These cases, on account of their severity and fatality in young subjects, might be justly described as malignant. The term is, however, usually confined to cases in which the nervous symptoms are overwhelming, and the child dies rapidly from blood-poisoning in a state of profound depres sion and coma ; or to cases where the disease assumes a hemorrhagic character. In this hminorrhagic form bleeding occurs from all the mucous membranes—the nose, the mouth, the air-passages, and the bowels. The urine is smoky or red with blood ; the eruption is dark, and mixed up with petechim or larger subcutaneous extravasations ; and the fluid in the vesicles is tinged with blood. The general symptoms are severe, the prostration great, and death takes place after a few clays. My friend, Dr. Twining, has described to me a variety of the malignant form of small-pox which has often come under his notice at the Homerton Fever Hospital. In this the child appears overwhelmed by the violence of the disease. He lies in a state of stupor, and has no true variolous rash nor any of the ordinary symptoms of the illness. On inspection of the skin a number of deep purple, almost black, spots are seen. These are well defined, and are more or less circular in shape. They vary in size from a rape to a millet seed, and are twenty or thirty in number. Mixed up with them are larger patches of subcutaneous extravasation, like bruises. These patients have a very offensive smell, as if putrefaction had begun before death, and sur vive but a few hours.
Varioloid, the modified form of the disease, is usually a mild com plaint. The early symptoms are the same as in true small-pox, and may .even be of some severity. A child may have high fever, much pain in the back, repeated vomiting, and be convulsed ; but the after-course of the disease is usually benign, and in particular the secondary fever is slight or completely absent. Often, the rash is preceded by a roseolous eruption. The proper rash of varioloid, which comes out at the usual time, is in most cases comparatively thinly scattered over the surface, and the spots are very rarely set sufficiently closely to be confluent, even on the face. As in variola, the mucous membranes are affected ; and salivation, difficult deglu tition, snuffling, hoarseness, and cough are common symptoms. The spots run through their stages more quickly than in the unmodified form, and the stage of desiccation usually begins on the fifth or sixth day of the erup tion. The stage of maturation is also less severe ; there is less swelling and redness of the skin ; and pyrexia is slight or absent. Generally the pustules, instead of rupturing and discharging their contents, dry up, so that the pock gradually changes into a thin brown scab, which falls off in a few clays. There is besides little or no ulceration of the skin, and conse
quently no pitting is left after the subsidence of the disease, except here and there where the inflammation had proceeded farther than usual. Lastly, in varioloid complications are rare, and the disease is usually at an end in a fortnight.
Diagnosis.—Before the eruption appears the diagnosis of small-pox is difficult in children, for fever and vomiting usher in many of their acute diseases, and pain in the back is not always complained of. In young children the existence of the spinal pain can seldom be ascertained ; but if a child, in addition to vomiting and fever, loses control over his sphincters, we may suspect small-pox, for such incontinence is not a common symptom, and points to some special condition not present at the onset of an ordinary acute illness. In small-pox it may be the consequence of the spinal irri tation.
When the eruption first appears on the face it is often mistaken for measles. The colour is very similar ; and the early papules may be easily confounded with that form of measles rash in which the spots are more than usually elevated above the surface. On closer inspection, however, differences will be noticed. The measles spot is much less raised than the small-pox papule, and is not hard and resisting to the finger. Moreover, in measles the cough, coryza, and lachrymation are significant symptoms, and are quite absent in the early period of variola. The temperature, too, is less elevated in measles during the stage of invasion than in small-pox. In measles it is usually between 102.5° and while in variola it is often between 105° and 106°. After a day or two the change of the papule into a vesicle removes any doubts that may have been entertained as to the nature of the illness.
The roseolous rash which sometimes precedes the papular eruption may be mistaken for scarlatina. It is distinguished from it by noting its less complete diffusion over the surface, its brighter tint, and more mottled character. Moreover, according to M. See, in cases of small-pox, when the roseolous eruption is present, the variolous papule has already begun to appear, and may be discovered by careful examination.
The remission of the fever, which often takes place when the papular eruption is completed, cannot be relied upon for diagnosis, as it is very uncertain. In the boy whose case was referred to at the beginning of this chapter there was no remission of the fever at the early period of the eruptive stage. On the contrary, the temperature rose still higher, and when the patient was sent away to the small-pox hospital on the third day of the rash, the spots being then vesicular, his temperature (at 8 A.m.) was 103.4°.