I. Variola Vera. { a. Discrete.
{ b. Confluent.
{ c. Purpura variolosa
II. Variola Hemorrhagica. { (black smallpox)
{ d. Variola hemorrhagica pustulosa.
III. Varioloid. e. Smallpox modified by vaccination
or partial immunity.
=Discrete Variola Vera.=—Incubation symptomless and averages 12 days.
Prodromal stage, from first symptom to eruption. Averages three days.
The longer the stage the more severe the infection. Intensity bears
little if any relation to prognosis; however, if onset is mild, disease
will not be confluent or hemorrhagic.
Invasion begins with severe chill, often repeated. Initial fever
rises suddenly to 103° or 104°, and reaches maximum on second or
third day. Pulse is rapid and full. Skin is red, hot and dry. There
may be sweating in the discrete form and in the favorable cases. The
headache appears with the chill and is usually frontal. When severe
and accompanied with neckache and vomiting it may suggest meningitis.
The backache appears with the chill and lasts about two days. It is a
lumbar pain, very like lumbago; it occurs slightly less frequently than
the headache and vomiting. This pain is rare in other fevers likely to
be confused with smallpox. Vomiting is constant in children and usual
in adults. The initial eruptions, which are present in about 10 to 12
per cent, are of considerable diagnostic importance. They are usually
limited to the lower abdomen, inner side of the thighs, axillæ, and
sometimes on the extensor surfaces of the knees and elbows.
=The Eruptive stage= consists of the following sub-stages: =macules and
papules; vesicles, and pustules=.
The macules and papules occur on the fourth day and progress for about
three days. They begin on the forehead, near the hair, with itching and
burning and resemble flea-bites. These soon become papules, which are
reddish, elevated, circular, hard or shotty and discrete. On second
day of this stage they appear on the body, and on the next day on the
extensor surfaces of the extremities. If the eruption appears on the
second day the confluent type may be anticipated; if on the third day
of the disease, the discrete type.
The vesicles which occur on about the seventh day of the disease,
contain lymph. Umbilication occurs in the centers of many of the
vesicles, and it is suggestive of smallpox.
The suppurative stage begins about the ninth day with clouding of the
vesicles and inflammation around them. This continues for three days.
The pustules become opaque, then yellow, and a thick pus obliterates
the umbilication. The inflammatory “halo” becomes more vivid and edema
may follow around these haloes. This edema causes increased tension
and deformity, particularly of the face, and produces great tenderness
and pain. The pustulation follows in the order of eruption, from the
face downward, and are the thickest on the extremities and head. The
pustules evacuate spontaneously, or may dry up without rupture. The
skin gives off a peculiar, offensive odor. Bed-sores are now most
likely to develop.
The eruptions also may occur in the mucous membranes, particularly in
the mouth and nasopharynx. These pass through the successive stages as
do those of the skin, but less typically. With the pustulation there
is usually a gradually rising =secondary fever=. In the discrete type
the secondary fever does not remain high more than twenty-four to
thirty-six hours, with morning remissions. A marked leucocytosis occurs
with the secondary fever and its extent depends upon the severity
of the infection. Delirium, albuminuria, acute exhaustion and heart
paralysis are to be guarded against during this stage.
The state of involution, or decrustation, begins about the twelfth day.
It follows the order of eruption, and is accompanied with a decrease
in edema, redness and pain, but is attended with intolerable itching.
Crusts form, the hair falls out and by the end of the second week the
temperature returns to normal. If fever persists during this stage
it indicates some complications. Scars occur when the true skin is
involved and lasts three or four weeks. Complete convalescence follows
the disappearance of the last crust.
=Confluent Variola Vera.=—This is a malignant type and used to be more
prevalent than now. The initial stage is violent, and the headache and
backache very agonizing. The fever remission is very slight or absent,
and attended with hardly any improvement in symptoms. The earlier the
exanthem occurs in variola the more likely it will be of the confluent
type. The confluent eruptions occur especially upon the face and head,
sometimes on the hands and feet. It is largely discrete on the body
and extremities. Great edema appears with the fusion of the eruption,
with the swelling and erosion of the mucous membrane, the eyes close
and the nostrils become obstructed. The fever is high, pulse high and
rapid (often irregular), dilirium, albuminuria, persistent nausea
and vomiting, great thirst, husky voice, enlarged cervical glands,
salivation in adults and diarrhea in children are symptoms present.
Death occurs from acute toxemia, usually within a week, but may last a
little longer. Recovery from confluent variola is very infrequent.
=Purpura Variolosa.=—This is “Black Smallpox.” That is, smallpox with
primary hemorrhage in the initial stages. It is the worst type and
results almost invariably in death. It is very important because it is
so difficult to diagnose. Its incubation period is short (6 to 8 days),
invasion very severe, lumbar pains almost unbearable, prostration
great, pulse soft, small and rapid and respiration unusually high. The
initial pains and vomiting may last until death.
On the first or second day a plum colored eruption appears, with
brick-red, purple or inky ecchymoses particularly about the eyes.
The condition is desperate. Hemorrhages may occur from any cavity
of the body, sometimes accompanied by gangrene of the pharynx. The
disease does not usually reach the period of real eruption, because
death usually occurs within four or five days. The diagnosis of this
condition is by history of exposure to smallpox and the characteristic
prodromes.
=Variola Hemorrhagica Pustulosa.=—This is the type with the =secondary
hemorrhage=, or the hemorrhage after the eruption appears, and is more
common than primary hemorrhage. It occurs in weakly and alcoholic
subjects. The initial stage is severe, and the hemorrhages occur
into the vesicles or pustules. There may be epistaxis, hematuria and
metrorrhagia. The outcome is almost always fatal, though the hemorrhage
at the vesicular stage may be followed by rapid abortion of the rash
and recovery.
=Varioloid.=—This is modified or mitigated smallpox; also known as
variola benigna. Persons exposed to smallpox sometimes suffer from
varioloid, and persons who have had smallpox may suffer from varioloid
at subsequent exposure to smallpox. Vaccination appears to initiate an
attack in persons peculiarly susceptible, or as a result of improperly
performed vaccination. The lesions remain in the epidermis, the course
of the eruption is shorter, the papules vesicate by the fifth day, the
process of suppuration is abridged, decrustation occurs rapidly with
little or no scarring, and all symptoms are milder. There are many
modifications.
=Other varieties= are (1) Variola sine exanthemate, which has the usual
symptoms without the eruption; (2) Variola verrucosa, which has large,
solid, conical papules with small vesicles at their apices, which
rapidly desicate and form crusts, and finally disappear without scars;
(3) Variola cornea (horn pox) which is known by the large mahogany
crusts.
=Complications and Sequelæ.=—Variola is often accompanied by many
complications and sequalæ which are an early severe toxemia and a
later secondary infection. During the secondary fever, there may be
bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds,
ulcerative eye, ear or laryngeal conditions, purulent arthritis,
orchitis, gangrene when the swelling is great and subcutaneous
abscesses form, often attacking the penis and scrotum, erysipelas
attacking the face, and rarely nephritis.
During convalescence, carbuncles, boils and other subcutaneous
abscesses are very common. Disturbances of the peripheral nervous
system as neuritis, paralyses especially of the palatal muscles,
neuroretinitis, and otitis media are less common. The sequalæ most
common are boils, abscesses, deep pitting, otitis media, blindness and
permanent baldness.
The =urine= has the usual febrile changes. =White blood= cells reach
10,000 to 20,000 or more. Lymphocytosis occurs during pustulation;
polymorphonuclear cells are decreased to 40%, sometimes to 12%;
myelocytes and irritation forms are found. During the febrile stage
there is a polycythemia followed by an anemia to 3,000,000 or less
during the pustular stage. Regeneration is slow, lasting about
fourteen days. Normoblasts are rare except in hemorrhagic forms.
Exudate taken from the pustules show streptococci, staphylococci, and
pseudodiphtheria bacilli.
=Treatment.=—The imperative demands of treatment are isolation,
ventilation, cleanliness and disinfection.
If symptoms are suspicious of smallpox, =notify the proper authorities
at once and isolate patient=. When diagnosis is made, cut hair and
beard very short.
1. Isolate patient in room free from draperies, rugs, carpets,
curtains, pictures, etc.
2. Disinfect all vessels used in room of the patient in carbolic acid
solution or in bichloride of mercury solution.