A Few Practical Suggestions in Reference to the Diagnosis of Smallpox.
Art. VI—
—By H. L. True, M. D., McConnelsville, O.
Smallpox prevails most during the Winter season. Last Winter was one in which it was unusually prevalent, and in view of the epidemic influences which have been in the atmosphere ever since, we may expect to see much smallpox during the coming Winter, therefore every physician should fully acquaint himself with the diagnostic symptoms of the disease, for in no other disease can such disastrous results to the community follow a mistaken diagnosis as in smallpox. Many a physician whose prospects were promising has been crushed, even compelled to fly for his life from a neighborhood where he failed to make a correct diagnosis of smallpox in time to prevent the community from becoming infected with the disease. No explanation will be sufficient to satisfy an exasperated people that such mistake was unavoidable. The physician, and he alone, is held responsible. In view of this all should be on the qui vive. How will we diagnose a ease of smallpox where the symptoms are not all developed, or where doubt exists?
Prof. Howe said it would be well for every physician during his leisure hours to visit the Court room and there hear the lawyers examine their witnesses. He thought we might thereby learn a lesson which would be of advantage to us in making a diagnosis in obscure cases.
I believe the suggestion to be a good one, and where doubt exists, one might with advantage imagine himself to be in the place of a lawyer who is working up his case to present to a jury. See how careful the lawyer is to notice every little circumstance that would tend to throw light on the subject. See how closely he examines his witnesses, and how he establishes link by link his chain of evidence. Thus should we do where the case is clouded in obscurity.
To illustrate, suppose we are called to a patient who is suffering with high fever, much pain in the head, back and limbs, flushed face, great nausea and vomiting. We can see no particular lesion sufficient to account for the great disturbance of the system. What is the matter with him? We will work up the case.
- We will note all the present conditions and symptoms.
- The history of the patient's health for some time previous; his occupation; the premonitory symptoms, etc. If we find that he has not recently undergone exposure sufficient to produce sickness; that he is not subject to inflammatory rheumatism, we are led to strongly suspect it to be one of the eruptive fevers.
- Is any one of the eruptive fevers at the present time prevailing in the neighborhood, and if so what one? (Right here it will be well to caution the reader against being biased in his opinion by the prevalence of a particular disease. We must not jump at conclusions, but on the contrary, weigh all the circumstances carefully before making up our minds.)
- Has the patient ever had rubeola? scarlatina? variola? varioloid? varicella? has he ever been vaccinated? If so, how long since? Examine the scar.
Diagnosis by exclusion is similar to deciding a case which is in litigation by circumstantial evidence, and like that, of great service to us in the absence of positive evidence. Now if the patient be an adult, has had measles, chicken pox, and has never been vaccinated, the probabilities are that it is smallpox, and yet unless we are able to ascertain from whence the contagion originated, we would not be justified in pronouncing it such. If we can hear of some suspected case of varioloid to which he has recently been exposed, we would do well to adjourn court and look after that case before deciding on this, but if after having done this we are still in doubt, all that we can do at the present is to put the friends on their guard and wait for the appearance of the eruption, which, if it is smallpox, will begin to appear on the third or fourth day from the attack, previous to which time the disease is not contagious. Then we must make a diagnosis or we will have trouble.
5. The appearance of the eruption. It closely resembles measles; in fact when smallpox eruption first makes its appearance, the resemblance is so close that I have been unable to see any difference. I mention this that those who have not seen it may know how it looks where blunders in diagnosis have been made. They have generally begun by calling it measles, after which the practitioner, finding it does not follow out the usual course of measles, to satisfy the friends of his wisdom, tells them it is French measles or "black measles," and attempts to define such diseases. I caution the inexperienced about being deceived in this way. French measles occur in Frenchmen and black measles in black men; that is all there is of this nomenclature.
6. The feel of the eruption. Some authors speak of hard points resembling grains of mustard seed under the skin. These are sometimes present, but will not do to depend upon, as they are not present in all. The symptom which is the most reliable is the distinct hardness in the skin where the eruption is making its appearance. It is the characteristic symptom of smallpox. If our patient has this with other foregoing symptoms, I think we will be justified in pronouncing it smallpox every time. However, some will wait to see the umbilicated character of the eruption. Young practitioners usually change their minds only with this symptom, and I have known older ones who could not tell smallpox even when that was fully developed; but the close observer will not wait to see it. He can pronounce upon it sooner.
By the line of investigation above laid down, I was enabled last Winter to make a correct diagnosis four days before three physicians whose heads were whitened by long years experience would admit it to be smallpox.
As respects treatment I have nothing to offer. Fully one-half of all the cases which occurred in this locality last Winter died. No matter whether the treatment was Allopathic, Homoeopathic, Eclectic, Thomsonian, or whether not treated at all, the mortality was about the same. Prevention is better than cure, and that "prevention" is vaccination.
The Eclectic Medical Journal, Vol. XXXIV, 1874, was edited by John M. Scudder, M.D.
