After considerable weighing of the question as to whether it were better to take up these affections or not, I have decided to give, for diagnostic purposes, a short description of this class of diseases, more especially of the eruptions.
Variola.
The eruption on the skin is characterized by the appearance of bright, red, hard acuminated points, the size of hemp-seeds, distinct from each other at first, and which, passing through the stages of vesicular and pustular inflammation, arrive at their maturity on the eighth day of eruption. The individual pustules then scab, their contents drying into brown masses which become detached in from twelve to fifteen days, and leave behind in their place permanent cicatrices, or “pits.”
Variola is often preceded, as regards its local state, by more or less erythema, which subsides on the appearance of the variola. This has been termed erythema variolosa. Variola is said to be discrete, when the pustules are scattered over the surface; coherent, when the eruption is plentiful, and the variola are “closely packed side by side but still distinct;” confluent, when they run together; modified, when the disease succeeds to a prior attack or occurs after inoculation. Variola is, by universal consent, divided into five stages: Incubation, which is reckoned by the length of time which elapses between exposure to the position of the disease and the development of the first effects (from five to twenty days); Invasion (two days); Eruption; Suppuration; Dessication.
The “Period of Eruption”-Eruption makes its appearance on the third day after the first occurrence of constitutional disturbance, and travels over the entire body within a day, when the febrile condition is greatly relieved.
There are exceptions to this when the rash appears on the second, fourth, fifth or sixth day. Should the eruption appear on the second day, the attack will be severe and the disease of the confluent variety; if on the fourth day or later it will be unusually mild and of the discrete variety.
The spots appear first on the face, about the forehead, and thence they extend to the trunk and limbs. These spots are, in the very outset, small papules, red, hard, and pointed, and their more or less closely packed or scattered condition affords a good guide as to whether the disease will be confluent or not; if the skin be very red and erythematous, probably the case will assume the confluent form. On the second day of eruption-fourth of disease-the papules formed from elevation of the epidermis by an increase of the cells of the Malpighian layer and distension of the vessels in the true skin, but particularly the papillary layer, are transformed into vesicles. If these vesicles be punctured, nothing escapes from the puncture. On the third day of eruption-fifth of disease-umbilication commences as a central depression, which becomes more marked everyday, pari passu with suppuration, which now commences; the pustules are “whitish and surrounded by an inflamed areola;” the fourth day of eruption.
If the contents are now turned out, a little “disc” of dirty plastic matter, presenting an umbilicated shape, and attached to the cutis beneath, will be noticed. It is not at all unusual to observe the confluent in one, the discrete form in another part of the same subject. The onset of maturation is observed about the end of the fifth or beginning of the sixth day of eruption, or the eighth of disease. The contents of the umbilicated vesicles soften down into pus, the umbilication diminishing with enlargement of the base of the pustule, and a yellow color replacing the white.
The stage of eruption, lasting about five days, is characterized by the cessation or at least by a remission of the febrile and other symptoms, which is not true of the other eruptive fevers. The temperature which has been 104 degree to 106 degree falls to 100 degree, the pulse ranging from 110 to 130 falls to 70 or 90-in fact, the patient may feel perfectly well. These diagnostic symptoms may be wanting if the disease proves to be of the confluent variety.
Maturation, as it is called, is complete on the eighth day of eruption; between the eighth and eleventh day, secondary fevers sets in, when the stage of dessication is reached. This is the period of recovery or resolution, when the local and general symptoms subside, the scabbing dries, and the discharge ceases. The crusts fall off in the next three or four days, exposing raw, red surfaces, which desquamate, and by-and-by leave behind red- looking marks, which gradually fade and assume the well-known aspect of small-pox marks.
Itching of the skin to a greater or less extent persists during the whole course of the eruption. The rash also appears on the mucous membrane of the mouth and throat at the same time, presenting the appearance of round opaque spots, which are situated mainly on the tongue and soft palate, but are not by any means confined to these parts, for in many instances the rash appears in the larynx, trachea, bronchi or nostril, upon the mucous membrane of the vulva, prepuce, etc., with resultant laryngitis, bronchitis, etc. Or the eruption may take place in the eye and as a consequence lead to destruction of the sight; in the tunica vaginalis, giving rise to variolous orchitis; upon the peritoneum surrounding the ovaries, giving rise to variolous ovaritis. Orchitis is more frequently met with than ovaritis. The eruption upon the mucous surface gives rise to considerable discomfort, for these ulcerated spots are as tender to the touch as ulcers in other situations.
When variola is produced by inoculation there are some differences. On the third day the puncture is inflamed, it is itchy, and surrounded by a little blush of redness, whilst the spot is slightly indurated; on the fourth and fifth day the central point acuminates, and a little coming vesicle is seen; on the sixth day there is an early state of pustule, and it is umbilicated; on the seventh day a perfect pustule is formed with an inflamed areola; on the ninth or tenth day, maturation takes place, and the umbilication of the pustules goes; from the twelfth to the fifteenth day desiccation takes place, and from the twentieth to twenty-fifth day the scab falls off. The disease is rarely confluent.
The fever, which had subsided or entirely disappeared, returns during the stage of suppuration. The temperature rises to 106 degree to 108 degree, the pulse runs up to 110 to 140 or higher, the thirst is urgent and there are no longer perspirations of any sort. This secondary or “suppurative” fever terminates in a few days in the discrete variety if there are no serious complications, but in the confluent it is somewhat prolonged.
Each pustule has an inflammatory areola of considerable extent. The face especially becomes greatly swollen-oedematous. In the confluent variety this oedematous swelling is frequently sufficient to completely close the eyes. The hands and feet are likewise swollen and burn like fire. As a consequence of the eruption in the mouth and throat a free and copious flow of saliva is to be expected. The glands and subcutaneous tissues of the neck become enlarged in many cases.
Hemorrhagic variola commences very much like the other varieties, but there is a marked coldness of the extremities followed by a deep purplish redness of the surface. The eruption at first shows a very deep red color, and when the vesicles appear they are of a bluish-black color; in other words, they are filled with blood. At the same time ecchymosed spots, resembling bruises, are seen more or less over the entire surface and in the conjunctivae of the eye. The patient expectorates blood, vomits blood, passes blood with stool and urine-there is a flow of blood from every outlet of the body. Recovery is very rare, and death may take place at any stage, but usually before the pustules form.
I have never had to treat a case of this form, but from a comparison of the symptoms as above given would recommend the employment of two remedies internally Crot. hor. and Phosphorus.
To prevent pitting lard and charcoal may be used, or the face may be painted with sweet cream; the object being to exclude light and air. Various expedients have been recommended, but they all fail in the majority of cases.
The advice of the dermatologist is not infrequently sought for the removal of certain disfiguring consequences of variola about the body.
In the first place redness of the face has to be dealt with therapeutically. This may be rendered much less visible by the use of some mild astringent, but the greatest care must be taken to avoid every application which could in any degree increase by stimulation the hyperaemia. The following makes a very excellent preparation:
Rx. Oxide of Zinc, 3jj.
Calamine powder, ss.
Glycerine, jj.
Rose water, vjjj.
It should be used after bathing with hot water, being dabbed in and allowed to dry. Scarring cannot in the nature of things be prevented. If the scars become the seat of hypertrophous growth of cicatricial tissue the knife must not be used, but the frequent application of contractile collodion had recourse to. It should be applied twice a day for some time. Acne spots may also develop about the nose, for which the ordinary treatment for acne should be employed.
