VARIOLA (SMALL-PDX), VACCI NATION, AND VARIOLOID.
Variola.
Definition.—An acute general febrile affection accompanied by characteristic eruptions on the cutaneous surface and propagated by a specific contagium.
a period of incuba tion varying from nine to fourteen days the active symptoms of variola com mence abruptly by a chill of varying de grees of severity, from mere chilliness to profound cold, continuing half an hour or more, during which the face is pale, with a leaden hue of the prolabia and fin gers; respirations unsteady; pulse small, frequent, and variable; severe pain in the loins, extending in severe cases to the head and epigastrium, with vomiting. At the end of the cold stage active febrile reaction supervenes; the face be comes flushed with suffused redness; the skin generally hot and dry; pulse mod erately full and frequent; respirations accelerated; pains in the back and head more severe; epigastric distress and vomiting more frequent, with great restlessness and sometimes delirium. The tongue is generally covered with a white fur, the bowels inactive, and the urine scanty and high colored.
Study of the urine of 1400 cases of small-pox, showing that albuminuria should be considered an almost constant accompaniment of small-pox. Positive reactions were obtained in 95 per cent. of the cases, and in 32 per cent. abundant quantities were present. The maximum amount corresponded in general to the early febrile period. Rarely the curve of the albuminuria reaches its acme at the time of suppuration or during desquama tion. Such cases were of more unfavor able prognosis, and frequently had an exacerbation of the albuminuria during convalescence. It was frequently ob served that there was an increase in the amount of albumin at the time of the urinary crisis and under the influence of increase in diet or of leaving the bed. Albuininuria persisted in 75 out of 100 cases in small amounts, even during con valescence. As a general rule, albumi nuria is more abundant in grave cases, and the grade of the albuminuria is a useful factor in prognosis.
It is believed that the albuminuria of small-pox is not simply functional, but due to an alteration of the renal tissue.
The inflammation of the kidneys is sus ceptible of recovery in mild cases, but more frequently a slight permanent lesion persists, usually a sclerosis, followed by some degeneration of the epithelium, and with this there exists albuminuria or a tendency to albuminuria. Francois Arnaud (Revue de Med., May 10, '98).
All the foregoing febrile symptoms generally increase in intensity for three full days, when the temperature is, in many cases, from 40° to 41° C. (104° to 100° F.), and the pulse from 100 to 120 per minute and full. In all except the more malignant cases the active febrile symptoms rapidly decline during the night of the third day, and after some sleep the patient is found on the ing of the fourth day quiet, nearly free from fever and pain, the skin a little moist, and urine more abundant. At the same time there is seen on the forehead, face, sides of the neck, and over the upper part of the sternum an eruption of small, hard papules, looking like small, red spots, but distinctly elevated and hard to the touch. After a few hours there appears a small vesicle filled with water-colored scrum on the apex of each papule. The eruption, thus began, continues to multiply and extend over the whole cutaneous surface, reaching the extremities nearly twenty-four hours later than on the face and neck. Both the vesicle at the apex and the hard papule on which it rests increase in size for three days, during which time each vesicle becomes filled with serum, flat tened on the surface, and distinctly de pressed or umbilicated in the centre. At the end of the third clay of the erup tion, the seventh from the initial symp toms of disease, inflammation attacks each point of eruption, causing an areola of redness around its base, with tumefac tion and heat, and a return of some gen eral fever and restlessness. At the same
time the serum or virus in the vesicles begins to be turbid or less transparent, and to accumulate in quantity for three or four days, when each vesicle looses its umbilicated appearance and becomes a pustule filled with purulent-looking fluid, and marks the completion of the suppurative stage. In cases of average severity the tumefaction accompanying this suppurative stage is sufficient to cause much swelling of the face and closure of the eyelids, and in many places the pustules merge into each other, con stituting confluent patches, especially on the face, upper part of the chest, and backs of the hands. In such cases dur ing the suppurating stage the febrile symptoms are more analogous to those of the typhoid type. The temperature ranges between 3S° and 40° C. (101° to 104° F.); the pulse from 110 to 130 per minute, soft or weak; mind dull and sometimes wandering; tongue dry along the middle; bowels generally quiet, though sometimes loose; and the urine still scanty and high colored. At the end of the suppurative stage, which is from ten to twelve days after the com mencement of the disease. if the case is progressing favorably, all the general febrile symptoms rapidly abate, the urine becomes more abundant, the patient takes nourishment more freely, the mind is more active, and the pustules begin to dry up, as shown by a dark-brown spot in centre of each. This brown spot in creases in size from day to day, until the whole becomes a dry brown crust or scab, and the tumefaction of the surface has disappeared. The process of desiccation and cicatrization of the pustules occupies about one week, after which the scabs become rapidly detached, leaving the surface clean, but covered with depressed or pitted sears that often remain through life.. Such is the usual course of an aver age case of variola, the whole time oc cupied, from the initial chill to complete eicatrization, being about twenty-one days. Cases, however, vary much in se verity and in their results. In some the amount of eruption or number of pus tules is so limited that each remains sepa rate from its fellows throughout the course of the disease, though each passes through the several stages described. But the suppurative stage is accompanied by less swelling of the face and less sec ondary fever, as well as less general pros tration. Such cases arc called distinct. or discrete. small-pox, and constitute the mildest variety of the unmodified form of the disease. On the other hand, many cases occur in which the premonitory fever is more intense, and the eruption so copious that in its development the pustules coalesce or become confluent over the greater part of the cutaneous surface; some pustules appear also in the mouth and fauces, thereby adding much to the discomfort of the patients; and with the commencement of the sup purative stage the respiration becomes unsteady and sometimes sighing; the pulse from 120 to 140, small and weak; temperature from 41° to 43° C. (106° to 110° F.); and much delirium. At this stage in many of these cases petechial or hTmorrhagic spots appear upon the sur face, or blood oozes from the gums, or sudden and copious haemorrhage from the bowels occurs, followed by speedy collapse and death before the end of the suppurative stage. In other cases of the confluent variety, with the commence ment of the suppurative stage, pneu monia supervenes and determines a fatal result before the end of the second week in the progress of the disease, though some cases recover.