A Practical Treatise on Smallpox 3

A Practical Treatise on Smallpox 3

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 septicæmia. 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

(106.4° 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. 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 o’clock, 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 108° 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. 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. 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. 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. 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. 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 conjunctivæ 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.