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قراءة كتاب A Practical Treatise on Smallpox
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Crustosa. (Tenth Day, Twelfth Day.)
In Fig. 1 an occlusion of the nasal passages is indicated by the lips parted in respiration. [P.] Fig. 2. shows a palmar condition which, in the adult, is found only in smallpox. [P.] Fig. 3 shows the desiccation of the facial eruption in advance of other regions. [P.] Fig. 4 shows a mild discrete case in which a diagnosis of acne had been made. [F.] Fig. 5 shows the eruption in the stage of desiccation. [F.]
Showing a few thick crusts remaining upon the face with numerous dull red spots from which the crusts have fallen. [F.]
Figs. 1 and 3 show the dried pustules remaining in the thickened skin of palm and sole after the crusts have fallen elsewhere. [F., P.] Fig. 2 shows the superficial desquamation which follows the falling of the crusts, producing rings of partly detached epidermis. [F.]
Fig. 1 shows a peculiar pigmentation sometimes left after the eruption. The central portion, being darker, produces a “bull’s-eye” appearance. [F.] Fig. 2 shows the hypertrophic condition of the scars which occurs in certain cases in place of the usual pitting, and which tends to disappear in time. [H.] Fig. 3 shows severe pitting, a partial loss of hair and eyebrows, and destruction of one eye. [H.]
Fig. 1 shows the typical appearance of a successful revaccination. (Fourth day.) [F.] Fig. 4 shows a small, well-formed vaccination pustule at its height. (Eighth day.) [F.] Fig. 2 shows a large, irregular pustule resulting from scarification of an area of unnecessary extent. (Eighth day.) [F.] Fig. 5 shows an ulcer resulting from infection of the vaccination lesion. [F.] Fig. 3 shows a primary vaccination at its height (eighth day) with a characteristic areola. [F.] Fig. 6, a case of Varicella on the third day. [F.]
PREFACE.
Whenever a physician is called to a case of suspected smallpox, he confronts a grave responsibility. If young or without special experience, he is apt to feel a sore need of assistance, and, although a book can never take the place of an experienced consultant, it is the object of the present work to render him as much aid as possible. The text aims to be practical rather than elaborate. The plates are reproductions of photographs from life, some of which have been obtained under great difficulty.
While many articles on variola have been illustrated by a few photographs of cases, mostly of the pustular type, this work is believed to be the first which has presented illustrations of the smallpox eruption in each of its successive stages. It is sincerely hoped that the reader will find it of service in familiarizing him with the peculiar features of the disease.
GEORGE HENRY FOX.
SMALLPOX.
CHAPTER I.
SYMPTOMS AND COURSE.
Variola, or smallpox, is an acute, contagious disease, characterized by an eruption upon both the skin and mucous membrane, with constitutional symptoms of greater or less severity. The eruption presents successively a macular, papular, vesicular, and pustular stage, the pustules finally drying into crusts, which fall and leave the skin temporarily discolored. Where ulceration has occurred it is permanently scarred or pitted. The lesions of the mucous membrane appear upon those parts more or less exposed to the air,—the mouth and eyes, for example,—but in exceptional cases they may be found throughout the entire intestinal tract, and in the uterus and bladder. These lesions do not run a course similar to those observed upon the skin, but appear as red macules, which rapidly change into ulcerations, covered with a whitish pellicle. The ulcers are imbedded in the substance of the mucous membrane and are not as superficial as in cancrum oris. The constitutional symptoms are most prominent during the periods of invasion and pustulation.
There are various clinical forms of smallpox, which may be conveniently described as (1) discrete, (2) confluent, and (3) hemorrhagic, or malignant; and then, according to intensity, as (a) very mild, (b) mild, and (c) severe. The few purpuric spots seen in the severe discrete and the confluent forms are not of great significance, as they are generally due to a peculiar diathesis, and as a rule the patient recovers. The malignant form is almost invariably fatal.
The term discrete implies that the lesions are separate and distinct, not coalescent. If the lesions coalesce and form patches of various shapes and sizes, the eruption is called confluent. For the purpose of differentiating the various forms above mentioned, it is convenient to first trace a normal, unmodified case of smallpox from the initial symptoms to recovery, and then to consider the severe forms, and finally the rare and obscure forms of the disease.
Period of Incubation.—This extends from the date of exposure to the occurrence of clinical symptoms, a period usually lasting from twelve to fourteen days.
Period of Invasion.—The disease is usually ushered in by fever, with a distinct chill or chilly sensations, headache, neuralgia, and a general malaise. Frequently the first symptom is a distressing backache. This is located in the lumbar region, but it may be as high up as the lower angle of the scapula, or it may be sacral and extend down into the thighs. The backache is an important symptom when present, but it is not always on hand to help one out in the diagnosis. The backache of smallpox is not peculiar or distinctive, but it is its severity which attracts attention.
The headache is usually frontal and is an ache that is constant in character. The neuralgia is about the orbits, but may be facial, and is of a lancinating character.
The fever may precede the backache or it may follow. It may be at first a rise of only a degree or two, or it may jump to 104° F., or as high as 106° F. The latter is most frequently seen in neurasthenic subjects and in children. The pulse rises in frequency and in tension.
In children a convulsion not infrequently ushers in the disease. At this time convulsions are of little significance, but late in the disease they are of serious import. There are other constitutional symptoms, such as loss of appetite, vomiting, muscular pains, a dry, coated tongue, and at times an active delirium.
The face is congested and swollen. The eyes are injected and present a bleared appearance, but the watery or weeping condition seen in measles is usually absent. The nose is dry, and a sore throat is not uncommon. Epistaxis is frequent.
A very important symptom which sometimes occurs in this stage is a cutaneous efflorescence, which may resemble urticaria, scarlet fever, or measles. This latter resemblance is very close and often leads to diagnostic error. The efflorescence occurs most frequently in the young, and also in vaccinated adults. In some epidemics it is not at all uncommon, but as a rule it is rare.
The duration of the stage of invasion varies from two to four days. Usually it is about three