SMALLPDX, or VARIOLA (

See also:

• VIRUS, CHRISTOBAL DE (1550?-1615?)

virus, " a pimple ")  , an acute likely to be an increasing number of individuals who have infectious disease characterized by fever and by the appearance become susceptible to smallpox . This probably explains its on the surface of the body of an eruption, which, after passing occasional and even apparently periodic epidemic outbreaks through various stages, dries up, leaving more or less distinct in large centres, and the well-known fact that the most severe cicatrices . (For pathology see PARASITIC DISEASES.) Few cases occur at the beginning—those least protected being diseases have been so destructive to human life as smallpox, necessarily more liable to be first and most seriously attacked . and it has ever been regarded with horror alike from its fatality, Symptoms.—While the symptoms of smallpox are essentially its loathsome accompaniments and disfiguring effects, and from the same in. character in all cases, they are variously modified the fact that no age and condition of life are exempt from liability according to the form which the disease may assume, there being to its occurrence . Although in most civilized countries its certain well-marked varieties of this as of most other infectious ravages have been greatly limited by the protection afforded maladies . The following description applies to an average case. by vaccination, yet epidemic outbreaks are far from uncommon, After the reception into the system of the smallpox contagion affecting especially those who are unprotected, or whose pro- the onset of the symptoms is preceded by a period of incubation, tection has become weakened by lapse of time. during which the patient may or may not complain . This period Much obscurity surrounds the early history of smallpox, is believed to be from about ten to fourteen days . In cases of It appears to have been imported into Europe from Asia, where direct inoculation of the virus it is considerably shorter . The it had been known and recognized from remote antiquity. invasion of the symptoms is sudden and severe, in the form of The earliest accounts of its existence reach back to the middle a rigor followed by fever (the primary fever) , in which the tempera-and end of the 6th century, when it was described by Procopius ture rises to 103° or 1040 Fahr. or higher, notwithstanding that and Gregory of Tours as occurring in epidemic form in Arabia, perspiration may be going on . A quick pulse is present, together Egypt and the south of Europe . In one of the narratives of the with thirst and constipation, while intense headache accompanied expedition of the Abyssinians against Mecca (c . 550) the usual with vomiting and pain in the back is among the most char-miraculous details are combined with a notice of smallpox break- acteristic of the initial symptoms .

Occasionally the disease is

ing out among the invaders.' Not a few authorities, however, ushered in by convulsions . These symptoms continue with 'See Noldeke, Geschichte der Terser ... aus T¢bari (Leiden, greater or less intensity throughout two entire days, and during 1879), p . 218 . Noldeke thinks that this notice may be taken from their course there may occasionally be noticed on various part_ genuine historical tradition, and seems to find an allusion to it in an of the body, especially on the lower part of the abdomen and old poem. inner sides of the thighs, a diffuse redness accompanied by slight spots of extravasation (petechiae), the appearance some-what resembling that of scarlet fever . These " prodromal rashes," as they are termed, appear to be more frequent in some epidemics than in others, and they do not seem to have any special significance . They are probably more frequently seen in cases of the mildest form of smallpox (formerly termed varioloid), referred to below as modified smallpox . On the third day the characteristic eruption begins to make its appearance . It is almost always first seen on the face, particularly about the forehead and roots of the hair, in the form of a general redness; but upon this surface there may be felt by the finger numerous elevated points more or less thickly set together . The eruption, which is accompanied by heat and itching, spreads over the face, trunk and extremities in the course of a few hours—continuing, however, to come out more abundantly for one or two days . It is always most marked on the exposed parts; but in such a case as that now described the individual " pocks " are separated from each other (discrete) . On the second or third day after its appearance the eruption undergoes a change—the pocks becoming vesicles filled with a clear fluid . These vesicles attain to about the size of a pea, and in their centre there is a slight depression, giving the characteristic umbilicated appearance to the pock .

The clear contents of these vesicles gradually become turbid, and by the eighth or ninth day they are changed into pustules containing yellow

matter, while at the same time they increase still further in size and lose the central depression . Accompanying this change there are great surrounding inflammation and swelling of the skin, which, where the eruption is thickly set, produce much disfigurement and render the features unrecognizable, while the affected parts emit an offensive odour, particularly if, as often happens, the pustules break . The eruption is present not only on the skin, but on mucous membranes, that of the mouth and throat being affected at an early period; and the swelling produced here is not only a source of great discomfort, but even of danger, from the obstruction thus occasioned in the upper portion of the air-passages . The voice is hoarse and a copious flow of saliva comes from the mouth . The mucous membrane of the nostrils is similarly affected, while that of the eyes may also be involved, to the danger of permanent impairment of sight . The febrile symptoms which ushered in the disease undergo marked abatement on the appearance of the eruption on the third day, but on the eighth or ninth, when the vesicles become converted into pustules, there is a return of the fever (secondary or suppurative fever), often to a severe extent, and not in-frequently accompanied by prominent nervous phenomena, such as great restlessness, delirium or coma . On the eleventh or twelfth day the pustules show signs of drying up (desiccation), and along with this the febrile symptoms decline . Great itching of the skin attends this stage . The scabs produced by the dried pustules gradually fall off and a reddish brown spot remains, which, according to the depth of skin involved in the disease, leaves a permanent white depressed scar—this " pitting " so characteristic of smallpox being specially marked on the face . Convalescence in this form of the disease is as a rule uninterrupted . Varieties.—There are certain varieties of smallpox depending upon the form it assumes or the intensity of the symptoms . Confluent smallpox (variola confluens), while essentially the same in its general characters as the form already described, differs from it in the much greater severity of all the symptoms even from the onset, and particularly in regard to the eruption, which, instead of showing itself in isolated pocks, appears in large patches run together, giving a blistered aspect to the affected skin .

This confluent condition is almost entirely confined to the face, and produces shocking disfigurement, while subsequently deep scars remain and the hair may be lost . The mucous membranes suffer in a similar degree of severity, and dangerous complications may arise from the presence of the disease in the mouth, throat and eyes . Both the primary and secondary fevers are extremely severe . The mortality is very high, and it is generally estimated that at least 50% of such cases prove fatal, either from the violence of the disease or from one or other of the numerous complications which are specially

apt to attendupon it . Convalescence is apt to be slow and interrupted . Another variety is that in which the eruption assumes the haemorrhagic form owing to bleeding taking place into the pocks after their formation . This is apt to be accompanied with haemorrhages from various mucous surfaces (particularly in the case of females), occasionally to a dangerous degree 4nd with symptoms of great prostration . Many of such cases prove fatal . A still more serious form is that termed malignant, toxic or purpuric smallpox, in which there is intense streptococcus septicaemia, and the patient is from the onset overwhelmed with the poison and quickly succumbs—the rash scarcely, if at all, appearing or showing the haemorrhagic or purpuric character . Such cases are, however, comparatively rare . The term modified smallpox is applied to cases occurring in persons constitutionally but little susceptible to the disease, or in whom the protective influence of vaccination or a previous attack of smallpox still to some extent exists . Cases of this mild kind are of very common occurrence where vaccination has been systematically carried out .

As compared with an average case of the unmodified disease as above described this form is very marked, the

differences extending to all the phenomena of the disease . (1) As regards its onset, the initial fever is much milder and the pre-monitory symptoms altogether less in severity . (2) As regards the eruption, the number of pocks is smaller, often only a few and mostly upon the body . They not infrequently abort before reaching the stage of suppuration: but should they proceed to this stage the secondary fever is extremely slight or even absent . There is little or no pitting . (3) As regards complications and injurious results, these are rarely seen and the risk to life is insignificant . Various circumstances affect the mortality in ordinary smallpox and increase the dangers attendant upon it . The character of the epidemic has an important influence . In some outbreaks the type of the disease is much more severe than in others, and the mortality consequently greater . In 1901 and 1903 there were epidemics in the United States in which it was only 2 % . The mortality in the Philadelphia epidemic is given by Welch and Schamberg as 26.89 in 7204 cases, while in the lasgow epidemic of 1900-1901, it reached 51.6% in the unvacci ated and 10.4% in the vaccinated . Belov are some particulars of the annual death rate .

Smallpox Death Rate,

England and Wales . Years . Number of Deaths from Deaths from Smallpox Smallpox.* to every Million living . ----- 1902 2464 75 1903 23 1 5760 9 5 1016 14 1906 21 0.6 1907 to 0.3 1908 12 0.3 *Deaths entered as being from chicken-pox are not included, though many are probably due to the graver disease . Smallpox is most fatal at the extremes of life, except in the case of vaccinated infants, in whom there is immunity from the disease . Again, any ordinary case with discrete eruption is serious, and a case of confluent or even semi-confluent character is much more grave, while the haemorrhagic variety is frequently, and the toxic always, fatal . Numerous and often dangerous complications, although liable to arise in all cases, are more apt to occur in the severer forms, and in general at or after the supervention of the secondary fever . The most important are inflammatory affections of the respiratory organs, such as bronchitis, pleurisy or pneumonia, diphtheritic conditions of the throat, and swelling of the mucous membrane of the larynx and trachea . Destructive ulceration affecting the eyes or ears is a well-known and formidable danger, while various affections of the skin, in the form of erysipelas, abscess or carbuncles, are of not infrequent occurrence . The prophylaxis of smallpox depends on successful vaccination and re-vaccination (see VACCINATION), together with the establishment of smallpox hospitals for the treatment of the disease when it has broken out, to which the patient should be at once removed, and those who have been in contact with the patient should be promptly re-vaccinated . The efficiency of the protection given by vaccination and systematic re-vaccination is demonstrated by the almost entire suppression of the disease in Germany(see Dr Bruce Low's Report to the Local Govern- proPhy" ment Board, 1903-1904) . Mrs Garrett Anderson,writing treat tand reatment. to The Times in September 1903, showed the enormous treatment. expense laid on the rates in England for the maintenance of smallpox hospitals in order to counteract inefficient vaccination .

London with a population of 61 millions reserves 2500 beds in a hospital removed from the city; Berlin with a population of 2 millions reserves 12 beds in the pavilion of a general hospital; Dresden with a population of 500,000 reserves 20 beds in the Friedrichstadt Hospital, but no case was admitted for to years previous to the Report . In Stuttgart (population 200,000) a hut of six beds is set aside for smallpox, but it has fallen into bad repair from disuse . Smallpox cases in Germany are usually sporadic cases introduced by foreigners . Where persons have been exposed to the infection of smallpox, if immediate vaccination fails to protect them from the disease, it has been shown to considerably modify the type . The plan of identification and surveillance of all contact cases has given good results . In the Bristol epidemic of 1908 there were 35 cases and 9 deaths . The contacts numbered 1354, and 16,398 visits of inspection were paid . The patient should lie on a soft bed in a well-ventilated but somewhat darkened room and be fed with the lighter forms of nutriment, such as milk, soups, &c . The skin should be sponged occasionally with tepid water, and the mouth and throat washed with an antiseptic solution . In a severe case, with evidence of much prostration, stimulants may be advantageously employed . The patient should be always carefully watched, and special vigilance is called for where delirium exists . This symptom may somytimes be lessened by sedatives, such as opium, bromides or chlordl .

With the view of preventing pitting many applications have been proposed, but probably the best are

cold or tepid compresses of light weight kept constantly applied over the face and eyes . The water out of which these are wrung may be a weak solution of carbolic or boracic acid . When the pustules have dried up the itching this produces may be much relieved by the application of oil or vaseline . What is known as the red light treatment, in which the actinic or chemical rays are excluded, has been advocated by Prof . Niels Finsen of Copenhagen and others . He considers it valuable only in that it protects the pustule from the deleterious effects of light, and he and other observers claim that if resorted to early it abolishes suppuration in the pustules, lessens scarring and shortens the course of the disease . Medical opinion in England is divided as to its merit . Herbert Peck of Chesterfield, in 244 cases so treated in 1902-1905, had only 6 deaths, a mortality of 2.4%, while the case mortality during the same period was, Lancashire 5.8%, Derbyshire 6 °/,, Cheshire 6-4%, Liverpool 2'7% and Manchester 5.6% in cases treated without red light . An interesting fact in connection with the treatment is its great antiquity in China and Japan, while in England in the middle ages smallpox patients wore red garments and lay in beds where the light filtered through red curtains . Complications are to be dealt with as they arise, and the severer forms of the disease treated in reference to the special symptoms presented . In cases where the eruption is tardy of appearing and the attack threatens to assume the toxic form, marked benefit attends the use of the wet pack . Disinfectants should be abundantly employed in the room and its vicinity, and all clothing, &c., in contact with the patient should be exposed to the vapour of formalin .

Beclere,

Thomson and Brownlee have advocated the use of the serum of immunized heifers . The dose, however, requires to be very large, being equivalent to one-fiftieth part of the body weight in adults and one-twentieth part in children . Inoculation.--Previously to the introduction of vaccination (q.v.) the method of preventive treatment by what was known as inoculation had been employed . This consisted in introducing into the system—in a similar way to the method now commonly employed in vaccination—the smallpox virus from a mild case with the view of reproducing the disease also in a mild form in the person inoculated, and 249 thus affording him protection-from further attack . This plan had apparently been resorted to by Eastern nations from an early period in the history of the disease . During the latter part of the Ming dynasty there was introduced into China a system of inoculation in which the method was to blow the pulverized germ-laden crusts from a small-pox pustule through a silver tube into the nostril, the left being chosen in a male, the right in a female . Inoculation was known to be extensively practised in Turkey in the beginning of the 28th century, when, chiefly through the letters of Lady Mary Wortley Montagu, it became known and was speedily adopted in England . There is no doubt, both from the statistics of the Smallpox and Inoculation Hospital, London, and from the testimony of physicians throughout the country, that this practice made a marked impression upon the fatality of the disease, and was itself attended with extremely little risk to life . The objections to it, however, were great, for, although usually conveying the smallpox in a mild form, it not infrequently took effect severely, and, while death might be averted, the disfiguring results of the disease remained . Further, each inoculated person upon whom the operation took effect became for the time being a possible source of infection to others, and in point of fact the practice tended to spread the disease and so to increase the general mortality . Although inoculation continued to be practised for a number of years subsequently to Jenner's great discovery, it gradually became displaced by vaccination, and in 184o an Act of Parliament was passed rendering smallpox inoculation unlawful in England .