A Practical Treatise on Smallpox 5

A Practical Treatise on Smallpox 5

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 physician’s 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 character of the treatment is demanded both by the

peculiarities of the eruption and the accompanying general symptoms.

Instead of considering the various types of variola from a therapeutic

stand-point, therefore, it would seem more practical to discuss in

their natural order those measures which are adapted to the successive

stages of the disease, beginning with the

 

*Period of Incubation.*--During this period, which extends from the

date of infection to the appearance of the earliest symptoms of the

disease, treatment is rarely demanded, since in the great majority of

cases the outbreak of the disease is a surprise, and in no case can

it be positively known that a patient has smallpox until the initial

symptoms appear, and often not until the characteristic eruption has

developed. In many instances, however, it is quite certain that an

individual has been exposed to the contagion of variola; and when

such a one happens to be unvaccinated, or has not been vaccinated in

recent years, the assumption is strong that the disease may have been

contracted and will manifest itself in due time.

 

The question as to whether vaccination can have any notable effect

in modifying the course of variola when performed after a person has

been exposed to and has contracted the disease is one concerning which

a considerable difference of opinion is expressed by modern writers.

While some contend that even if vaccination fails to prevent the

development of variola it is quite certain to modify its severity,

others claim that it can be of no more advantage than locking the barn

after a horse has been stolen.

 

The precise effect which vaccination during the stage of incubation

may exert upon the subsequent course of the disease is very difficult

to determine in one or even a small number of cases, since it is

almost impossible to predict in any given case what the severity of

the disease will be. In the opinion of Curschmann it is very doubtful

whether vaccination can even render the course of smallpox milder. He

states that in many instances where vaccination has been performed

after exposure to smallpox infection the pustules of vaccinia and

variola have been seen developing side by side, the former having

apparently no effect upon the latter. In the opinion of Welsh, on the

other hand, vaccination after infection often modifies the disease,

and not infrequently prevents it altogether. He believes that when

vaccinia has advanced to the stage of the formation of an areola around

the vesicle, about the eighth day, it begins to exert its prophylactic

power against smallpox; and as the period of incubation in variola

is usually twelve days or more, an early vaccination may exert its

protective influence in advance of the time when the variolous eruption

should appear.

 

Welsh reports one hundred and ninety-four cases of vaccination

performed during the stage of incubation, in which thirty-eight

were perfectly protected against smallpox, sixteen almost perfectly

protected, thirty-one protected to a well-marked degree, thirty

partially protected, and seventy-nine were unprotected.

 

Of these one hundred and ninety-four cases the death-rate was 12.90

among those vaccinated early in the stage of incubation; it was 40.98

among those vaccinated from one to seven days before the eruption of

smallpox appeared; while among the unvaccinated cases the death-rate

amounted to fifty-eight per cent.

 

As it is well known that a secondary vaccination runs its course more

rapidly than a primary one, it is evident that if an exposed patient

has been already vaccinated a secondary vaccination is more apt to

exert a protective influence. Since vaccination with humanized virus

is more speedy in its effect than when bovine lymph is used, it is

advisable to employ the former when readily obtainable and to make

several insertions in order to increase the probability of success.

Even a late vaccination in the stage of incubation may be of value,

as it sometimes happens that this period lasts fourteen days or more.

Early in the nineteenth century Waterhouse claimed that two days after

infection vaccination would save the patient.

 

Good results from the subcutaneous injection of vaccine lymph have also

been claimed by Farley and others, but the efficacy of this method of

treatment appears to have been assumed rather than proven.

 

The speedy vaccination of all those who have been accidentally exposed

to smallpox infection will do no harm, even if it fails to modify the

disease when contracted. Indeed, it is always advisable, since the

persons exposed, even if not already infected, are liable to contract

the disease through possible subsequent exposure; and in the case of a

threatening epidemic no precaution should be neglected which might tend

to lessen the number of possible cases.

 

Since no drug nor specific remedy exists which administered during the

period of incubation will abort or modify the subsequent eruption, the

only thing to be done is to prepare the patient by means of a rigid

regimen and all possible hygienic measures to withstand the impending

attack. When the fact of exposure is certain, forewarned should be forearmed.