symptoms to recovery, and then to consider the severe forms, and finally the rare and obscure forms of the disease. *Period of Incubation.*--This extends from the date of exposure to the occurrence of clinical symptoms, a period usually lasting from twelve to fourteen days. *Period of Invasion.*--The disease is usually ushered in by fever, with a distinct chill or chilly sensations, headache, neuralgia, and a general malaise. Frequently the first symptom is a distressing backache. This is located in the lumbar region, but it may be as high up as the lower angle of the scapula, or it may be sacral and extend down into the thighs. The backache is an important symptom when present, but it is not always on hand to help one out in the diagnosis. The backache of smallpox is not peculiar or distinctive, but it is its severity which attracts attention. The headache is usually frontal and is an ache that is constant in character. The neuralgia is about the orbits, but may be facial, and is of a lancinating character. The fever may precede the backache or it may follow. It may be at first a rise of only a degree or two, or it may jump to 104Â°Â F., or as high as 106Â°Â F. The latter is most frequently seen in neurasthenic subjects and in children. The pulse rises in frequency and in tension. In children a convulsion not infrequently ushers in the disease. At this time convulsions are of little significance, but late in the disease they are of serious import. There are other constitutional symptoms, such as loss of appetite, vomiting, muscular pains, a dry, coated tongue, and at times an active delirium. The face is congested and swollen. The eyes are injected and present a bleared appearance, but the watery or weeping condition seen in measles is usually absent. The nose is dry, and a sore throat is not uncommon. Epistaxis is frequent. A very important symptom which sometimes occurs in this stage is a cutaneous efflorescence, which may resemble urticaria, scarlet fever, or measles. This latter resemblance is very close and often leads to diagnostic error. The efflorescence occurs most frequently in the young, and also in vaccinated adults. In some epidemics it is not at all uncommon, but as a rule it is rare. The duration of the stage of invasion varies from two to four days. Usually it is about three days. *Period of Eruption.*--Late on the third day or early on the fourth the eruption makes its appearance, and the constitutional symptoms subside to a certain extent. The rash appears first on the confined and moist portions of the skin or in irritated parts,--under a blister, for instance, which may have been applied for the backache. Normally, it is first seen upon the forehead at the hair-line, then behind the ears and down the tender part of the neck. It gradually extends down the trunk and arms, the hands and lower extremities being affected last. The eruption generally takes from twenty-four to thirty-six hours to cover the entire body. The best location to observe the rash for diagnostic purposes is on the back, where it cannot be obscured by scratching and where the warmth of the body causes the mildest congestion to appear at its best. The exposed parts are usually ill adapted for study of the rash, being obscured by the swelling and congestion of the face and by more or less dirt or staining of the hands. The rash consists first of small round or oval, rose-colored macules, which seem to be in the skin, coming up from beneath it, as it were. They disappear readily on pressure or on tension of the skin. When coalescence occurs, the lesions may resemble the blotches of measles. The macule at this stage is about from one-eighth to one-fourth of an inch in diameter, and its color is of an intense red which shows well at night, even by the light of a match. In less than twenty-four hours the centre of the macule becomes hard; and as this hardness increases, the lesion gradually rises above the skin. It is now changing into the papular stage. The macular stage lasts usually from eight to twenty-four hours. The papules continue to increase slowly in size, the apex becoming flattened or indented in some lesions. While this change is going on the redness of the macule forms an areola about the hard portion or central papule. This areola tends to get smaller as the papule gets larger, and at last is completely lost. If the pulp of the finger is passed over the papule, especially in its early stage, the latter seems to roll beneath it, giving the sensation of a small shot buried in the skin. When the papule is fully developed, the surrounding skin is put on the stretch, and the rolling sensation is lost, but the papule is so dense and hard that it is frequently described as âshotty.â The papule of varicella and of acne is not so dense and resisting as the papule of variola. The fully-developed papule in smallpox is rarely surrounded by a halo of congestion as it is in varicella, but in the modified form of smallpox this is not infrequently the case. The papule always arises from the centre of its halo like a bullâs eye, whereas in chicken-pox it arises from within the circumference, but not always in the centre. The halo of congestion in chicken-pox is always very broad and extensive, and is best seen upon the back. When a halo is present in smallpox it is very narrow and insignificant. The papule is usually fully developed in twenty-four hours. At the end of another twenty-four or thirty-six hours the apex of the papule shows a further change. It appears to be transformed from a solid to a fluid. The color also changes as the fluid increases, and the lesion appears bluish or purplish. The fluid continues to increase in amount until the papule is converted into a little blister or vesicle. As the change is going on, the height of the papule grows less and less, and when vesiculation is complete we have a broad, flat, umbilicated vesicle with a firm, dense base. To the touch these vesicles are firm and resisting, and the membranous covering is not easily broken, unless macerated by the perspiration due to heavy flannels. The vesicle is divided irregularly by little bands, or septa, which permit only a portion of the fluid to escape when one is punctured. Vesiculation is usually complete about the third day, and the stage generally lasts three days. It may be stated here that the reckoning in smallpox is usually from the appearance of the rash. The period of incubation and invasion are considered in reckoning the length of illness, but in descriptions of smallpox it is considered best to state the day of the eruption, and not of the disease. There is an old and oft-repeated statement that a uniform rash is a characteristic of smallpox and that a mixed rash indicates chicken-pox. This deserves to be promptly refuted. It is most unusual to find a case of smallpox with its eruption all in one stage. While it is a well known fact that chicken-pox runs a hasty course,--so that in from one to two days we may have macules, papules, vesicles, and even crusts,--in smallpox this is not likely to occur, as the disease never runs such a rapid course. In the early stage we may see macules changing into papules on the head and the neck, while there are simply macules on the trunk. Later in the disease the eruption may be vesicular on the head while still papular on the body. When vesiculation is complete, we have the distinct umbilicated appearance that has long been recognized as a characteristic of smallpox. The vesicles are broad, firm, flat, and hard, and are invariably indented or umbilicated. It is not until the stage of vesiculation that the constitutional symptoms diminish to a marked degree. In fact it is considered one of the landmarks of the disease for the fever curve to show a decline at this time. Late in the fifth or early in the sixth day the vesicle begins to assume a cloudy or yellowish hue, which denotes the commencement of pustulation. The fluid continues to grow more yellow, and about the time that it has assumed a dense straw color the umbilication begins to disappear, so that in from one to three days the pustule loses its indented appearance and becomes globular in form. To the touch it appears to involve as much of the skin below the surface as it is high above it. It is during the stage of pustulation that the surrounding skin becomes swollen and Ådematous, with an area of redness about the pustules giving the appearance of a bullâs eye. It is also during the pustular stage that the constitutional symptoms become more intense and the fever rises in proportion to the severity of the attack. The pustules are fully matured about the eighth day of the eruption. During the pustular stage the affection of the mucous membranes reaches its height. The eyelids, lips, and nose are often tremendously swollen. The tongue swells and deglutition becomes impossible. The voice is husky, and is sometimes lost, owing to the swelling of the glottis. About the ninth or tenth day of the rash another change appears in the pustule. In mild cases this change sometimes takes place several days earlier. In the centre of the pustule is observed a small, darker spot, which gradually grows larger. The membrane of the pustule becomes shriveled, and the little, dark spot continues to get larger and darker until it involves the entire area of the pustule. This is the drying stage, during which the fluid part of the pustule is absorbed, leaving the solid part behind to be exfoliated in the form of a crust. It is during this stage that, owing to the softening of its membranous covering, the pustule is broken by the movements of the patient or the contact of rough bed-linen. The pustules of the face are usually the first ones broken, and an ulceration frequently occurs which destroys the true skin and results in a pit or scar. Pustules do not rupture spontaneously and discharge their contents. Dessication lasts usually from five to twenty days, the exposed parts being the first to dry and shed their crusts. On the palms and soles the dessicated dÃ©bris is left deeply buried in the skin, and often has to be removed by the aid of a lancet or other instrument. Sometimes there is a pustule under the nail, and the removal of the kernel or seed is quite painful, though necessary. The crust is usually thin, of a light yellowish-brown tint, but slightly adherent, and is shed or picked off without discomfort. The spot where the crust has been is of a deep purplish hue, and the many little stains here and there give the patient a peculiar spotted appearance, which in time disappears, except where the ulceration has left a pit or cicatrix. The pit soon loses its color and becomes of a whitish hue. As dessication proceeds the constitutional symptoms decline, the appetite returns, and the patient gains strength. *Complications.*--Sepsis is the one generally to be expected, and this may assume any form from a local affection, such as a furuncle, to a general septicÃ¦mia. Furunculosis is frequent and is often annoying, and no sooner is one boil healed than others follow. Bed-sores are also frequent if proper care is not used to prevent them. Bronchitis from the affection of the mucous membranes may occur. When simple, this can be handled easily; but when general pneumonia results, death is inevitable in the weakened condition of the patient. Ulcers and opacities of the cornea, laryngitis and croup (the latter generally fatal), zoster, sciatica, nephritis and gastritis, are all frequent complications, especially in severe cases. *Confluent Smallpox.*--In this form the vesicles coalesce or run together, forming variously shaped and sized blisters, which as pustulation proceeds are usually ruptured in some manner and become infected, forming large, thick scabs with extensive ulceration underneath. The inability to properly cleanse such cases causes a very fetid odor to be given off and makes the patient an exceedingly difficult one to treat. In the mild confluent form the disease is similar to the discrete form only that several lesions coalesce. In the severe confluent form the coalescence is extensive and large blisters are formed. The swelling about them is intense, and with the extensive sepsis the patient rarely survives. The swelling of the face and extremities is sometimes enormous, and the suffering is so severe as to make death a welcome visitor. Confluent smallpox runs a course similar to that of the other forms, except that it is not as rapid as the third and is usually more severe than the first. *Hemorrhagic Smallpox.*--This is recognized as the malignant form of variola, and is rapidly fatal in most cases. It runs its course precipitately, and at times most unexpectedly,--sometimes killing the patient in a few hours and in other cases not completing its career until the fourth or fifth day. Hemorrhages may come on suddenly and the patient expire before any rash appears. In one case an efflorescence appeared and so closely resembled scarlet fever that it was mistaken for it. Suddenly hemorrhages set in, and within six hours the patient was dead. There was a question at the time as to whether the case was malignant scarlet fever or malignant smallpox. Later a room-mate came down with a typical case of smallpox and helped to clear the doubt. The hemorrhage usually occurs as the disease changes from vesiculation into pustulation. The severity of the hemorrhagic form of the disease is shown by the rapidity with which it passes through the various stages. Macules appear, and within a few hours rapidly change into papules, which almost as rapidly change into pustules; and before pustulation is complete hemorrhage occurs, and death quickly follows. It is not unusual in these cases for the disease to run its course in from twenty-four to thirty-six hours. In many, severe constitutional symptoms mark the onset, hemorrhages occur immediately, and death results before the rash appears. The hemorrhages are from the mucous membrane of the eyes, nose, and mouth, and from the anal, vaginal, and urethral orifices, the membrane swelling enormously. Hemorrhage occurring in the skin causes it to become raised and of a livid purple or bluish tint. The eyes seem to bulge as if about to drop from the orbital cavity. On the abdomen the hemorrhage is beneath the skin, causing raised lesions with a sharp border and a flattened top, feeling dense and firm to the touch. In the peritoneum the hemorrhages are extensive. The constitutional symptoms in this severe form are typhoidal in character. The mind appears at ease, quietly passing into a comatose state. The countenance is pinched and sunken, and the skin is dusky and purplish. The eyes appear bloodshot and listless. The breathing is rapid and superficial. The delirium is of a quiet character, and death comes as a most welcome termination. CASE I.--McD. Admitted to the hospital with a high fever (106.4Â°Â F.) and complaining of sore throat. One hour after admission there was noticed a very intense red rash, eyes bloodshot, and patient stupid. Patient isolated for scarlet fever. Hemorrhages came from eyes, nose, and mouth. Vomited blood in large quantities. Purplish spots appeared on the skin and spread rapidly over the whole cutaneous surface. Three hours after admission the patient died. CASE II.--The patient, J.Â H., attended the funeral of a relative in New Jersey. Ten days afterwards he received a letter stating that the person had died of smallpox, but that they desired the matter to be kept secret. Feeling nervous, he got vaccinated. Three days from the receipt of the letter he did not return to work after his lunch, and complained of feeling weary. Went to bed, telling his wife to call him at four oâclock, as he had an important engagement. At half-past three his wife went to call him, and found him bleeding profusely. She called a neighboring doctor, who notified the Board of Health. The health inspector called at five P.M. Patient unconscious; face dark and dusky; eyeballs bulging and blood oozing from them. Hemorrhage from nose and mouth. Vomited a large quantity of dark, coagulated material. Pulseless at both wrists. Temperature 108Â° F., by rectum. Diagnosis, hemorrhagic variola. Ordered patient removed. Ambulance arrived at 7.15, just after the patient had died. No autopsy. Through the courtesy of Dr. A.Â H. Doty, the following cases may be quoted. They were reported to the Health Department of New York City with a diagnosis of malignant hemorrhagic smallpox. CASE I.--Mr. J.Â F., aged forty-four years. Removed to Reception Hospital on suspicion of typhus fever, December 8, 1893, when the following history was obtained: Patient was taken ill on December 3. On the following day, December 4, great weakness was experienced. Gradually became worse. Epistaxis, etc. On December 7 an eruption appeared. On December 8 the patient presented the following appearance: Face uniformly red, or of a dusky hue, and swollen; on close examination a faintly papular condition was apparent. Over chest, abdomen, and extremities was found a profuse papular eruption, of a very dusky or violet-colored hue. On the abdomen some of the papules had coalesced. Papules were noticeable on the hands and feet, particularly on the palms. On the inner surface of the thighs the entire skin presented the appearance of a scarlatinous eruption, although darker in color. Pressure on the surface did not leave a white streak or spot typical of scarlet fever. In some parts of the body papules were found which were almost black. At this time, December 8, there was no evidence of vesication. On December 9, the third day of the eruption, the latter presented no particular change in its appearance or progress. It still remained papular. Intense depression and delirium were present. At 3 P.M., December 9, the patient was removed to North Brothers Island. On December 10, the fourth day of the eruption, a few vesicles appeared for the first time. These formed slowly about the lower part of the abdomen and thighs. At these sites were four or five typical umbilications. On December 11, the fifth day of the eruption, many more umbilications were found. The patient became rapidly worse, and died on the following day, December 12. CASE II.--Mr. F.Â S., aged twenty-four years. Removed to Reception Hospital on suspicion of typhus fever. On December 8 the appearance of this case was similar to Case I., inasmuch as the face was swollen and presented an erysipelatous appearance, although the color was more of a dusky hue. Large erythematous patches, suggestive of scarlet fever, were found covering different parts of the body. The same condition was present in this case as was noticed in Case I.,--_i.e._, the color of the patches was darker than in scarlet fever, and when the finger was drawn over the patch it did not leave a white line. No patches were found on the arms; but at these sites were dark, almost black, papules, which slowly became vesicular and umbilicated. The eruption was confluent on the upper part of the thighs and the face, and the patient died on December 8. CASE III.--Mr. P.Â B., aged twenty-six years. Removed to Reception Hospital, December 16, 1893, on suspicion of typhus fever. On December 17 he presented the following appearance: The face and the entire trunk and upper portions of the thighs and shoulders presented an eruption which could easily have been mistaken for scarlet fever. The eruption was dotted with dark or black papules; some vesicles were noticed on the trunk. The eruption on the thighs was shotty and umbilicated and quite characteristic of variola. The face presented the same appearance as in Cases I. and II. On the legs and forearms, where the general redness was not present, the eruption had hardly gone beyond the macular stage, but was very dark,--almost black. As in the other cases, the finger drawn across left no white mark. It was stated that epistaxis had occurred. The patient became rapidly worse, without much change in the eruption, and died on December 17. CASE IV.--Mr. L.Â R., lawyer, aged forty-three years. Removed from boarding-house, December 24, 1893, to Reception Hospital. Seen at home previous to removal, December 24. Patient felt badly on December 17. On December 20 was quite ill; pains in different parts of the body; nausea and vomiting. This condition continued until December 23, when an eruption appeared. Diagnosis, scarlet fever. On December 24, with the exception of the legs and forearms, the entire body and face was involved in a general eruption resembling scarlet fever. However, as in the preceding cases, it was of a darker hue than that found in scarlet fever, and pressure upon the skin made no impression so far as changing its color. Over the legs and forearm was distributed a profuse papular eruption, very dark in color. On other parts of the body were scattered some dark or almost black papules, with a few vesicles; typical umbilication was also present in some. A few small vesicles were noticed on the nose. These had the appearance of inflamed follicles, and were not as dark colored as the rest. The conjunctivÃ¦ were very much congested, and the membrane of the mouth was so much swollen that it was impossible to examine the throat. Hematemesis was present, also great prostration from the outset. The patient died on December 25. CHAPTER II. DIAGNOSIS. There are few diseases the prompt recognition of which is of greater importance to the physician than variola. On the one hand, failure to recognize the disease may subject the family of the patient and the community at large to the danger of contagion, and thus even be the starting-point of a widespread epidemic; on the other hand, to pronounce a case smallpox when it is not, entails so much needless pain and anxiety that the physician guilty of so grave an error merits the severe condemnation which will certainly be visited upon him. The recognition of a case of smallpox may be simple, difficult, or even impossible, depending on the case and on the stage of the disease. In general the disease is readily recognized when the case is typical and the eruption has reached the vesicular or pustular stage. The diagnosis is difficult in atypical and complicated cases. It is impossible with any degree of positiveness in most cases in the pre-eruption period,--the stage of invasion. The initial symptoms of smallpox resemble the first symptoms of so many infectious fevers that it is only through a consideration of the prevalence of an epidemic and the opportunities for infection in a given case that the physician may be put on his guard. It is important in this connection to notice whether the patient has been successfully vaccinated within a recent period. The physician who during the prevalence of an epidemic finds an unvaccinated subject suffering from a febrile disease of acute onset, with severe lumbar and dorsal pains, may, in the absence of definite symptoms pointing to some other disease, suspect smallpox; but a positive diagnosis at this stage is, of course, impossible. *Prodromal Rashes.*--The occurrence of the prodromal rashes, the roseola variolosa,--a more or less diffuse scarlatiniform, morbillic, or urticarial rash which may appear on the second day of the fever,--has a certain diagnostic value; but this roseola occurs in only a small percentage of the cases, and, unfortunately, sometimes appears in other acute toxÃ¦mic conditions,--typhoid, for instance. The scarlatiniform rash may lead to a diagnosis of scarlet fever and the morbillic roseola be mistaken for measles; but these diseases would be excluded by the absence of the angina and the strawberry tongue of scarlatina in the one case and of the catarrhal symptoms of measles in the other, aside from other considerations. The appearance of the eruption on the second day of scarlatina is followed by a marked defervescence, while the scarlet rash of smallpox is not accompanied by any change in the temperature curve. The eruption in measles occurs on the fourth day of the illness, a circumstance which alone suffices to differentiate it from the morbilliform roseola of smallpox. The characteristic and pathognomonic âKoplik spotsâ on the buccal mucous membrane in measles are, of course, absent in smallpox. Furthermore, these prodromal eruptions of variola are of extremely evanescent character and usually disappear within eight or ten hours. Of somewhat greater diagnostic value in this stage is the appearance of small hemorrhages, or petechiÃ¦, varying in size from a pinâs head to a pea, in the brachial and crural triangles of Simon. This form of prodromal eruption, however, is extremely rare, and, it may be added, is of grave prognostic significance, as it is usually the precursor of hemorrhagic smallpox. *Meningitis.*--The intense headache, vertigo, delirium, and coma of meningitis, especially meningitis of the convexity without localizing symptoms, may be mistaken for severe prodromal symptoms of smallpox. As a rule, pulse and respiration are slow in meningitis, while in smallpox respiration and pulse are both markedly rapid. *Cerebro-spinal Meningitis.*--In cerebro-spinal meningitis, in which an erythematous or purpuric rash appears, the difficulties of diagnosis are often such as tax the skill of the most expert clinician. It is important to remember that the rash of cerebro-spinal meningitis usually develops gradually or in successive crops, and that its distribution over the cutaneous surface is irregular, while the eruption of smallpox makes its complete appearance within the space of a few hours and is localized chiefly on the face and extremities. The stiffness at the back of the neck and the retraction of the head are symptoms that do not belong to smallpox. *SepticÃ¦mia and PyÃ¦mia.*--Acute septicÃ¦mic and pyÃ¦mic conditions in which there are hemorrhagic and bullous lesions in the skin sometimes present grave difficulties in making a differential diagnosis from smallpox. In general, however, a careful elucidation of the history of the case will bring out some points that serve for differentiation. It must be admitted, however, that the diagnosis between cryptogenetic septicÃ¦mia and hemorrhagic smallpox is sometimes impossible _intra vitam_. A case of this kind may be cited which occurred in New York during the epidemic last year. A woman of thirty, not vaccinated since childhood, living in a house adjoining one from which a case of smallpox had been removed, was reported to the authorities as a possible case of smallpox. It was the sixth day of her illness, which had begun abruptly with headache, backache, vomiting, and fever. On the third day of the illness there was a profuse hemorrhage from the uterus, and thereafter metrorrhagia was almost constant. On the fourth day a scarlatiniform eruption was noticed on the legs and abdomen. The rash rapidly extended and was soon interspersed with hemorrhagic points. When seen on the evening of the sixth day the patient was semi-comatose. The skin was literally covered with a dusky scarlet rash in which were noted countless hemorrhagic macules, from a pin-point to a bean in size. The conjunctivÃ¦ bulbi were chemotic, the tongue was swollen, and the fauces were deeply congested. The post-mortem examination made the following morning, six hours after death, revealed a septic endometritis, and streptococci were cultivated from the blood and the peritoneal serum. *Grippe.*--An attack of grippe may simulate the early symptoms of smallpox very closely. The onset may be sudden, the muscular pains severe, the pyrexia decided, the general prostration as marked as in smallpox. In grippe, however, the muscular pains are, as a rule, more general than in smallpox, there is rarely profuse sweating, and symptoms referable to the respiratory tract soon develop, if indeed they are not present from the beginning. *Rheumatism.*--The severe lumbar and sacral pains of smallpox have been mistaken for rheumatism, but such an error can be made only where the use of the clinical thermometer is unknown. A febrile movement in lumbago is absent or but slight, while in smallpox the pyrexia is usually pronounced. *Typhoid and Typhus.*--Typhoid and typhus fevers have at times been confounded with smallpox. But errors of this kind can be made only where the history of the case is completely ignored. In typhus, it is true, the eruption, petechial and almost papular in character, may suggest hemorrhagic smallpox; but the eruption of typhus rarely appears before the fourth or fifth day of the illness and is located chiefly on the trunk, sparing the face. The rash of malignant smallpox develops usually on the third or even the second day of the illness and is not limited to the trunk. Upon the appearance of the rash in a typical case of smallpox the febrile diseases with which it is most frequently confounded are measles and varicella. It is interesting to note that until the time of Sydenham, in the latter part of the seventeenth century, measles and smallpox were regarded as manifestations of the same disease, and that the Vienna school of dermatologists, even to this day, insists on the etiological unity of variola and varicella. *Measles.*--As a matter of fact the early papular eruption of measles bears a considerable resemblance to the first stage of the eruption of smallpox. In both the eruption is noted first in the face. In smallpox, however, the papules have a firm, âshottyâ feeling on palpation, while in measles they are smooth and velvety to the touch. In measles the eruption, viewed at a little distance, seems to present a distinctly corymbose or crescentic grouping, an arrangement which is absent in smallpox. The eruption of smallpox appears at the end of the third day, that of measles on the fourth day. The temperature in smallpox undergoes a rapid defervescence upon the appearance of the rash, while in measles it continues to rise after the eruption appears. The pronounced pain in the back is absent in measles, while the very marked catarrhal symptoms, coryza, conjunctivitis, etc., are lacking in smallpox. The subsequent course of the eruption will leave no room for doubt, since within twenty-four hours the papules of smallpox will have developed into characteristic vesicles. *Varicella.*--In varicella the stage of invasion is usually much shorter than in smallpox, the prostration less marked, and the lumbar pains of the latter disease are absent. The eruption in varicella comes out in successive crops and runs a shorter course, so that lesions in various stages of development may be seen side by side. The temperature does not necessarily fall on the appearance of the eruption, and there may be a more or less marked rise with each fresh crop of vesicles, the temperature curve presenting thus a remittent character. The eruption itself presents marked differences in the character and the course of the individual lesions, as well as in their distribution. The clear vesicles shoot up from the surface, as it were, without warning; or there may be for a brief period only a circumscribed erythema like that which usually precedes the appearance of an urticarial wheal. The vesicles of varicella have usually a somewhat obtusely conical shape, while those of smallpox are distinctly hemispherical. The characteristic umbilication of the smallpox vesicle is wanting in varicella. It is true the varicella vesicle often shows a depression at its apex; but this false umbilication, as it is called, is due to the rupture of the vesicle and the escape of some of its fluid or to a partial drying of its watery contents, and occurs only after the vesicle has existed for some time. The vesicle of varicella appears much more superficial in its seat, and its roof is much thinner, so that it ruptures readily. Very moderate pressure with the finger suffices to break it. When ruptured in this way the vesicle usually collapses completely, contrasting in this respect with the smallpox vesicle, from which, owing to the multilocular character of the lesion, all the fluid does not escape. In varicella the distribution of the lesions over the surface is far more erratic than in smallpox. The very decided tendency to grouping of lesions upon the face and about the wrists so characteristic of smallpox does not occur in varicella, in which the vesicles may appear even more extensively on the trunk than upon the face. In varicella the palms and the soles, except in infants, are almost never affected; while in smallpox these regions are practically never exempt. It is true that in the extraordinarily mild cases of smallpox, such as have constituted the majority of cases during the past two years throughout the West, lesions may or may not be present on the palms and soles; but in the severe and moderately severe cases, such as have characterized the recent epidemic in New York, the soles and especially the palms have practically without exception shown the lesions. The localization of smallpox lesions on the palms and soles deserves far more emphasis than is generally accorded it in the textbooks, many of which even fail to mention it all. It may be put down as a safe rule that a case showing an extensive eruption of vesicles or pustules, however suspicious in other respects, is not smallpox if the palms and soles are free. *Acne.*--Among the skin diseases proper there are a few whose appearance upon hasty examination may occasion some confusion with smallpox. Acne pustulosa presents only a superficial resemblance to variola, but in cases where it is accidentally associated with an acute febrile disease, like grippe, for instance, it may give rise to some diagnostic difficulty. In these cases, however, inquiry will develop the fact that the acne lesions have been present before the inception of the febrile disease; and the presence of comedos, the limitation of the lesions to the face, chest, and back, together with the absence of any lesions on the palms and soles, will serve to exclude smallpox. *Impetigo Contagiosa.*--In impetigo contagiosa there might under similar circumstances be a momentary doubt as to the nature of the illness. Impetigo lesions have no typical distribution on the surface, the mucous membranes are always exempt; the vesicle itself is extremely superficial, ruptures very readily, and is at once replaced by a crust, so that lesions in various stages, vesicles, pustules, and crusts may always be seen at the same time. *Zoster.*--Zoster is, as a rule, readily distinguished by the definite grouping of the lesions in the tract supplied by one or more nerves, its asymmetrical distribution, and the more or less severe neuralgic pain that precedes or accompanies the eruption. It must be remembered, however, that in zoster, in addition to the typical grouped lesions, there are occasionally seen a few isolated vesico-pustules scattered promiscuously over the entire surface; and the difficulty of diagnosis may be increased by the occurrence of a moderate temperature movement. In these cases, to which attention was first called by Teneson, the history of the case, the presence of characteristic herpetic groups, and the evolution and course of the individual lesions will suffice to clear the diagnosis. *Drug Eruptions.*--The ingestion of bromides, iodides, and quinine is sometimes followed by an eruption which may create some confusion in diagnosis. In general the drug eruptions may be distinguished by the absence of fever and of the subjective symptoms of smallpox. The bromide and the iodide acne never occur on the palms and soles, where there are no sebaceous glands, and the lesions lack the evolution and course of the variolous eruption. The erythematous and purpuric eruption of quinine may be confused with the hemorrhagic form of smallpox; but here, too, the history of the course of the illness and the absence of fever will obviate the difficulty. *Syphilis.*--Of all the diseases of the skin it is the pustular syphilide which most resembles the lesions of smallpox. Dermatologists and experts in variola are agreed that the pustular syphilide may be absolutely indistinguishable from smallpox so far as the appearance and distribution of the lesions is concerned. Furthermore, the pustular syphilide is frequently accompanied by a decided febrile movement. The differential diagnosis can be made in these cases only by the closest inquiry into the history of the case and by careful observation of the course of the disease. The characteristic history of an acute illness of short duration followed by a remission on the appearance of the eruption will of course be wanting in syphilis. The syphilitic eruption is more sluggish in its evolution as well as in the course of its subsequent changes; and though there may be lesions of syphilis on the mucous membrane of the mouth, they will lack the characteristic appearance of the vesicles and pustules of smallpox in this region. The palms and soles are not apt to show any lesions in this form of syphilis; and finally some other forms of syphilitic manifestation are very often present in this polymorphic disease to give the clue to the real nature of the eruption. In conclusion, the fact should be emphasized that there are cases of smallpox of so mild a character, with general symptoms so slight and eruption so sparse and ill-defined, as to make a positive diagnosis extremely difficult. It is a good plan to employ vaccination in such cases as a test. Within three or four days the experienced observer will be able to determine whether the vaccination is successful or not; a negative result will of course have but a moderate value, but a positive result will serve to definitely exclude the diagnosis of smallpox. In all cases of doubt, whether before or after the eruption has appeared, the physician owes it to himself not less than to the patient and the community to frankly explain to the patient or his family the difficulty in arriving at a diagnosis, and to express his suspicions that the case may be one of smallpox. It need hardly be said that such a case should be as strictly isolated as if the diagnosis of smallpox were already established. CHAPTER III. TREATMENT. 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 physicianâs 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
{'title': 'A Practical Treatise on Smallpox by George Henry Fox', 'source': 'Project Gutenberg', 'lang': 'en'}