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.
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.
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.
The indications for remedies are as follows:
Aconite.-During the febrile stage at the beginning, headache, epistaxis, injected eyes and frequent pulse.
Anxious restlessness. Pain in the back and aching in the limbs. Apprehension of a fatal issue. Excessive thirst.
Ammon carb.-Hemorrhagic diathesis, from fluidity of blood and dissolution of red blood-corpuscles; tendency to gangrenous ulcerations.
Ammonium mur.-Eruption well developed upon trunk and upper extremities, but scanty on lower ones; sore throat, with swelling about neck; hemorrhages.
Antimon. crud.-Gastric state, with vomiting and heavily coated tongue, especially during prodromal stage.
Apis mel.-Erysipelatous redness and swelling, with stinging, burning pains in skin and throat; absence of thirst; scanty micturition; at a later period great dyspnoea; sensation as though he would not be able to breathe again; great restlessness; suppression of urinary secretion.
Arsenic.-Asthenic cases, with great sinking of strength; burning heat; frequent small pulse; great thirst; great restlessness; irregularly developed variola, with typhoid tendency; hemorrhagic variola, or when the pustules sink in and their areolae grow livid; metastasis to mouth and throat in last part of eruptive period.
Baptisia.-Typhoid symptoms; fetid breath; pustules appear thickly upon palatine arch, tonsils, uvula, and in nasal cavities, but scantily upon skin; profuse salivation; great prostration, with excessive pains in sacral region. After taking the drug appetite improves and the patient is able to take and to retain nourishment.
Belladonna.-During first stage, high fever with cerebral congestion; intense swelling of skin and of mucous membranes, with tickling cough, dysuria, and the tenesmus of bladder; sleeplessness, with desire to sleep; delirium and convulsions; photophobia; ophthalmia. During later stage Belladonna modifies the itching of the desiccating pustules.
Bryonia.-Brings out the eruption when it is delayed, or when it suddenly disappears. In the first stage with gastric symptoms, or after the eruption is out, if ascites sets in, very cross and irritable; wants to lie still; dry mouth without thirst, or else wants large quantities at long intervals. Constipation of hard, dry stools.
Camphora.-Sudden collapse, with coldness of the surface; the swelling of the skin suddenly sinks in, and the pustules seem to dry up, from the complete giving out of the life forces; excessive weakness; the patient, though cold, cannot bear to be covered.
Calcarea sulph.-Pustules discharging matter.
Cantharis.-Hemorrhagic state; patient passes bloody urine, with cutting burning pains; burning pains through whole intestinal canal, with unquenchable thirst and disgust for all kinds of drinks.
Carbolic acid.-Dr. Middleton believes this drug to be as near a specific for variola as it is possible for any drug to be for any disease, and even in the hemorrhagic variety, if used early, there will be greater prospects of recovery than with any other drug known. He employs the IX. When given at an early stage of the disease, Dr. Montefero has found that the pustules fail to develop; they shrink and dry up after a few days without any swelling of the subcutaneous tissue. In the suppurative stage it moderates the fever, and lessens the suffering in the mouth and pharynx. The urine turns black when standing, and in some cases shows some traces of albumin.
Carbo veg.-Asthenic variola, with cold breath and excessive prostrations; great desire for fresh air; livid purple look of the eruptions; hippocratic face.
Chamomilla. Great fretfulness of children during eruptive stage, with the usual impatience and coldness.
China.-Variola hemorrhagic, with great exhaustion from the copious painful stools; excessive debility and prostration after a severe attack.
Cimicifuga.-In the precursory stage, for the muscular rheumatoid pains; during eruptive fever great wakefulness, mental excitement as if the brain would burst out; dull heavy aching in small of back, relieved by rest, increased by motion; excessive muscular soreness; prickling itching heat of the whole surface; eruption of white pustules over face and neck; it modifies the disease, prevents the development of pustules, and thus reduces the danger of pitting.
Coffea.-Restlessness and bilious vomiting at the commencement of the disease.
Cuprum.-Convulsions preceding the eruption; vomiting, delirium, sopor.
Ferrum.-Fiery redness of the face after recovery.
Gelsemium.-Predominance of nervous symptoms, as nervous chills, restlessness; intense and painful fever at the commencement of disease, with tendency to convulsions.
Hamamelis.-Hemorrhagic variola; blood dark, venous; oozing of dark blood from nose; bleeding gums, hematemesis, bloody stools; uterine hemorrhage, petechiae; tearing pains across the small of back, with fulness of the joints of the legs; typhoid condition. (If Hamamelis fails, try Crot. horr.).
Hepar.-Loose, rattling cough, without expectoration; suppurative stage; swelling and suppuration of the glands. Hydrastis.-Itching tingling of eruption, face swollen, throat sore, pustules dark, great prostration; buccal cavity full of pustules; pulse slow and labored, with palpitation of heart; intense aching pain in small of back, legs feel very weak and ache; is said to prevent pitting to a great degree.
Hyoscyamus.-Eruption fails to appear at the proper time, causing great nervous excitement, with rage, anguish, delirium, coming on in paroxysms; patient wants constantly to get out of bed and to be uncovered (hyperaesthesia of skin); vesicles coming out in crops; restless sleep; slight fever; dry teasing cough, relieved by sitting up.
Ipecac.-Gastricismus during eruptive stage, with constant nausea.
Kali mur.-Controls the formation of pustules.
Kali phos.-Putrid conditions, heavy odor, exhaustion and stupor. Adynamic symptoms indicating blood decomposition.
Kali sulph.-To promote the formation of healthy skin and the falling off of the crusts. Malandrinum 30x was used during the epidemic of 1880-I with great success as a preventive as well as a curative agent. It prevented the suppurative fever, or lessened it at least to a considerable degree, and took away all offensive exhalation.
Mercurius.-Variola in the stage of maturation; ptyalism; tendency of blood to head; irritation of mucous membranes; moist swollen tongue, with great thirst; diarrhoea or dysentery, with tenesmus, especially during the period of desiccation.
Natrum mur.-Salivary flow, confluence of pustules and drowsiness.
Opium.-Drowsiness and stertorous breathing. Complete loss of consciousness. Impending paralysis of the brain.
Phosphorus.-Hemorrhagic diathesis; bloody pustules; hard, dry, exhausting cough, with pain or feeling of rawness in chest; bronchitis; hemorrhage from lungs; backpains as if broken, impeding all motion; frequent faintings; typhoid variola, even so from the start.
Phosphoric acid.-Confluent variola, with typhoid conditions; pustules do not fill with pus, but degenerate into large blisters, which, bursting, leave an excoriated surface; patient is stupid, does not want anything, not even a drink; answers questions, but does not talk otherwise; subsultus tendinum, great restlessness; fear of death; watery diarrhoea.
Rhus tox.-Typhoid symptoms, dry tongue; great restlessness; patient wants to get out of bed, notwithstanding his great debility; sordes on lips and teeth; confluent smallpox, with great swelling at first, but afterwards the eruption shrinks and becomes livid; blood in pustules; bloody stools.
Sarracenia.-From reports, the consensus of opinion seems to be in favor of this plant in the treatment of severe cases of variola; there are no reliable indications as yet.
Silicea.-Suppurative stage exhausts the strength of patient and desiccation is delayed; caries of bones, following severe attacks of variola, with fistulous openings and discharge of thin pus and bony fragments.
Solanum nig.-Hemorrhagic variola.
Stramonium.-Entire swelling of the face before the eruption, with muttering delirium.
Sulphur.-Tendency to metastasis to the brain during suppuration;stage of desiccation; occasionally indispensable as an intercurrent remedy, where others fail.
Tartarus emet.-Eruption tardy in coming out, with great oppression under sternum, nausea, vomiting, sleepiness, or for suppression of eruption; putrid variola, with typhoid symptoms, especially typhoid pneumonia, with tendency to paralysis of lungs; vomiting of viscid mucus, clogging the air-passages; pustules in larynx, mouth, throat, and digestive organs; leaving bluish-red marks on face, genitals, and thighs.
Vaccininum has been used undoubtedly with great benefit in variola; its use has shortened and ameliorated all stages quite considerably. Sulphur was given afterwards.
Variolinum.-Especially where the disease throws itself with full force on throat. Given steadily during the disease it will run a milder course, changing imperfect pustules into regular ones, which soon dry up; it promotes suppuration and desiccation, and prevents pitting.
Veratrum vir.-Intense fever, with excessive pain and restlessness. Used in alternation with Macrotin the pustules flattened rapidly, dried, and fell off.
This is a disease of childhood. After pyrexia lasting a few hours, or not more than a day, the eruption of varicella appears, often on the back first of all, as distinct red papulae, which become vesicular in a few hours; the eruption is successive during three or four days. The same kind of changes occur in the eruption as in variola, but the disease is more superficial, and the vesicle is unilocular, and it is not generally umbilicated; the contents are serous rather than puriform. On the first day the vesicles are transparent; opalescent on the second and third; on the fourth they shrink and desiccate; and on the sixth the scabs fall off. Sometimes, however, the contents of the vesicles become puriform. The general pyrexia is slight.
The prognosis is favorable. If the fever runs high with much disturbance of the system, the patient may require one of the following remedies: Aconite, Belladonna, Mercurius, Rhus, Tart. emet., or Veratrumv.
This consists of two component parts:
1. A subcutaneous mottling, of a more or less livid hue, and diffused generally over the body.
2. Petechiae, small, about the size of pin`s heads, scattered all over the body, and showing out from the mottling; at first these are slightly raised, and their color increases gradually in intensity; they do not fade by pressure, except slightly in the very early stages. The eruption of typhus is not prolonged by successive crops.
It makes its appearance between the fifth and eighth day of disease, and disappears a few days before convalescence. It has been mistaken for syphilitic rash.
Is characterized by the appearance between the eighth and twelfth day of disease of rose-colored, elevated, circular, softish spots, about a line or so in diameter, on the abdomen, back of hand, arms, chest, and back (if kept warm). These rose- colored spots disappear by pressure, and they appear in successive crops, each spot lasting three or four days, and then gradually fading. There may be from half a dozen to a score of these spots present at one and the same time. Sudamina often co- exist with them.
Within fourteen days from the reception of the contagion, the eruption of measles appears, the first stage, the stage of invasion, consisting of a catarrhal attack upon the head and chest. The child is restless and feverish with headache. The eyes grow red, weak and watery, unable to bear the light. There is frequent sneezing, with watery discharge from the nose and a constant short, dry and sometimes croupy cough. In exceptional cases there may be vomiting and delirium. About the fourth day, the stage of eruption comes on, the rash appearing first on the face and extending in the course of 48 hours over the body. About the third day of the disease the rash may be observed on the fauces. The eruption consists of numerous deep red circular spots resembling flea-bites. Between these spots the skin retains its normal color, except upon the face, where it may be oedematously swollen. On the cheeks the rash sometimes becomes confluent, forming blotches and presenting a crescentic shape. In the same order as it came on the rash fades, beginning to grow faint on the face when it is at its height on the body. In this stage the fever increases, the temperature rising to 102 degree to 106 degree. The third stage, the stage of desquamation, begins about the eighth or ninth day of the disease, when the rash disappears and the epidermis peels off in fine scales. This is the course of the normal type, but in some cases the onset of the disease is so violent that the child dies in the second stage from asthenia with typhoid symptoms. In other cases, inflammatory measles, the rash grows darker, assumes a purple color, remaining visible for some days, and all the symptoms are intensified. The cough becomes croupy and there may be lobular pneumonia. This runs to exhaustion, with disappearance of the eruption and collapse. The sequelae of measles are chronic catarrhal cough and chronic pneumonia, which may end in consumption, also scrofulous affections, chronic inflammation of the eyes, otorrhoea, swelling of the glands.