Variola

(SMALLPOX)

=Definition.=—=Variola= is an acute, specific, highly infectious and

contagious, epidemic disease. Its beginning is sudden with a chill,

vomiting, severe headache and lumbo-sacral pains. It has a typical

fever curve and a typical eruption on the skin and mucosæ of macules,

papules, pustules and crusts successively.

=History.=—Prevailed in China and India at least 1000 years before the

Christian era. Epidemics occurred in the sixth century and during the

crusades. Its first clinical description was given in Arabia during the

ninth century. It was brought into Mexico about 1520 by the Spaniards

and between three and four million people contracted the disease. In

1718 preventive inoculation was introduced into England and in 1796

Jenner discovered vaccination.

=Etiology.=—The specific agent which is the cause of this disease is

unknown, but the virulence of the agents is retained for a long period

and is the most virulent found in all diseases. There is no period

from the initial fever to the final desquamation that the disease is

not contagious, although the stage of suppuration is the most violent.

Although the disease is so highly contagious and the entrance of this

particular poison into the system produces this disease, still no

one has yet been able to discover a germ nor what the nature of the

infective agent is. To contract the disease it is not necessary to

touch an individual already afflicted, not to even approach the sick

room. It may be only necessary to touch a garment that has once been

in contact with a smallpox patient, or which has simply hung in his

vicinity.

The blood is infectious at a very early stage. As smallpox is

contagious without eruption it seems that the secretions and

excretions convey the virus. The dried pustules seem to have the

greatest infectiousness. Cadavers of smallpox (Variola) victims are

very dangerous and relatives of them should be carefully warned. The

disease often persists in infected communities for years. The disease

is evidently spread by fomites, contact with the pustular contents, and

crusts or scales of the desquamating skin. It attacks all classes, ages

and conditions of people, which is unlike other erythematous diseases.

A previous attack usually confers immunity. Vaccination is claimed to

confer immunity but apparently in not all instances, for there are

records of “successfully vaccinated” individuals having severe attacks

of the disease.

The susceptibility to smallpox, as to all other infectious diseases,

varies in different individuals, in different races, and under

the influence of conditions as yet unknown. Some persons are not

susceptible to the disease, nor are they to vaccination, and yet others

have been known to have had the disease as much as three times. The

Negro and Indian races seem to be more susceptible than the Caucasian.

Then again at intervals of a few years, the general susceptibility of

the people seems to be increased so that cases of smallpox become far

more numerous than usual.

A point of considerable interest is the fact that the child, while in

the mother’s womb, may experience the disease along with the mother

and thereby acquire, before birth, the usual immunity conferred by one

attack of the disease. In most cases of smallpox in pregnant women,

abortion or miscarriage occurs, yet a sufficient number of instances

are on record in which healthy children have been born, exhibiting the

characteristic pitting of smallpox, and possessing no susceptibility to

vaccination. Again there are other cases in which pregnant women have

smallpox and the babes in the wombs have escaped entirely; while the

most singular fact is that while the fetus may experience the disease,

the mother through whom the exposure was effected, escapes, either

because of a previous attack or possibly because of vaccination.

While there seems to be no reason for believing that an attack of

smallpox can be, or ever has been, aborted by artificial means, yet

there is a prevalent belief that this process occurred during certain

epidemics of smallpox, cases having been known in which individuals

presented all the symptoms indicating the invasion of smallpox, and

yet no eruption occurred, and yet such individuals were thereafter

insusceptible to smallpox or vaccination.

The mortality of smallpox varies like the susceptibility of it—with the

age of the patient and with some unknown conditions of the atmosphere

or soil which favor the occurrence of the epidemics. The average in

scattered cases—sporadic—is probably not greater than one in nine or

ten. A fatal result occurs more frequently in the second week of the

disease than at any other time.

=Pathology.=—Granular and fatty degeneration occurs in the liver,

spleen, kidneys and heart. Infiltration is found in the adrenal glands

and testicles. During the papular stage, there is local hyperemia of

the papillæ, with interstitial exudation and colliquative necrosis

of rete cells, so that a vesicle is formed, peculiar in that it is

traversed by delicate bands of epithelial cells. This, with the fact

that coagulation-necrosis occurs mainly in the center, gives it the

umbilicated, or depressed appearance. The contents of the vesicle are

plasma, fibrin and cell detritus. Leucocytic invasion converts vesicles

into pustules. This has a more globular, elevated appearance than the

umbilicated vesicle. Pyogenic organisms are found in the pus. When the

inflammation injures the corium, scars are apt to result; this occurs

when the skin is scratched. The actinic light rays increase the danger.

=Diagnosis.=—Mistakes in the diagnosis of the first cases of smallpox

in an epidemic are almost inevitable. Hemorrhagic scarlatina or measles

sometimes cause confusion; in the hemorrhagic scarlatina the mucous

membrane hemorrhages are less frequent than in smallpox. The prodromal

eruptions plus purpura are very suggestive. The invasion stage lasts

about three days.

Smallpox is characterized by sudden onset with violent chill and

shivering; agonizing pain in the back and legs; intense headache,

mostly frontal; temperature rapidly reaching 102 to 104 degrees

F.; full, strong, rapid pulse, going to 100 to 140; uncontrollable

vomiting; pharyngitis; red face, bright eyes, coated tongue; anorexia;

constipation; sleeplessness; delirium; often copious perspiration and

extreme prostration.

An “initial exanthem,” clearing within 24 to 48 hours, appears. It

is either hemorrhagic or erythematous. About the third day the true

eruption appears, first upon the forehead and in the scalp, then the

rest of the face, the backs of the wrists, trunk, arms, and lastly the

legs, most abundant upon the parts exposed to the atmosphere. With the

appearance of the eruption, all symptoms abate, the temperature falls,

and the patient may feel quite comfortable. The eruption consists of

coarse, red spots upon the body, like flea-bites, rapidly becoming,

within 24 hours, slightly raised red papules, feeling hard and shotty

to the touch, and each surrounded by a broad red inflammatory band,

the areola. Usually by the sixth day the papules become converted into

umbilicated vesicles, at first clear, then turbid. They are hard and

indurated to the touch, and on the eighth or ninth day they become

pustular. The areola becomes much darker, the temperature rises to 103

to 105 degrees F., and the pulse to 110 to 120. The other symptoms

all reappear, with salivation and delirium. Marked edema of the skin

renders the skin unrecognizable. The pustules are painful, especially

in places where the skin is thickened. The maturation lasts about three

days, when the fever falls by lysis. If fatal, death usually takes

place about the tenth day, preceded by feeble and more rapid pulse,

marked delirium, subsultus and sometimes diarrhea. About the eleventh

day, desiccation begins, the pustules begin to dry, forming tight scabs

which are closely adherent. The fever and other symptoms subside but

itching becomes annoying. The odor from the pustular stage on is a

peculiar greasy one.

After the rupture of large pustules the centers frequently dry and sink

in, often in the shape of the Maltese cross. This is most typically

seen on the backs of the hands and is pathognomonic. Toward the end

of the third week the scabs fall, leaving red glistening pits which

disappear or change into deep white striated scars. The hair falls but

may grow again. The diagnosis is not certain until the eruption is

seen. In the smallpox without eruption the diagnosis must be made from

the history of exposure, the presence of an epidemic, fever, lumbar and

head pains, delirium, and possibly the initial rash.

Mistakes in diagnosis may be made even by smallpox experts, but

attention to the history, somatic findings and the course of the

disease, rather than to the eruption, will prevent disastrous results.

Always isolate any and all suspected patients.