VARIETIES 



1489 



blotches are situate, and bleeding occurs from the mucous membranes and 

 internal organs, of which the most common are oozing from the gums and 

 hsematuria, but epistaxis, haematemesis, haemoptysis, melsena, and metror- 

 rhagia, may one or all be present. Even retinal haemorrhages may occur. 



The temperature is now below normal, the patient is restless, with often 

 a sensation of weight in the praicordium. The pulse is now soft and com- 

 pressible. Sordes form on the gums, and the patient dies on the third to 

 sixth day, with a clear mind and often without any sign of the typical smallpox 

 eruption. 



Purpura variolosa fulminans. — -Very rarely the disease is more severe, with 

 a temperature of 105 F. or more, associated with delirium, coma, and collapse, 

 and followed by death in a few hours without any signs of external haemorrhage . 



Variola h(zmorrhagica pustulosa. — -In this variety the initial symptoms are 

 severe, and delirium sets in early. Haemorrhages appear from and under 

 the mucous membranes and under the skin, and at the same time the typical 

 smallpox eruption appears, into which blood also passes. The symptoms 

 resemble those of confluent smallpox, with the addition of haemorrhages. 



A milder form is when the haemorrhage occurs only into the eruption, and 

 may or may not be associated with haematuria and some bleeding from the 

 mouth. 



Varioloid. — Repeated vaccination is an excellent protective against small- 

 pox, but if the disease does appear in a person who has been several times 

 vaccinated, it is remarkably modified and is most difficult to recognize. 

 Epidemics have been known to show such a mild type that the disease was 

 mistaken for a length of time for chicken-pox, and have also been considered 

 to be due to a new form of disease, to which such names as ' Cuban itch ' and 

 ' Philippine itch ' have been given. Indeed, such epidemics have in some 

 cases not been recognized until a fatal case has occurred ; and Osier and McCrae 

 have recorded a small outbreak in one of their wards for coloured patients in 

 which the disease was at first mistaken for chicken-pox. 



The varieties of ' Varioloid ' are numerous. In the first place, there may be 

 no eruption, and the usual initial symptoms may be slight, or they may be 

 severe and accompanied by an erythema, but all symptoms disappear by 

 the third or fourth day. 



In other cases the disease begins with the usual symptoms, but at the end 

 of the first day a few maculae appear, which become vesicles in another twenty- 

 four hours, when the constitutional symptoms begin to abate, and are full 

 grown in about three to four days, when they are seen to be conical vesicles, 

 often without any depression, surrounded by a very faint red line. On the 

 . third to fourth day they become somewhat opaque, and then shrink and 

 desiccate, forming small dry prominences on the skin, which finally desqua- 

 mate, and the patient is convalescent. In other cases a few vesicles may become 

 pustules by the sixth day of the eruption, which dry up and cast off their 

 crusts in about a week. 



Diagnosis. — The headache, the severe backache, the epigastric pain, the 

 vomiting, the high temperature, and the rapid pulse, associated with an 

 erythematous or petechial eruption on the abdomino-crural region, are 

 important factors. The erythema, however, is apt to be irregularly dis- 

 tributed in blotches, but it does not affect the face. The petechial eruption is 

 usually found about the flexures of the joints as small bright red petechias. 

 Any acute febrile disorder associated with purpura should be suspected as 

 being probably variola. 



The typical eruption comes out on the second or third day of the illness as 

 hard shotty papules on the forehead, face, arms, and legs, which have become 

 papulo-vesicles and pustular, presenting umbilication, and not flattening on 

 pricking. 



From Varicella. — -The first point in the differential diagnosis between 

 smallpox and chicken-pox is to remember that it is very difficult, and' that the 

 most distinguished physicians have owned to not one mistake, but a series. 

 No one point of absolute diagnostic value can be given, but the following 

 table will indicate some of the points : — 



94 



