Part 70

The question of repair with or without the production of cicatrices rests upon the behavior of the connective-tissue elements. If these are not torn asunder, but remain in connection with each other, the re-formation of a glue-giving basis-substance is possible, and new bundles of fibrous connective-tissue take the place of the old. If, on the contrary, the latter are completely destroyed, their place is filled with the cicatricial new growth. The pigmentation, which is such a common transitory sequela of the skin lesions, is due both to the imbibition of the coloring matter of the blood by the epithelia and by direct hemorrhagic exudation into both the rete and derma.

The umbilication of the mature pock is doubtless due to the situation of such lesions at the orifices of the excretory ducts of the skin-glands. The epidermis, in one or more of its strata, dips downward to form a living investment for such glands, and in this situation ties down the centre of the roof-wall of the pustules. Eventually, it too, as a result of the maceration and tension incidental to the complete filling of the pock with pus-elements, is ruptured or stretched, and the umbilication of the pustule disappears.

The anatomy of the exanthematous lesions in hemorrhagic variola is not different from that described above. The pocks in such cases are merely filled with blood instead of with pus or sero-pus. In some forms of hemorrhagic variola, as indeed would be suggested by their clinical observation, there is hemorrhage directly into the tissues of the integument, or, more probably in severe cases, a mere passive leaking of the sanguineous fluid with its coloring matter through the relaxed and weakened vascular walls.

The morbid changes occurring in the viscera are described by Curschmann as follows: The mucous surfaces may be the seat of pustules, diffuse purulent infiltration, and catarrhal, croupous, or diphtheritic inflammation. As regards the extent of diffusion of the pustular lesions, they occur, according to Wagner, in bronchi of the second and even of the third order, rarely in the stomach and intestines, and in the rectum only in its lowest portion. The bladder, urethra, and serous surfaces are always exempt. The lungs, breast, liver, spleen, brain, and spinal medulla are variously involved. Often the tissues of these organs are quite unchanged as regards their macroscopical appearance. At other times the tissues appear swollen, granular, and undergo a fatty degeneration. In purpura variolosa the spleen and walls of the heart, however, are seen to be firm, dark-red, and more or less indurated.

DIAGNOSIS.--The establishment of a correct diagnosis where there is question of variola is one of the most critical and important of the duties of a physician. Upon such decisions have turned, again and again, {448} professional success or disaster. To pronounce that case to be variolous which is not of such a nature is to subject one to the indignation of the few and the ridicule of the many. On the other hand, to be guilty of treating a patient with small-pox, and of remaining ignorant of the nature of the malady, is to subject many ignorant people to the danger of exposure to the disease and to render one's self liable for the redress sought by recourse to the civil authorities and the law. It is difficult to decide which predicament is the graver.

Typical variola vera is readily recognized by its characteristic features. As usual, it is the atypical and modified forms where the difficulty most often arises and where the danger to the physician is proportionately increased.

In the invasion stage of the disease it is often impossible to recognize any symptoms characteristic of variola. High fever with severe lumbar pain, considerable gastric distress, and the appearance of one of the invasion rashes (roseola variolosa) would, however, put the observant practitioner on his guard. I have often noticed in these cases a symptom which, apparently insignificant, has on more than one occasion preceded the eruptive period. It is the occurrence upon the centre of the two cheeks of a vivid damask-red blush, occasionally having a purplish-red hue, and with a very remarkable circumscribed area. This may be recognized in children and adults of both sexes when it occurs in typical aspect, and is undoubtedly a hyperæmia of the character of that producing the rashes in Simon's triangles.

When the variolous exanthem first appears the practitioner should secure as soon as practicable a history of the invasion stage if this has not been subject to his personal observation. He should then make careful inquiry as to the possibility of a neighboring source of contagion, and ascertain by inspection whether the person of the patient exhibits the evidences of successful vaccination. In this connection it is always well to estimate the value of the elements represented by (a) the period ascertained as having elapsed since the last successful vaccination; (b) the typical or atypical character of the existing cicatrices of vaccinia; (c) the unicity or multiplicity of the cicatrices simultaneously resulting from vaccinations performed at one and the same date.

Without question, the first papular lesions of variola resemble those of rubeola or measles to an extent which has often deceived the most expert diagnosticians. The distinguishing points are--(1) In measles, catarrhal symptoms (conjunctival, nasal, laryngeal, bronchial), which are usually absent in the early stages of variola, and later are obviously associated with the irritation set up of the pustules of the maturing period. (2) The difference in the temperature record, that noted in the invasion stage of variola varying from 104° to 105° F., while in rubeola it is rarely registered above 103° F. Moreover, in typical variola the defervescence is marked and characteristic on the appearance of the exanthem, while in rubeola, when the rash appears, the temperature is usually sustained at a maximum, and may even rise. (3) The differences in the rashes of the two disorders. The papules of variola, even in its confluent forms, are, when first observed, remarkably discrete and exhibit not the slightest tendency to grouping, while the maculo-papules of rubeola are (a) developed simultaneously on the face and trunk, while those of variola {449} commonly appear first on the face and afterward on the trunk, the older, and larger therefore, in the site of earliest appearance; (b) are set in clusters or groups having a distinct tendency to crescentic arrangement, a symptom decidedly best appreciated by the eye when the eruption is viewed in totality or in large areas with the eye of the observer somewhat removed from the surface; (c) are often made to disappear or pale beneath the pressure of the finger, while there is greater persistence of color in the variolous papules; (d) are surrounded by little or no halo, each elementary lesion of the eruption being abruptly defined upon the sound skin, while the variolous papule is apt to rest upon a circlet of hyperæmic integument.

Even with careful observation of all the specific differences between the two diseases, they may, for a brief time, so resemble each other as to defy the skill of the expert. In all doubtful cases the physician should invariably admit the doubt and defer an exact diagnosis for twenty-four hours. During the delay the variolous exanthem should betray its individuality by the formation of a minute vesicular apex at the summit of several papules.

In scarlatina the uniform diffusion of the exanthematous blush, the absence of papules and vesico-papules, the continuance of the fever after the rash has appeared, the characteristic scarlet or boiled-lobster color of the skin, and the anginose condition of the throat, are all significant symptoms. In hemorrhagic small-pox the color of the integument is a much more purplish and lurid-reddish hue, rapidly reaching that stage where it refuses to pale under the pressure of the finger, and never leaving in the track of the finger-nail quickly drawn over its surface the peculiar transitory yellowish-white line which can be usually obtained in the skin of the patient with scarlatina.

The pustular stage of variola might be confounded with the pustular syphiloderm. But in the latter there should be a history of a chronic rather than of an acute affection, and, as a result, the simultaneous appearance of lesions in very different stages of their career, some distended with pus, others ruptured and crusted, yet others which have recently formed in the immediate vicinity of the oldest lesions, while the latter have been in full involution or have been replaced by superficial losses of tissue.

The resemblance of pustular variola to certain suppurative and other disorders of the sebaceous glands is well attested by the name given by certain French authors to molluscum epitheliale (M. contagiosum, M. sebaceum)--viz. acne varioliformis. But in the case of acneiform disorders the concurrence of comedones, the chronic course of the disease, the absence of fever and systemic disturbance, and the particularly irregular distribution of the lesions upon the face, with failure to appear elsewhere,--all these facts forbid the confusion of the affection with variola. In medicamentous acne, accompanied by the sudden appearance of numerous pustular lesions symmetrically displayed upon the surface, there will indeed be a source of error. In such cases, of course, a history of the ingestion of a medicament capable of producing a rash will afford valuable aid in the diagnosis. In pustular forms of dermatitis medicamentosa there will usually be found a more abundant development of the pus-containing lesions upon the head and both arms and forearms, with {450} no tendency to extension over very large areas of the trunk and lower extremities--a circumstance which a delay of but a few hours will often substantiate.

The absence of marked defervescence is the most characteristic difference between variola in its eruptive stage and typhus, typhoid, and relapsing fevers. Pneumonia, cerebro-spinal meningitis, acute miliary tuberculosis, and gastric fever are all to be differentiated from variola by the occurrence of symptoms characteristic of the involvement of the several organs which in these diseases respectively are more particularly impaired.

PROGNOSIS.--The prognosis of variola is wellnigh inseparably associated with the question of protection by vaccination. Variola vera in the unprotected is an exceedingly fatal malady, the death-rate varying in different epidemics according to the severity of each and the ages and hygienic surroundings of the victims of the disease. Certainly, from 15 to 50 per cent. of unprotected individuals affected with the disease occurring in epidemic form in any given community will perish. This number may, however, be enormously increased, as, for example, among a large number of unprotected negroes crowded together in a filthy prison, or when the malady makes a periodical visitation to an insular community where long isolation has begotten a carelessness with respect to vaccination.

With respect to individual cases it may be asserted, first, that an intense series of prodromic symptoms, followed by the appearance of an unusually large number of cutaneous lesions, is often unfavorable. Confluence of the latter adds to the gravity; hemorrhagic and purpuric symptoms are in the highest degree portentous, and commonly indicate a fatal result. Women pregnant or in the puerperal state, infants at the breast, and persons of both sexes at advanced ages, are little able to resist the ravages of the disease. According to Kaposi, women recently delivered prematurely or who have lately suffered from an abortion succumb more often than others of their sex. Chronic alcoholism among male subjects and the cachexia induced by all chronic visceral and systemic disorders are sources of weakness which largely increase the death-list by adding to the heavy strain upon the vital energies. The prognosis is rendered uncertain or unpromising by extensive involvement of the mucous as well as of the cutaneous surfaces, by marked visceral complications, by evidences of shock or exhaustion before the apogee of the exanthem is reached, by grave sequelæ, and even by simple complications of the malady when, instead of entering promptly upon convalescence, the patient lingers for weeks in a typhoid condition. An unfavorable symptom in any case is the sudden cessation of the processes actively pursued upon the surface of the body. The swelling of the integument then suddenly diminishes and the crusts by which it was covered shrivel. The eruption, in brief, seems to undergo what may be described as a collapse. The pulse at such moments usually flutters feebly, and there are other portents of dissolution which the eye of the physician will hardly fail to interpret correctly. The fluids in such instances mechanically drain away from the surface of the body to seek the deeper parts. This is not peculiar to small-pox. Similar phenomena occur even in the case of other than exudative affections of the skin. In pityriasis rubra the {451} patient dies leaving an integument apparently unaffected, and I have seen a patient dead of even multiple sarcoma of the skin when the tumors were reduced fully one-half in bulk as the result of a similar cause.

On the other hand, the practitioner should never forget that even apparently desperate cases of variola rally and are won back to life. That the exudative process should be in full evolution at the surface of the body is, cæteris paribus, certainly so far a good omen. The most hideous, extensive, and stench-emitting crusts have hidden for a time the forms that have for many subsequent years not only known the enjoyment of life, but have made that life of inestimable value to others. The physician in the presence of this most loathsome and formidable disease should never despair.

PROPHYLAXIS AND TREATMENT.--The loftiest end to be reached by the physician of our day with respect to variola is its complete removal from all civilized countries, and indeed from the face of the earth, by the practice of universal vaccination and revaccination. The evident modifications which the disease has undergone in late years as a consequence of the extraordinary attention given to this subject is an earnest of the future. The day is probably not far distant when the man, woman, and child unprotected by vaccination will properly be regarded as an enemy of the human race, and treated accordingly. Evidences of the most satisfactory character as to successful vaccination should be imperatively required of all applicants for admission to schools, academies, colleges, charitable institutions, public libraries, art-galleries, and places of labor controlled by incorporated institutions; of all members of conventions, legislatures, political, religious, and deliberative bodies; of every purchaser of a ticket for purposes of travel; and of every voter. In addition, there should be in every district a systematic and periodical inspection of all persons registered in the census by persons qualified and competent to perform compulsory vaccination. This is the scientific treatment of variola.

Respecting the therapeutic management of variola, it must be admitted that there are no remedies known to exert the slightest influence in either cutting short the curriculum of the disorder or in checking its progress in any stage. When vaccination is practised after the disease is fully developed, the two disorders, vaccinia and variola, apparently concur, and proceed pari passu to the evolution peculiar to each. Quinia, the sarracenia purpurea, the salicylate of sodium, emetics, diaphoretics, purgatives, and other remedies and methods vaunted as efficacious, have again and again failed to establish the claims which have been put forth respecting the value of each.

The most important of the considerations to be regarded at the outset of the management of the small-pox patient relate to his hygienic surroundings and nursing--considerations which scarcely differ from those recognized as of general importance in the case of all septic, contagious, and filth-producing diseases.

The timid, the fearful, and the unprotected are to be at once dismissed from the bedside, and trustworthy attendants secured who have received protection by either recent vaccination or a prior attack of the malady. The sick chamber should be sufficiently large and capable of the most thorough ventilation by free access of air. Solar light should be excluded {452} as rigidly and completely as possible, since it is reasonably certain that its access to the face has an etiological relation to the pitting of that part, often the most serious sequel of the affection. It is an interesting fact that pitting is much less frequently noted on those parts of the body from which light is excluded by the covering of the clothing. The temperature of the sick room during the febrile stages of the disorder should not rise above 70° F. nor be permitted to fall below 60° F. Between these extremes a variation may be made in accordance with the sensations of the patient.

During the invasion stage of the disease the patient can rarely assimilate food, but if this be possible it should be given throughout the entire course of the disease in the form of animal broths, eggs, nutritious soups, and milk. Iced and acidulated beverages are often grateful to the palate, and small lumps of ice should be permitted to dissolve slowly in the mouth. Lime-water may be required by unusual gastric irritability. As the disease progresses and the palate and buccal membrane become painful and sore by reason of the localization there of pustular and other lesions, various mouth-washes and gargles may be ordered, such as those containing the chlorate of potassium, the tincture of myrrh, the tincture of cinchona, or even the milder demulcent fluids made by the addition of flaxseed, gum acacia, or powdered elm-bark to water. In almost all such cases the skilled nurse will accomplish a grateful result by frequently cleansing the mouth of the sufferer (especially before the deglutition of aliments) by covering the finger with a soft handkerchief, dipping it in pure hot water, and then thoroughly and gently cleansing the entire buccal cavity. The spray of a saturated solution of boracic acid in rose-water may then be directed over the parts.

Applications of cool and iced water to the skin are commonly grateful, and, as a rule, are accompanied by no danger to the patient, though in the early periods of the disease they unquestionably retard the full evolution of the cutaneous symptoms. For the pain in the back, therefore, which is often the most urgent symptom of the invasion stage of the disease, it is usually preferable to make hot applications. The large rubber bags now in common use, filled with hot water and from time to time applied to the lumbar region, may be employed with good effect simultaneously with iced, spirituous, or camphorated applications to the head.

Numerous indeed have been the topical applications made to the surface of the skin in the pustular stage of the malady, both with a view to assuage the soreness and pain and to obviate the tendency to pitting. The opening of the pustules and the evacuation of their contents (practicable only in other than confluent forms of the disease) has been practised from an early date, but is ineffectual from the standpoint of any practical results thus obtainable. The same may be said of the subsequent cauterization of the floor of the pustular chamber, which only adds to the distress experienced by the sufferer in his skin. Medicated unguents, applied to the skin, containing mercury, iodine, and other substances, are not known to be followed by any better results. It may indeed be laid down as a general rule that fatty applications to pus-producing surfaces where the pathological product is virulent are apt to undergo decomposition and otherwise act unfavorably upon the tissues--a fact first pointed out by Ricord in connection with the treatment of the {453} chancroid. Vaseline, as not liable to undergo chemical decomposition, is not open to this objection.

Curschmann, Kaposi, and other authors are in agreement respecting the value of water-compresses over the surfaces invaded by the eruption--a method of topical treatment which I desire to fully endorse after personal observation of its value. Curschmann recommends compresses dipped in iced, Kaposi those moistened with tepid water. The sensation experienced by the patient will prove the best guide to the temperature of this fluid. I prefer a solution containing one drachm of boracic acid to the pint of water as hot as can be discovered to be productive of comfort, a drachm or two of glycerine being added to the solution. The compresses dipped in this (or a carbolated solution, if the latter is preferred by either physician or patient) should be assiduously moistened and changed regularly by the attendants just as long as they can accomplish good. They operate, first, by protecting the part; second, by keeping it moist; third, by maintaining the surface temperature at the point most pleasant to the patient; fourth, by exercising the gentlest degree of equable compression over the surface. When desired, this may be covered with the Lister protective material or a piece of oiled silk to prevent evaporation at the surface.

In Vienna warm baths, administered either by the process of continuous immersion so generally practised there or by immersion for from two to three hours of each day, have been found to furnish the greatest amount of comfort to the patient. The skin is thus speedily relieved of its tension, the exfoliation of the crusts is hastened, and the time required for the evolution of the cutaneous lesions, if not shortened, is at least not retarded by the accidents of exposure to the desiccating influences of the air--ends which for the patient are practically one. In this country, and especially in private practice outside the larger charities with their ampler provision for these emergencies, nearly the same result may be reached by wrapping the patient completely in sheets wrung out of water of the temperature desired.

From first to last in the treatment of variola, all indications should be made subordinate to that most prominently set forth by the general character of the symptoms--viz. the conservation by every possible means of the vigor of the patient. The tax upon all reserves of vital energy is here so enormous and constant that he will gravely err who for a moment loses sight of this fact. Hence it is that anodynes, chloral, opium and its alkaloids, the bromide of potassium, and similar medicaments, introduced either by the stomach or by hypodermic injection, are to be jealously reserved for emergencies when it would seem cruel to withhold the temporary comfort they may impart. Stimulants are of course to be freely employed whenever they are indicated by exhaustion as this may be shown by a weak pulse and other failing functions of the body, but are certainly best reserved for such emergencies. In general, it may be remarked that the fewer the medicaments ingested by the stomach, and the larger the restriction of the labor of this organ to the task of sustaining the nutrition of the body, the better are the chances of a favorable issue.

It is unnecessary to add that all other indications presented in any given case are to be met, subject to the conditions indicated above. Abscesses {454} are to be opened and antiseptically treated; delirious patients are to be sedulously prevented from doing themselves injury; daily movements of the bowels are to be secured; while the diarrhoea of the typhoid state, occasionally resulting from the exhausted condition of the system when the force of the disease is spent, demands proper control.