(Smallpox)
Definition. An acute, highly contagious disease, characterized by febrile prodromata and followed by successive stage of macules, papules, vesicles, pustules and crusts, usually leaving pits or scars.
Symptoms. The incubative period is from five to twenty days, usually about ten. The onset of the initial stage or period of invasion is sudden and violent and is characterized by a distinct chill, which is quickly followed by a rapid rise of temperature from 103* to 104* F., with full, tense and accelerated pulse. Nausea, vomiting, headache, restlessness and insomnia are common in adults while children are more apt to be drowsy, with convulsions comparatively frequent. If the temperature is high, delirium may ensue. Pain in the lumbar and sacral region of the back is almost diagnostic, appearing in more than half of the cases, although generalized aches and pains are common. Vertigo is a frequent symptom and in severe cases prostration and muscular relaxation are pronounced. Prodromal rashes often occur, usually on the second day but they usually disappear within two days. The type known as “roseola variolosa,” resembling measles, is the most common type. It may be generalized or limited but is not elevated above the level of the skin, hence is scarcely appreciated by the finger and is distinctly ephemeral. The form resembling scarlet fever is less common and, while it may involve a large part of the surface, is more apt to affect the thighs, trunk, inguinal region, and extensor surfaces of the extremities. A petechial or hemorrhagic rash has been noted, which shows a particular affinity for the lower abdominal, inguinal and genital regions and inner aspects of the thighs, forming a triangle 9the so-called crural triangle of Simon). An axillary triangle is also described, including the inner aspect of the arms, axilla and pectoral region. this eruption, being due to hemorrhage in the skin, does not disappear upon pressure. Urticarial and erythematopetechial eruptions have also been reported. The hemorrhagic type usually presages a severe smallpox, while the roseolous form is much more common in cases of varioloid, and rarely may be the only cutaneous symptom (variola sine exanthemata). In these very mild forms, prodromal symptoms are the only ones, and the condition subsides without the development of the typical eruption.
The eruption first appears as minute red macules which within twenty-four hours develop into pin-head-sized or larger, firm, conical papules, the feeling of which has been likened to imbedded shot and often they are better appreciated by the touch than by the eye. They usually appear the morning of the third or fourth day, on the face and scalp. Later, the neck, trunk and limbs are involved and, in well-marked cases, every portion of the surface is invaded, including the palms and soles. Usually the fever disappears when this eruption occurs and the patient experiences much relief. In a few cases, a lowered fever persists. During the first two days of the eruption, the papules multiply and become correspondingly aggregated. The papules which appeared earliest are first to become vesicles containing translucent serum. This vesicle is characteristically umbilicated but its central depression is large beyond all proportion, and the undistended epidermis about it is often puckered or fluted. From the fifth to the twelfth day, the vesicles become pustules, the process beginning with the oldest vesicles, usually those on the face and upper parts of the body. The pustules become pea-sized, surrounded by a distinct areola and, when fully distended, the central portion, which holds down the roof wall, ruptures and the umbilication is lost. So-called secondary fever, which however is not essential to the disease, develops with the process of suppuration. It is caused by extensive suppuration occurring locally or internally and may be septicemic, symptomatic or sympathetic in nature. This is the most serious condition of the patient, for he now presents such a degree of edema and swelling that the features are indistinguishable, the lips, eyelids, nostrils and mucous outlets disfigured and obstructed with irritative discharges and swallowing is painful and often impossible, causing an abnormal flow of saliva. This general pustular condition is also present in the gastrointestinal tract as has been shown by autopsies but strange to say, gangrenous complications are not often seen.
Between the twelfth and fourteenth day, desiccation begins and is usually completed in from ten to twenty-one days. As the pustules rupture, yellowish, brownish or blackish crusts are formed and, with this formation, the secondary fever decreases, the appearance becomes more normal, tumefaction disappears, and the characteristic and intolerable fetid odor is less noticed. Pigmentations are purplish or violet in color and slowly disappear leaving symmetrical scars, at fist depressed and of a dull red hue, later becoming white. Naturally these scars are more plainly seen upon the surfaces exposed to air and light such as the face. Time will usually render these scars less pronounced, but they are persistent nevertheless. Four to six weeks is necessary before the course of the disease is entirely completed. Brief mention only will be made of atypical forms.
Varioloid is a modified variola, whether occurring after vaccination or bearing no relation to it. It may present severe prodromal symptoms, often a scantily developed and shorter eruptive stage, earlier desiccation and fewer and less disfiguring scars. There may be a cessation of the eruption stage at any of its several stages and the secondary fever may be absent. It is curious to note that, although an epidemic may take this form, a patient with varioloid may transmit to another the most malignant form of variola.
Hemorrhagic variola (malignant smallpox) is rare, and is usually described in two types. The purpuric form usually occurs in the debilitated, in infants, in puerperal women or in alcoholics, while the other type is known by the tendency of its pustules to become hemorrhagic. The typical lesion is a deep purple-red, pin-head to split-peasized papule, suggestive of measles in severe form. Later the color becomes a deep indigo or almost black and the general symptoms are proportionately magnified. Petechial eruptions may appear in any locality and may be mingled with the papules. Although the regular stages of variolous lesions may develop, extravasation of blood in and around the lesions is usually noted. There are apt to be hemorrhages from all the mucous outlets and hence mucocutaneous orifices are particularly involved. Internal or visceral complications are always present and death usually occurs from shock, coma, pneumonia or rapid exhaustion.
confluent variola, while less malignant than the form just mentioned, is very severe. The prodromata are intense and often do not cease with the appearance of the eruptions. While the lesions may develop typically at the onset, they finally occupy the entire surface by a process of coalescence. Edema is usually marked, respiration and deglutition are interfered with and, if the patient survives the stage of desiccation, a brownish or black-brown crust involves all or most of the body, Systemic phenomena are commonly grave and death often ensues.
Complications and sequelae are many and varied, although remarkably infrequent when the total number of cases is considered. Furuncles are the most frequent complication, followed by abscesses, carbuncles, erysipelas, bed sores and gangrene, while systemically pneumonia, pleurisy, nephritis, diseases of the eye, middle ear, joints, respiratory and gastrointestinal tracts and motor and sensory paralyses may be noted.
Etiology and Pathology. Age, sex and condition of life appear to exert no influence on smallpox which is one of the most contagious and infectious of all diseases. It is somewhat influenced by the season, being more prevalent in the cold months of the year in temperate zones. It is infectious at all stages; least so during the initial stage and markedly so during suppurative and early desiccative periods. It may be transmitted by mediate or immediate contact and is often epidemic. A microorganism is not doubt the specific causative factor, but the exact parasitic cannot be named at this time. Numerous organisms such as streptococci and spore-bearing bacilli have been urged as causative while Guarnieri and others have suggested a protozoon, the cytoryctes variolae, as the causative factor, but other investigators believe these bodies are merely the products of degeneration.
The histopathology of the pock has interested many investigators. The theories of unna are those usually accepted. He believes that the vesicle of smallpox is the result of peculiar degenerations of the protoplasm of the epithelial cells. These changes are of two varieties, both forms of fibrinoid degeneration, and have been called by unna recticulating and ballooning colliquation or softening. It is not necessary here to go into a detailed statement of the essential steps in this pathological metamorphosis.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war