Transcriber’s notes:
In this plain text transcription, paired underscores denote _italicised text_ and
paired asterisks denote *bold text*.
A short table of contents has been inserted to assist readers.
The following spelling errors have been corrected silently:
pathognomic —> pathognomonic
accidently —> accidentally
coalesence —> coalescence
hematomesis —> hematemesis
hemorraghic —> hemorrhagic
uniformily —> uniformly
A
PRACTICAL TREATISE
ON
SMALLPOX
_ILLUSTRATED BY COLORED PHOTOGRAPHS
FROM LIFE_
BY
GEORGE HENRY FOX, A.M., M.D.
CONSULTING DERMATOLOGIST TO THE HEALTH DEPARTMENT OF NEW YORK CITY
WITH THE COLLABORATION OF
S. D. HUBBARD, M.D., S. POLLITZER, M.D., AND J. H. HUDDLESTON, M.D.
Technical Book Co.
Domestic and Foreign Directories,
Telegraphic Codes, Maps, Foreign
and Domestic Periodicals,
Technical Books
MILLS BUILDING SAN FRANCISCO
Telephone Garfield 19
Copyright, 1902
By GEORGE HENRY FOX
PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U. S. A.
CONTENTS
Chapter Page
I Symptoms and course 1
II Diagnosis 9
III Treatment 15
IV Vaccination 26
LIST OF ILLUSTRATIONS.
NOTE.--The names of the colored plates are in capitals. The
letters H., P., and F. in brackets indicate that the cases were
photographed by Hubbard, Pollitzer, or Fox.
PLATE
I. VARIOLA ERYTHEMATOSA. (First Day.)
This shows the earliest eruption upon back and buttocks. The
photograph was taken about seven hours after its first appearance.
The patient was sent to Riverside Hospital, where she developed
hemorrhagic smallpox, and died on the fourth day. [H.]
II. VARIOLA PAPULOSA. (Second Day.)
Showing numerous incipient papules upon the face. Those upon the
forehead were the first to appear and are most prominent. The
cheeks present a characteristic leathery appearance. [H.]
III. Variola Hemorrhagica.
Showing upon the face and cheeks a form of the disease commonly
known as “black smallpox.” Figs. 1 and 2 were photographed on the
second day and show a profuse and dark eruption. The swelling and
disfigurement of the face present a most striking appearance. Figs.
3 and 4 were photographed on the fourth day, when the patient was
in a moribund condition. [H.]
IV. VARIOLA VESICULOSA. (Fourth Day.)
A case of moderate severity, with well-developed vesicles and
characteristic grouping of lesions upon the face. [P.]
V. Variola Vesiculosa.
Fig. 1 shows a mixed eruption of papules and vesicles upon the
right thigh. (Third day.) This condition is exceptional in Variola,
though quite common in Varicella. [F.] Fig. 2 shows well developed
umbilicated vesicles upon the forearm. (Fifth day.) [H.] Fig. 3
shows a hemorrhagic effusion into the vesicles on the thigh and
leg, a condition far less serious than the purpuric eruption of
malignant variola. [P.]
VI. VARIOLA SEMI-CONFLUENS. (Fifth Day, Sixth Day.)
These illustrations show a partly confluent character which the
eruption frequently presents, even in mild cases, and especially
upon the legs. The influence of pressure in developing a more
profuse eruption may be noted above the ankles, where shoes were
laced, and below the knees, where garters were worn. [F.]
VII. VARIOLA CONFLUENS. (Seventh Day, Eighth Day.)
Fig. 1 shows umbilicated pustules with an intense œdema of the
foot, considerably increasing its size and causing much pain.
Fig. 2 shows the epidermis raised in a large, irregular patch by
the confluence of pustules. [F.]
VIII. Variola Pustulosa. (Ninth Day.)
Fig. 1 shows an eruption discrete upon the trunk and even upon the
hand, while confluent upon the forearm. [H.] Fig. 2 shows a vaccine
pustule coexisting with variolous pustules. The vaccination took
place before the disease began, but too late to exert a decided
prophylactic effect. [P.] Fig. 3 shows an eruption of large,
flaccid pustules with swelling of the foot. [P.] Fig. 4 shows an
eruption of discrete, tense, hemispherical pustules. [F.]
IX. VARIOLA DISCRETA. (Ninth Day.)
A typical case of mild smallpox occurring after vaccination and
sometimes called Variola modificata or Varioloid. [P.]
X. VARIOLA PUSTULOSA. (Tenth Day.)
A severe case, showing the characteristic aggregation of lesions on
the face and extremities. [P.]
XI. VARIOLA PUSTULOSA. (Ninth Day, Tenth Day, Eleventh Day.)
These illustrations show the pustular lesions in the stages of
complete distention, when they present a rounded appearance, and
of incipient desiccation, when they appear flattened and with a
central depression or “secondary umbilication.” [P., F., F.]
XII. Variola Pustulosa et Crustosa. (Tenth Day, Twelfth Day.)
In Fig. 1 an occlusion of the nasal passages is indicated by the
lips parted in respiration. [P.] Fig. 2. shows a palmar condition
which, in the adult, is found only in smallpox. [P.] Fig. 3 shows
the desiccation of the facial eruption in advance of other regions.
[P.] Fig. 4 shows a mild discrete case in which a diagnosis of
acne had been made. [F.] Fig. 5 shows the eruption in the stage of
desiccation. [F.]
XIII. VARIOLA CRUSTOSA. (Eighteenth Day.)
Showing a few thick crusts remaining upon the face with numerous
dull red spots from which the crusts have fallen. [F.]
XIV. VARIOLA DESICCATA ET SQUAMOSA. (Twentieth Day.)
Figs. 1 and 3 show the dried pustules remaining in the thickened
skin of palm and sole after the crusts have fallen elsewhere.
[F., P.] Fig. 2 shows the superficial desquamation which follows
the falling of the crusts, producing rings of partly detached
epidermis. [F.]
XV.
Fig. 1 shows a peculiar pigmentation sometimes left after
the eruption. The central portion, being darker, produces a
“bull’s-eye” appearance. [F.] Fig. 2 shows the hypertrophic
condition of the scars which occurs in certain cases in place of
the usual pitting, and which tends to disappear in time. [H.]
Fig. 3 shows severe pitting, a partial loss of hair and eyebrows,
and destruction of one eye. [H.]
XVI.
Fig. 1 shows the typical appearance of a successful revaccination.
(Fourth day.) [F.] Fig. 4 shows a small, well-formed vaccination
pustule at its height. (Eighth day.) [F.] Fig. 2 shows a large,
irregular pustule resulting from scarification of an area of
unnecessary extent. (Eighth day.) [F.] Fig. 5 shows an ulcer
resulting from infection of the vaccination lesion. [F.] Fig. 3
shows a primary vaccination at its height (eighth day) with a
characteristic areola. [F.] Fig. 6, a case of Varicella on the
third day. [F.]
PREFACE.
Whenever a physician is called to a case of suspected smallpox,
he confronts a grave responsibility. If young or without special
experience, he is apt to feel a sore need of assistance, and, although
a book can never take the place of an experienced consultant, it is
the object of the present work to render him as much aid as possible.
The text aims to be practical rather than elaborate. The plates are
reproductions of photographs from life, some of which have been
obtained under great difficulty.
While many articles on variola have been illustrated by a few
photographs of cases, mostly of the pustular type, this work is
believed to be the first which has presented illustrations of the
smallpox eruption in each of its successive stages. It is sincerely
hoped that the reader will find it of service in familiarizing him with
the peculiar features of the disease.
GEORGE HENRY FOX.
SMALLPOX.
CHAPTER I.
SYMPTOMS AND COURSE.
Variola, or smallpox, is an acute, contagious disease, characterized by
an eruption upon both the skin and mucous membrane, with constitutional
symptoms of greater or less severity. The eruption presents
successively a macular, papular, vesicular, and pustular stage, the
pustules finally drying into crusts, which fall and leave the skin
temporarily discolored. Where ulceration has occurred it is permanently
scarred or pitted. The lesions of the mucous membrane appear upon
those parts more or less exposed to the air,--the mouth and eyes, for
example,--but in exceptional cases they may be found throughout the
entire intestinal tract, and in the uterus and bladder. These lesions
do not run a course similar to those observed upon the skin, but
appear as red macules, which rapidly change into ulcerations, covered
with a whitish pellicle. The ulcers are imbedded in the substance of
the mucous membrane and are not as superficial as in cancrum oris.
The constitutional symptoms are most prominent during the periods of
invasion and pustulation.
There are various clinical forms of smallpox, which may be conveniently
described as (1) discrete, (2) confluent, and (3) hemorrhagic, or
malignant; and then, according to intensity, as (_a_) very mild, (_b_)
mild, and (_c_) severe. The few purpuric spots seen in the severe
discrete and the confluent forms are not of great significance, as they
are generally due to a peculiar diathesis, and as a rule the patient
recovers. The malignant form is almost invariably fatal.
The term discrete implies that the lesions are separate and distinct,
not coalescent. If the lesions coalesce and form patches of various
shapes and sizes, the eruption is called confluent. For the purpose of
differentiating the various forms above mentioned, it is convenient
to first trace a normal, unmodified case of smallpox from the initial
symptoms to recovery, and then to consider the severe forms, and
finally the rare and obscure forms of the disease.
*Period of Incubation.*--This extends from the date of exposure to the
occurrence of clinical symptoms, a period usually lasting from twelve
to fourteen days.
*Period of Invasion.*--The disease is usually ushered in by fever,
with a distinct chill or chilly sensations, headache, neuralgia, and
a general malaise. Frequently the first symptom is a distressing
backache. This is located in the lumbar region, but it may be as
high up as the lower angle of the scapula, or it may be sacral and
extend down into the thighs. The backache is an important symptom when
present, but it is not always on hand to help one out in the diagnosis.
The backache of smallpox is not peculiar or distinctive, but it is its
severity which attracts attention.
The headache is usually frontal and is an ache that is constant in
character. The neuralgia is about the orbits, but may be facial, and is
of a lancinating character.
The fever may precede the backache or it may follow. It may be at first
a rise of only a degree or two, or it may jump to 104° F., or as high
as 106° F. The latter is most frequently seen in neurasthenic subjects
and in children. The pulse rises in frequency and in tension.
In children a convulsion not infrequently ushers in the disease. At
this time convulsions are of little significance, but late in the
disease they are of serious import. There are other constitutional
symptoms, such as loss of appetite, vomiting, muscular pains, a dry,
coated tongue, and at times an active delirium.
The face is congested and swollen. The eyes are injected and present a
bleared appearance, but the watery or weeping condition seen in measles
is usually absent. The nose is dry, and a sore throat is not uncommon.
Epistaxis is frequent.
A very important symptom which sometimes occurs in this stage is a
cutaneous efflorescence, which may resemble urticaria, scarlet fever,
or measles. This latter resemblance is very close and often leads to
diagnostic error. The efflorescence occurs most frequently in the
young, and also in vaccinated adults. In some epidemics it is not at
all uncommon, but as a rule it is rare.
The duration of the stage of invasion varies from two to four days.
Usually it is about three days.
*Period of Eruption.*--Late on the third day or early on the fourth the
eruption makes its appearance, and the constitutional symptoms subside
to a certain extent.
The rash appears first on the confined and moist portions of the skin
or in irritated parts,--under a blister, for instance, which may have
been applied for the backache. Normally, it is first seen upon the
forehead at the hair-line, then behind the ears and down the tender
part of the neck. It gradually extends down the trunk and arms, the
hands and lower extremities being affected last. The eruption generally
takes from twenty-four to thirty-six hours to cover the entire body.
The best location to observe the rash for diagnostic purposes is on the
back, where it cannot be obscured by scratching and where the warmth
of the body causes the mildest congestion to appear at its best. The
exposed parts are usually ill adapted for study of the rash, being
obscured by the swelling and congestion of the face and by more or less
dirt or staining of the hands.
The rash consists first of small round or oval, rose-colored macules,
which seem to be in the skin, coming up from beneath it, as it were.
They disappear readily on pressure or on tension of the skin. When
coalescence occurs, the lesions may resemble the blotches of measles.
The macule at this stage is about from one-eighth to one-fourth of an
inch in diameter, and its color is of an intense red which shows well
at night, even by the light of a match. In less than twenty-four hours
the centre of the macule becomes hard; and as this hardness increases,
the lesion gradually rises above the skin. It is now changing into
the papular stage. The macular stage lasts usually from eight to
twenty-four hours.
The papules continue to increase slowly in size, the apex becoming
flattened or indented in some lesions. While this change is going on
the redness of the macule forms an areola about the hard portion or
central papule. This areola tends to get smaller as the papule gets
larger, and at last is completely lost.
If the pulp of the finger is passed over the papule, especially in its
early stage, the latter seems to roll beneath it, giving the sensation
of a small shot buried in the skin. When the papule is fully developed,
the surrounding skin is put on the stretch, and the rolling sensation
is lost, but the papule is so dense and hard that it is frequently
described as “shotty.” The papule of varicella and of acne is not so
dense and resisting as the papule of variola. The fully-developed
papule in smallpox is rarely surrounded by a halo of congestion as
it is in varicella, but in the modified form of smallpox this is not
infrequently the case. The papule always arises from the centre of its
halo like a bull’s eye, whereas in chicken-pox it arises from within
the circumference, but not always in the centre. The halo of congestion
in chicken-pox is always very broad and extensive, and is best seen
upon the back. When a halo is present in smallpox it is very narrow and
insignificant. The papule is usually fully developed in twenty-four
hours.
At the end of another twenty-four or thirty-six hours the apex of
the papule shows a further change. It appears to be transformed from
a solid to a fluid. The color also changes as the fluid increases,
and the lesion appears bluish or purplish. The fluid continues to
increase in amount until the papule is converted into a little blister
or vesicle. As the change is going on, the height of the papule grows
less and less, and when vesiculation is complete we have a broad,
flat, umbilicated vesicle with a firm, dense base. To the touch these
vesicles are firm and resisting, and the membranous covering is not
easily broken, unless macerated by the perspiration due to heavy
flannels.
The vesicle is divided irregularly by little bands, or septa, which
permit only a portion of the fluid to escape when one is punctured.
Vesiculation is usually complete about the third day, and the stage
generally lasts three days. It may be stated here that the reckoning
in smallpox is usually from the appearance of the rash. The period
of incubation and invasion are considered in reckoning the length of
illness, but in descriptions of smallpox it is considered best to state
the day of the eruption, and not of the disease.
There is an old and oft-repeated statement that a uniform rash is a
characteristic of smallpox and that a mixed rash indicates chicken-pox.
This deserves to be promptly refuted. It is most unusual to find a
case of smallpox with its eruption all in one stage. While it is
a well known fact that chicken-pox runs a hasty course,--so that
in from one to two days we may have macules, papules, vesicles,
and even crusts,--in smallpox this is not likely to occur, as the
disease never runs such a rapid course. In the early stage we may see
macules changing into papules on the head and the neck, while there
are simply macules on the trunk. Later in the disease the eruption
may be vesicular on the head while still papular on the body. When
vesiculation is complete, we have the distinct umbilicated appearance
that has long been recognized as a characteristic of smallpox. The
vesicles are broad, firm, flat, and hard, and are invariably indented
or umbilicated.
It is not until the stage of vesiculation that the constitutional
symptoms diminish to a marked degree. In fact it is considered one of
the landmarks of the disease for the fever curve to show a decline at
this time.
Late in the fifth or early in the sixth day the vesicle begins to
assume a cloudy or yellowish hue, which denotes the commencement of
pustulation. The fluid continues to grow more yellow, and about the
time that it has assumed a dense straw color the umbilication begins
to disappear, so that in from one to three days the pustule loses its
indented appearance and becomes globular in form. To the touch it
appears to involve as much of the skin below the surface as it is high
above it. It is during the stage of pustulation that the surrounding
skin becomes swollen and œdematous, with an area of redness about the
pustules giving the appearance of a bull’s eye. It is also during the
pustular stage that the constitutional symptoms become more intense
and the fever rises in proportion to the severity of the attack. The
pustules are fully matured about the eighth day of the eruption.
During the pustular stage the affection of the mucous membranes reaches
its height. The eyelids, lips, and nose are often tremendously swollen.
The tongue swells and deglutition becomes impossible. The voice is
husky, and is sometimes lost, owing to the swelling of the glottis.
About the ninth or tenth day of the rash another change appears in
the pustule. In mild cases this change sometimes takes place several
days earlier. In the centre of the pustule is observed a small, darker
spot, which gradually grows larger. The membrane of the pustule becomes
shriveled, and the little, dark spot continues to get larger and darker
until it involves the entire area of the pustule. This is the drying
stage, during which the fluid part of the pustule is absorbed, leaving
the solid part behind to be exfoliated in the form of a crust. It
is during this stage that, owing to the softening of its membranous
covering, the pustule is broken by the movements of the patient or the
contact of rough bed-linen. The pustules of the face are usually the
first ones broken, and an ulceration frequently occurs which destroys
the true skin and results in a pit or scar. Pustules do not rupture
spontaneously and discharge their contents. Dessication lasts usually
from five to twenty days, the exposed parts being the first to dry and
shed their crusts. On the palms and soles the dessicated débris is left
deeply buried in the skin, and often has to be removed by the aid of
a lancet or other instrument. Sometimes there is a pustule under the
nail, and the removal of the kernel or seed is quite painful, though
necessary.
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.