III. Exanthematous Diseases.
Variola.
Synonym:—Smallpox.
Definition:—An acute infectious disease, the chief characteristic of which is an eruption which passes successively through the various stages of macule, papule, vesicle and pustule, ultimately becoming umbilicated. There is an active febrile movement, severe pain in the back, and vomiting.
Etiology:—Much difficulty has been experienced in determining the exact cause of smallpox. More recent observations have confirmed the opinion that it is due to a parasitic microorganism, the cytorrhyctes vacciniae.
The contagion is spread by direct contact with the body or clothing of the patient, or by anything that he may have come in contact with. It may be readily carried by an individual, from one patient to another, and has been conveyed by letters sent by the patient or from the sick room to friends at a distance. It is also conveyed by insects and vermin. Much effort has been made to determine to what degree the infection is carried directly through the air, with no intervening medium. It is believed that it may be so conveyed for nearly half a mile. The vitality of the virus remains for a long time after the death of the patient, and the bedding and furniture of a room will convey the disease for many days, unless thoroughly disinfected. The disease is peculiar to no age, race, climate or sex. Infants and young children are more readily attacked and are more seriously affected. Adults from twenty to thirty-five years of age furnish the larger per cent of the cases, probably because at that age they are in a position to more readily become infected, or to carry the infection. The negro race is particularly susceptible, and with them the disease is very fatal.
It prevails more extensively in the winter months, declining in the spring and as the summer approaches. It prevails in tenement neighborhoods and in the crowded regions of large cities. The severity of the attack in an individual patient does not depend so much upon the virulence of the infection, as upon the susceptibility of the individual. A typical case, however mild, may convey the disease in all the virulence of a confluent, or hemorrhagic form, to a susceptible individual.
Symptomatology:—From six to twelve days after exposure to the infection the first symptoms appear. The premonitory symptoms are a most severe backache, general malaise, extreme muscular soreness and an excruciating headache, usually frontal. Almost simultaneously with the occurrence of these symptoms is a severe rigor and the rapid development of a high temperature. The pulse becomes decidedly rapid, the respirations are increased and the patient has all the evidences of severe illness.
During the past five years our country has been subjected to a visitation of the disease in an exceedingly mild form, so mild that its real character has been seriously questioned by many observers, it having been frequently diagnosed and treated as a severe case of chicken pox. The infection from these cases did not convey the typically severe form of the disease in any instance.
Other symptoms are nausea, vomiting, loss of appetite and usually obstinate constipation, although in a few cases an intractable diarrhea has appeared. The pulse at the onset is rapid, but it is usually full and strong until the eruption appears. The temperature at the onset may reach 105° F. within the first twenty-four hours, and perhaps 106° F. at the end of forty-eight hours. This high temperature is maintained with but little variation, until the eruption appears. At this point there is a rapid reduction of the temperature to perhaps 99° F. or perhaps 99.5° F., where it will remain until the pustular stage of the eruption occurs, when it will rise abruptly from 102.5° F. to 104° F. This is called the secondary fever. It has regular morning remissions, and if the disease progresses favorably will ultimately end by lysis on the twelfth or fourteenth day. In some cases this secondary fever may be so mild as to be overlooked.
This disease is properly classified by the character of the eruption, into three distinct forms, the commonest of which, the discrete form, presents the symptoms which we have just given. The other forms are the confluent form, and the hemorrhagic form, known as black smallpox, or malignant smallpox.
In the discrete form of the disease, the eruption appears about the third day, in the form of coarse red spots, usually upon the forehead first, and at the edge of the scalp, and on the wrists. The macular appearance of the eruption soon develops into a distinct papule, somewhat elevated and hard upon pressure, and conveying to the finger an indurated feeling, as if a single small shot was just beneath the skin. After perhaps twenty-four hours a tiny vesicle appears at the seat of the induration, which increases in size to the fifth day, when it is about the sixth or the fourth of an inch in diameter and contains a peculiar lactescent fluid. The vesicle does not collapse upon the escape of the fluid, and is surrounded by a distinct, narrow, bright red areola. The center of the vesicle becomes depressed, and by the sixth day it assumes the characteristic umbili-cated form. The fluid may become cloudy or purulent until, by the seventh or eighth day, it is distinctly pustular. The pus dries upon the surface of the eruption and forms a distinct scab, which is supposed to contain the characteristic infection of the disease.
There is a characteristic odor from the pustule of smallpox which to those who are familiar with it, becomes diagnostic.
In the confluent form of this disease the symptoms at the onset are apt to be more severe and the eruption appears earlier, the papules are much more abundant, the bases approximate each other more immediately, and by the time the pustule has developed, the entire surface of the skin is covered with a suppurating eruption. So severe an involvement of the entire surface of the body produces most serious impressions. The nervous system becomes involved, the lymphatics are swollen with the inflamed condition of the skin, and symptoms of general pyemia, with extreme typhoid phenomena, will develop.
In the form known as black smallpox a change takes place in the character of the blood. Its coagulability is impaired and hemorrhages take place into the skin, the mucous membrane and the viscera. In the more benign form, hemorrhage occurs into the pustule only, especially in those of the lower extremities. In the more dangerous form, the hemorrhages occur from the eruption, and from various points on the mucous surface, and into the various organs of the body. When a distinct hemorrhagic diathesis develops, the blood becomes diffused beneath the skin also, and there are extensive ecchymoses. These may appear before the characteristic eruption shows itself; nose bleed, bleeding from the gums, bleeding from beneath the conjunctiva, from the palate or tongue, is common, as well as bloody vomit, bloody stools and hematuria. These cases are nearly all fatal.
A rash appears in some cases of smallpox, which may be general over the entire surface of the body, and mislead the physician in his diagnosis. In some cases it closely resembles the initial rash of scarlet fever, in others it is similar to that of measles. As these rashes disappear quickly on the development of the smallpox eruption they should not deceive the physician, if he is a close observer.
VARIOLOID:—When smallpox develops after successful vaccination, every phase of the disease is greatly modified, the disease presents itself in a mild form, with symptoms characteristic of the modified disease. It is not necessary to describe the symptoms of varioloid separately, as it would be simply a presentation of all the phenomena in a milder type. It may be well to state that a diffused eruption is more apt to occur in varioloid than in variola. This simple or modified form of the disease is more apt to occur in patients who have not been vaccinated for many years, or in patients who possess a natural immunity to the disease. It should be borne in mind, however, that the infection from varioloid is not necessarily modified, but that the severe type of smallpox may be as readily contracted from this as from the primary severe disease.
Complications:—Considering the severity of smallpox, it is a matter of surprise that so few complications occur. Perhaps the commonest is septic arthritis; bed sores appear in protracted cases, erysipelas is not uncommon, inflammation of the lymphatic glands, with abscess, appears as a natural result of pus infection, and inflammation of the post nasal membrane, mastoid abscess, pharyngitis, laryngitis and bronchitis may appear, although they are not common sequelae.
A pregnant woman attacked with smallpox may abort early or she may pass through all of the stages of the disease with no abortion induced. The child may be born with all the manifestations of the disease, or it may be found to be immune to the disease, without presenting the usual evidences, or the disease may develop shortly after birth.
Diagnosis:—It is only in the early stages of this disease that the diagnosis presents any difficulties. The presence of an epidemic, and the fact that the patient has been exposed, will suggest the possibility of the occurrence of this disease. The sudden onset, with severe illness from the first, the extreme backache and headache are characteristic. The absence of any soreness of the throat will exclude the probability of scarlet fever or diphtheria, as will also the absence of the peculiar abrupt vomiting, which is present at the onset of scarlet fever. There is but little clanger of confusing the eruption of smallpox with any other eruption, except perhaps that of chicken pox and impetigo contagiosa. In chicken pox the constitutional symptoms are very mild, and in impetigo the development of the disease begins with the appearance of single blebs or blisters which have none of the peculiarities of the developing smallpox pustule.
Prognosis:—In varioloid the prognosis is always favorable. In the confluent and hemorrhagic types, the prognosis must be guarded as the mortality is very high. If large ecchymoses develop or severe hemorrhages occur, death is almost certain. In young men and in negroes the mortality is greater. The cases which have been previously vaccinated at whatever period of life are greatly modified. The occurrence of complications will increase the death rate.
The mortality from smallpox in unvaccinated cases is about twenty per cent. In vaccinated cases, where the disease occurs, which is rare, the mortality is from three to eight per cent.
Treatment:—The first and essential course to adopt with all patients, when known to have been exposed, or when the disease is anticipated, and it is not known that the patient has been exposed, is to have the patient immediately vaccinated, as this invariably modifies the course of the disease, if it does not prevent it. The patient must be isolated. This can not be successfully done except in a well equipped smallpox hospital, although in localities where the disease is not generally prevalent a small detached house can be secured and temporarily equipped to accommodate one or more patients. Good ventilation is important in the sick room, with the very best of nursing. Everything should be removed from the room, except the essential furniture, the patient should be allowed to drink water freely, and iced milk or buttermilk, with lemonade or fruit jellies dissolved in water, may be administered ad libitum. The administration of alcoholic beverages in regular small doses, is essential during the period of the remission of the fever, and at any time when there seems to be a failure of the vital forces. During the period of active fever a special sedative should be selected with reference to the most conspicuous fever indications, and to this remedy belladonna in reasonable doses should be added, and continued usually during the entire period of eruption.
We have no more important remedy in smallpox than echinacea. It should be given from the first and persisted in till the end of convalescence. It aatagonizes all the essential processes of the disease and exercises no influence that could be at any time detrimental or that would not work harmoniously with any other indicated remedy. It has been applied externally also with the very best of results. Its influence as an internal and external antiseptic is all important. It stimulates the capillary circulation, promotes free elimination, antagonizes septic development of whatever character, inhibits to a marked degree the formation of pus, prevents gangrene and stimulates the skin in such a manner that the eruption is very mild, and in some cases the pustule heals with but little if any pock.
Combined with this to excellent advantage is berberis; it should be given in small doses, perhaps five minims with fifteen minims of echinacea every two hours. Phytolacca decandra and baptisia are both excellent remedies, antagonizing sepsis and promoting normal glandular activity.
It is advisable often to stimulate the kidneys to a slight degree, which may be done with small doses of the acetate or the citrate of potassium.
Rhus tox is a valuable remedy in the eruptive stage, especially if the skin is very red, with burning and itching. It modifies the cutaneous inflammation and favorably influences the progress of the disorder. Some cases present the specific tongue and mouth symptoms of this remedy conspicuously, and in these it should not be omitted. Ten drops in four ounces of water should be given in teaspoon-ful doses, every hour, for a short time.
Sarracenia purpura has been advised by a number of writers as a remedy that will meet many of the indications of smallpox satisfactorilv. It should be persisted in from the onset.
Black cohosh is spoken highly of as meeting many of the indications. It is indicated by the extreme muscular and bone pains, and persistent aching in the muscles. Scudder lays great stress upon the action of this remedy. A remedy which is important in antagonizing the septic processes is the calcium sulphide; it should be given in doses of from the one-twentieth to the one-twelfth of a grain, in the latter stages of the disease.
All of these agents antagonize to a greater or less degree certain elements of the profound toxemia which occurs in this disease as its most conspicuous factor, due largely to the complete shutting off of exudation through the skin. It is difficult to procure sufficient elimination. The kidneys must not be over stimulated, and experience has proven that cathartics are worse than useless; these facts render efficient action of the above named remedies the more important.
For external application echinacea is of the highest importance, as has been stated. It may be used twice or three times daily with which to sponge the surface. A ten per cent solution is about the proper strength in mild cases. Where ecchymosis or gangrene are threatened it should be occasionally applied in full strength, over small areas, although there can be no objection to so applying it to the entire body.
The author has applied a stiff ointment made by combining equal parts by weight of the subnitrate of bismuth and lanolin to which a little boric acid is added, to a characteristic vaccination pustule, with the result that the inflammation was not great and the scar was almost completely obliterated. He has thought from this, that if this ointment was applied over the eruption on the face and neck freely, and covered with a mask, it might modify the pock marks somewhat, and it would undoubtedly ameliorate the violence of the inflammation of the skin, especially if echinacea had been previously applied.
Hare suggests the use of carron oil, which is composed of a mixture of equal parts of linseed oil and lime water, to the skin to relieve the itching and burning.
As auxiliary treatment, if the pain be severe, a solution should be made of one grain of morphin, a dram and a half of sodium bromid, and ten minims of specific hyoscyamus in two ounces of water or simple syrup. This should be given in dram doses every half hour or hour, for severe pain, general distress, violent muscular aching, great restlessness or sleeplessness, until the patient is relieved. It will usually not be found necessary to administer more than three doses until relief is obtained, after which an occasional dose only should be administered as needed.
When hemorrhages occur gallic acid should be given in full doses of ten grains every two hours for a time. Thuja is also of much service at this time, exercisng a double influence in antagonizing sepsis also. As a restorative, iron is important, either in the form of the tincture of the chlorid, the precipitated carbonate or the citrate.
While these suggestions cover the prominent indications, no two cases will exhibit the same characteristics, and the true specific medicationist will find other conspicuous indications arising, which, from his knowledge of the action of his remedies, will point strongly to a specific agent, which should be administered unhesitatingly if the indications so demand, without reference to whether the agent has or has not been advised in the treatment of the disease.
The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.
