Synonyms.—Small-pox; German, Blattern; French, La Petite Verole.

Definition.—A specific, infectious, and highly contagious febrile disease, which, after a definite period of incubation, lasting from seven to fourteen days, commences abruptly with chilly sensations, accompanied by headache, an intense pain in the back, especially in the sacral and lumbar regions, and characterized by a dermatitis, in which the eruption passes from papule to vesicle, and this in turn to pustule, finally desiccating, leaving small cicatrices, where the suppurative processes have extended to the deeper tissues of the skin.

With the appearance of the eruption, usually on the second or third day, there is a decline in the temperature, to be followed by a secondary fever during pustulation.

History.—The origin of small-pox is more or less a mystery, and three different countries are named as the original home of this loathsome and dreaded disease. Moore regards China as the original seat of the plague, and gives the earliest records as 1122 B. C. The disease is called Tien-hwa, meaning the "Heavenly Flower." It has been deified, and temples have been erected in honor of the goddess who bears the name of "Holy Mother of Small-pox." While there is great doubt as to the authenticity ol these early records, it is well known that the disease has prevailed from a very remote period, inoculation having been practiced in China for more than a thousand years.

Hirsh regards India and Central Africa as the original habitats of the disease. The traditions of the Brahmin caste, from time immemorial, give India as the starting place. Here, as in China, temples are erected for the worship of a deity whose protection was invoked at the outbreak of an epidemic. The disease was unknown to the early Greeks and Romans, although some regarded the great plague of Athens, 430 to 425 B. C., as small-pox.

It appeared in Europe during the sixth century, devastating the shores of the Mediterranean. During the crusades it again invaded Europe. The fourteenth century found it in Ireland, and the following century in Germany.

Fifteen years after the discovery of America, small-pox visited the New World, and, in 1620, Mexico was the scene of one of the most dreadful epidemics in the history of this most loathsome plague. The United Colonies escaped until the seventeenth century, and Australia until the nineteenth century.

The mortality, previous to vaccination, was frightfully large, and when the disease entered a country for the first time it numbered its victims by the millions. Thus its first invasion of Mexico resulted in the death of three and a half millions of her people, while in Iceland one-fourth of her population succumbed at the first outbreak, and a quarter of a century later Greenland was almost depopulated.

This disease, which at one time was the scourge of the world, has largely been shorn of its terrors, thanks to Jenner, one of the greatest benefactors of his century, and also to the modern sanitary and hygienic measures adopted during every outbreak of any contagious disease. Ever since Jenner's discovery there have been, at various times, attempts to discredit its prophylactic power, owing either to its occasional failure or as the result of a death from vaccination or the transmission of other diseases.

That unpleasant and serious results have followed vaccination. none will deny; nevertheless, a prophylactic measure of such vast importance should not be discouraged because of faulty vaccine virus; rather should there be extra precautions that only pure, fresh virus be used. Could this be secured, and vaccination universally practiced, there can be but little doubt that Jenner's prophecy that small-pox would become extinct would be soon realized.

Etiology.—The contagion of small-pox is the most virulent of all the infectious diseases, and all persons who are unprotected by vaccination are almost certain to contract the disease when exposed, although there have been notable exceptions.

The true nature of the virus is unknown, and although certain micro-organisms have been described which are found in the pock, there is no proof that they are responsible for producing the poison. All that is positively known is, that it is developed in the system and reproduced in the pustule.

The virus exists in the secretions, and excretions from the skin, kidneys, and bowels. The crusts, or scabs, however, contain by far the most important factors in the dissemination of the poison, and the dust from this source impregnates the air, furniture, and clothing of the sick-room.

The virus possesses a tenacity exceeding that of all other contagious diseases, and may remain in a dormant stage for months or years, ready to break out afresh whenever the conditions are favorable for its propagation. Just how early the disease becomes contagious has not been definitely determined, although it is probably not until after the eruption makes its appearance. The poison of a mild case of varioloid is sufficient to produce a malignant type of small-pox in the unprotected; hence the wisdom of universal protection by vaccination.

Figure 8: Confluent smallpox. Age.—No age is exempt, although the mortality is greatest among young children. The fetus has been attacked, and cases have been recorded where the child came into the world with the rash already developed, and still others bore the scars as a proof of having undergone the disease in utero.

Sex.—Sex carries with it no predisposing power, save the more frequent exposure of the male.

Race.—The colored race seems more susceptible to the contagion than the white race, and especially is this true of the negro. The mortality is also greater, although this may be accounted for more on sanitary grounds than on that of race. The aborigines have always suffered greatly in an outbreak, and the history of epidemics among the Indians of our own country reveals a mortality truly appalling.

Figure 9: Variola. Pathology.—The most marked pathological change occurs in the skin, due to the cellular infiltration during the inflammatory process. The eruption is the result of changes which take place in the rete mucosum, and consists of papilla, vesicle, pustule, and scab.

The hyperemia is first made apparent by small red spots which very soon assume the hard, shot-like characteristic papillae, due to the increase of cells in the rete mucosum. As the inflammation progresses, molecular changes occur, the cells deliquescing, and a vesicle forming on the apex of the papilla. The vesicle consists of several small cups or pockets separated by fibrinous reticuli, and filled, at first, with a clear, whey-colored fluid composed of serum, leukocytes, and fibrin filaments.

The fibrous reticuli being firm, the center of the vesicle becomes depressed, while the circumference swells and becomes elevated; hence the cup-shaped or umbilicated vesicle, characteristic of small-pox. The blood-vessels throughout the cutis are now dilated, and a stream of leukocytes engorges the vesicle, the contents change to a yellowish or purulent character, and the pustule is formed.

The suppurative process softens and often breaks clown the fibrous septum, and the pustule becomes conical. If the suppurative process, extends to the cutis vera, cicatrization follows, and pitting necessarily results. The pustules may dry up, but usually rupture, exuding their contents, which, drying, form the scabs or crusts. These consist of dried pus cells, and the detritus resulting from the previous destructive processes.

The mucous membrane of the nose, mouth, pharynx, esophagus, and rectum may be the seat of the eruption, and Peyer's glands may be swollen and infiltrated. Only when the mucous membrane is exposed to the external air, are fully developed pustules seen, while in the larynx bronchi and esophagus the tissue changes result in ulceration.

In the hemorrhagic form, extravasation takes place in the serous and mucous surfaces, while parenchymatous changes occur in the various viscera. Although there is no characteristic change in the lungs, hypostatic congestion and broncho-pneumonia are not uncommon.

Early we may have myocardial changes, and endocarditis and pericarditis have been associated with this disease. There may be diffuse hepatitis with swelling, although in the hemorrhagic form it is firm and hard. The spleen shows cloudy swelling, and there may be fatty degeneration. The kidneys may reveal a similar condition and nephritis may follow. The blood does not reveal any microscopic changes, although darkened in color.

Symptoms.—All writers agree as to the division of small-pox into three varieties, the symptoms varying according- to the form presented.

1. Variola Vera; Discrete; Confluent.

2. Variola Hemorrhagica; Purpura Variolosa; Hemorrhagica Pustulosa.

3. Varioloid.

Variola Vera.—The disease may be described consecutively under the stages, incubation, invasion, eruption, maturation, and desquamation.

Incubation.—This stage embraces a period of from ten to fifteen days, extending from the time of exposure to the infection to the ushering in of the disease by the chill. The average duration is twelve days, although it may be prolonged to three weeks.

Prodromal symptoms are generally wanting, the period of invasion coming on suddenly; but when they are present they consist of malaise, and aching of the entire body. The tongue is furred, there is loss of appetite, more or less headache, with general soreness of the muscular tissues.

Invasion.—A chill, more or less pronounced, attended with nausea and sometimes vomiting, marks the stage of invasion in the adult, while a convulsion may be the symptom which first announces its presence in the child. The chill may consist of a hard rigor, or there may be chilly sensations alternated with flashes of heat, extending over a period of twenty-four hours. As reaction follows, the pain in the back, lumbar and sacral regions, becomes intense in character, while the face is flushed and the headache intolerable.

The temperature rises rapidly till it reaches 105° to 106°, or even higher, although in milder cases it will not go over 100° or 102°. The pulse is full and bounding, respiration short and hurried, while the bronchial cough, which so frequently accompanies the invasion, reveals the bronchial irritation. The tongue is coated with a moist, dirty, pasty coating, which is somewhat characteristic. The skin is often moist despite the high temperature. There may be soreness of the throat thus early in the disease, and auscultation reveals dry rales.

Examination of the left hypochondrium shows slight spleenic enlargement. During this period there may be present an initial or accidental rash, erythematus in character, resembling scarlatina or measles, and making its appearance on the lower part of the abdomen and inner surface of the thighs and arms. If the physician is not on his guard, this may mislead him in his diagnosis.

The period of invasion lasts about three days, during which time the pain in head and back continues, the patient is very restless, and, in the severe form, delirium occurs.

Eruption.—By the third, or beginning of the fourth day, the eruption makes its appearance in the form of small red spots resembling flea-bites, first upon the forehead at the edge of the hair, then upon the face, neck, wrists, trunk, and lastly upon the extremities. The fever now begins to decline, and there is relief from the pain in the head and back. The small red spots soon become hard, and when the finger is passed over them it receives the sensation of feeling a shot beneath the skin. A burning sensation gives rise to a pruritis. These hard, shotty bodies are the papules, which by the sixth day show their apices to be filled with a clear, whey-like fluid.

As the process of evolution continues, the vesicles replace the papules, and the center becomes depressed, giving them an umbilicated appearance. The vesicles are inclined to be grouped in threes and fives, although in the confluent form this peculiarity is not observed. As the eruption progresses, there is marked tumefaction at the base of the vesicle, and the parts become greatly swollen. The nose becomes distorted, the eyes are closed, and the patient is scarcely recognizable by his most intimate friends. The vesicle, after forty-eight hours, or on the eighth day of the eruption, changes its consistency, the contents become yellow, the center gives way, and the pustule is then fully developed.

Maturation.—The center now breaks down, and many of the pustules become conical in shape. The swelling that attends the development of the pustules in the nose and throat, renders both respiration and deglutition quite difficult, and the suffering of the patient is extreme. The pustules rupture, either spontaneously or as the result of injury—the itching being almost unbearable—and the contents exude as a gluey or syrupy substance. A disgusting, fetid odor now is emitted, and one is ready to class this as one of the most loathsome of all diseases.

During the maturation of the pustules, a secondary fever arises, and for forty-eight or seventy-two hours the temperature runs high, the pulse is rapid, the patient restless, and, in severe cases, delirium again appears, although usually the fever is much milder than in the early stage.

Desiccation.—Even before the eleventh day, many of the pustules break, and the sticky contents, drying, form the crusts or scabs, and the period of desiccation is begun. As this stage progresses, the swelling and pain subside, the redness disappears, the eyes open, the nostrils become clear, respiration is easy, and the patient experiences relief, after many days of suffering. The crusts soon separate and drop off, leaving a blue or purplish mottled appearance, and when the cutis vera has been invaded, a small pit or pock results. In the severer forms, the period of desiccation and separation extends over a period of several weeks, although it is usually complete by the twenty-first day.

Desquamation.—In addition to the separation of the crusts, there is often a branny desquamation, somewhat resembling that of scarlet fever, which continues for a week or ten days after the skin has become free of crusts.

Discrete.—In the discrete form the eruption appears later, is not so profuse, and but few pustules, which are grouped, make their appearance. The fever does not run so high, the systemic disturbance is not so great, the secondary fever is mild and of short duration, and the period of desiccation is materially shortened.

Confluent.—This is just the opposite of the discrete. The eruption is seen earlier and is much more profuse, running together in the severe types. The fever is very active, and the systemic disturbance of a most serious nature. Maturation and desiccation are more prolonged, while the secondary fever is quite active. Suppuration is much greater, and the cutis vera is more often involved. Cicatrization and desquamation follow.

Hemorrhagic Small-pox.—This variety appears in two forms, purpura variolosa—the so-called black small-pox, in which the symptoms appear very early and death occurs in from forty-eight hours to six days before the pustules develop—and variola hemorrhagica pustulosa, in which the disease progresses as an ordinary small-pox till the development of the vesicle or pustule, when the hemorrhage takes place in these bodies. There may also be hemorrhage from the mucous membranes.

Purpura Variolosa.—The period of invasion is more intense in character than in the former varieties. By the second or third day a dingy hyperemic flush appears, and petechia is seen over a large portion of the body. "The skin may have a uniformly purplish hue, and the unfortunate victim may even look plum-colored." (Osier.)

In the most severe forms, death may result before the eruption appears. As the disease progresses, hemorrhages may occur from the mucous surfaces. The face becomes swollen, and ecchymosis occurs in the conjunctiva, giving the patient a most terrible appearance. Moore, of Dublin, says: "A condition of acute hemophilia is in fact produced, so that the ill-fated sufferer bleeds from every pore and orifice of the body. There is chemosis, blood being effused into the connective tissue binding the conjunctiva to the eyeball, sometimes to the point of bursting, so that the patient may even weep tears of blood. Retinal hemorrhage may destroy the eyesight."

There is epistaxis, terrible because uncontrollable. Blood oozes from the lips and gums. The patient spits or coughs up blood; he vomits blood; the motions from the bowels are tarry. Blood pours from the kidneys, and in the female from the genital organs. The tongue looks as if it were parboiled, and there is unquenchable thirst. Fortunately, one rarely sees such desperate cases as these.

Another peculiar phase of this form is the retention of the mental faculties. In most intense lesions, nature kindly dulls the mind, and coma or delirium veils the present. Here, however, the mind remains clear, and the unfortunate victim looks death in the face almost to the last hour.

Variolosa Pustulosa Hemorrhagica.—In this form the disease does not begin in such a tempestuous form, but progresses as a severe case of small-pox till the vesicle or pustule forms, when there is extravasation of blood into the vesicle. The earlier the hemorrhage, the greater the danger. Of these two forms Moore says: "They differ merely in degree; in both, the blood is profoundly altered and devitalized to such an extent that it is apparently rendered incapable of throwing out or developing the characteristic or pathognomonic rash of variola. . . . The blood is so devitalized and defibrinated as to establish an acute hemophilia, the patient becoming 'bleeders' from an infectious dissolution of the blood."

Varioloid.—This is a mild form, which has been modified by vaccination. In some, this prophylactic measure is only partially protective, while in others, after a few years, it loses its protective value, and on exposure the individual contracts small-pox in a very much modified form. That it is genuine small-pox is proven by the contagion giving rise to the fully developed disease in a person who has not been vaccinated, and by affording perfect immunity from variola.

It differs from small-pox only in that the symptoms are milder and it runs a shorter course. The symptoms are those of a mild case of discrete small-pox. The eruption is scanty, in some cases only one or two pustules showing. There is but little fever, which subsides upon the appearance of the eruption. The period of maturation is generally but six or eight days, and the secondary fever, if any, is of short duration. The desiccation and removal of the crusts is also rapid, so that by the twelfth or fifteenth day the surface is well freed from them.

Plate 7: Small-Pox. Complications.—The complications are generally inflammatory in character, the respiratory apparatus suffering most frequently.

Laryngitis, resulting in edema of the glottis, attended by dangerous symptoms of asphyxiation, is not uncommon.

Bronchitis.—This is one of the most frequent complications, and occurs early in the disease.

Pneumonia also frequently occurs, followed 'by an effusion into the pleural cavity.

Cardiac complications are more rare, although myocardial changes do sometimes take place. Endocarditis and Pericarditis are among the rare complications.

Nephritis occurs but seldom, although a temporary albuminuria is not uncommon. Boils and abscesses are among the common and painful sequences.

Catarrhal and Purulent Conjunctivitis may occur, although not so common as in former years, owing to the better care and more aseptic measures that are used.

Baldness may result from the destruction of the hair follicles.

Otitis Media occasionally results, leaving the patient with a disgusting fetid discharge from the ear.

Diagnosis.—If an epidemic is prevailing, with a history of exposure, there is but little difficulty in a diagnosis; but in this age of rapid transit, where a patient may be exposed one day and be a thousand miles away in twenty-four hours, it is often impossible to obtain a history of exposure, and we are to be guided by the more positive symptoms which are characteristic of the disease.

For the first few days there may be danger of mistaking this for measles, scarlet fever, or chicken-pox. The sudden onset of the disease, the great pain in the head and back, the high fever, and dirty, pasty tongue, are at once suggestive of small-pox, while the absence of catarrhal symptoms and the marked papular and shotty feeling of the eruption, excludes measles.

In scarlet fever there is merely the exanthematous redness and the deep scarlet redness of the throat. It is distinguished from varicella by the mildness of the symptoms of the latter, the irregular vesicle, together with an early maturation, which makes the diagnosis easy.

The hemorrhagic form may be diagnosed with difficulty when the patient dies before the eruption appears, and one must be guided by the history and general symptoms. Where the epidemic is of a very mild character, like the one, that prevailed in Cincinnati in 1899-1900, where the patient had but little if any fever, and was not compelled to go to bed, the vesicles being small and insignificant, much doubt existed as to its true character, and, although it was denied by some, the Health Department regarded it as true small-pox and compelled its recognition.

Prognosis.—Although the mortality is far less than in former years, the prognosis will be determined by several conditions.

First, as to its form. The milder cases all recover; for example, in the epidemic of 1899 in this city, two hundred and fifty cases were reported and no deaths. In the confluent form, where there is early disorganization of the blood, or where there are serious complications, the prognosis must be guarded. The hemorrhagic form is also grave, and a certain per cent of cases will prove fatal.

Age and race will also figure in the prognosis, the disease being more fatal in the young and in the colored races. Taken as a whole, however, the prognosis is favorable, especially if diagnosed early and if modern methods are employed.

Treatment.—As soon as the diagnosis is made, the patient should at once be isolated and placed, when possible, in a large, airy room. All unnecessary furniture, drapery, and carpets should be removed and the room kept thoroughly ventilated. The impregnated air must be removed and fresh air take its place. While cleanliness is of great importance in any disease, it is doubly so in this. The bed clothing must be daily changed as well as that worn by the patient, and warm water and soap must be freely used, especially during the period of maturation.

As a disinfectant, Platt's chlorides can be freely used. It may be sprinkled on the bed, on the carpet, and some placed in shallow vessels around the bed; and where the odor is especially disagreeable, the room may be sprayed with the solution.

Veratrum.—We begin the treatment by the use of the sedative. Just in proportion as we keep control over the fever will we modify the poison. When the pulse is full and bounding we add specific veratrum, twenty or thirty drops to a half a glass of water, and give a teaspoonful every one or two hours. If the patient is a child, or if the pulse be frequent but small, aconite takes the place of the veratrum, although we add only five drops of the latter to half a glass of water. These remedies have a controlling effect upon the circulation, and so modify the disease that the patient passes safely through the trying illness.

Macrotys.—For the backache and other distressing symptoms macrotys has earned a deserved reputation. To a half glass of water add specific macrotys from one-half to one drachm. Should the skin be dry and constricted, specific jaborandi, one drachm, to water, four ounces, should be given.

Specific Echinacea.—This is to be used for the sepsis, which is shown by the full broad tongue and purplish tissues.

Baptisia.—The indications for baptisia are similar. When there is a full purple tongue and all the tissues look as if frozen, baptisia is the remedy.

Sodium Sulphite.—One of the most reliable of all agents is sulphite of sodium. The moist, dirty, pasty tongue calls for a saturated solution, a tablespoonful every one, two, or three hours.

Rhus Tox.—In children, where there is irritation of the nervous system as shown by the sharp cry and starting in the sleep, rhus tox. 5 drops, to water, 4 ounces, a teaspoonful every hour, is one of our best remedies. Also where the tongue is red at tip and edges, and the stroke of the pulse is sharp.

Gelsemium.—This is to be used where there is great irritation of the nervous system, and the flushed face, bright eyes, and contracted pupils suggest either convulsions or delirium.

Other agents may be called for, but these remedies will be needed most frequently, and if faithfully used will show a very low death rate.

The room should be darkened, care being taken that, in the darkening process, the free flow of air is not obstructed.

To prevent pitting, the face and hands should be kept softened by the free use of olive-oil, and a mask, made of oil silk, with openings for eyes, nostrils, and mouth, should be used. All parts of the body must be protected from the light.

The patient must be thoroughly impressed with the necessity of restraining from scratching, and thus tearing the pustules, causing ulceration and, necessarily, resulting in scarring. Children's hands should be encased in mittens and carefully guarded by the nurse. If properly cared for in this way, there will be little, if any, pitting, and one of the horrors of small-pox is thus removed.

Diet.—The diet should be of the simplest character. Milk in some form, either cow's milk or some of the artificial preparations, such as malted milk, lacta preparata, buttermilk, or koumiss, should be given. Where an acid is indicated, pepsin or sherry whey will prove useful. Broths and gruels may be given as soon as the fever subsides. During convalescence the patient is to be cautioned as to the danger of overeating.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.