The Initial Exanthem of Smallpox

The Initial Exanthem of SmallpoxAuthor(s): M. Tsurumi and S. IsonoSource: The Journal of Infectious Diseases, Vol. 29, No. 2 (Aug., 1921), pp. 109-113Published by: Oxford University PressStable URL: http://www.jstor.org/stable/30082194 .

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THE INITIAL EXANTHEM OF SMALLPOX

M. T S U R U M I AND S. I S 0 N 0

Prior to the peculiar eruption of smallpox is the so-called initial exanthem. This eruption bears a close resemblance to the eruptions of scarlet fever and measles, and is of significance in the diagnosis of smallpox, especially in cases of so-called variola sine exanthemate, when it may be the only symptom to base an intelligent diagnosis on.

Looking over the reports on the initial exanthem we find that they agree, in the main, but as it often does not appear, coming out more

frequently in cases of varioloid, it may be passed over. Both Hebra and Simon classified the initial exanthem into the two

kinds, hemorrhagic and nonhemorrhagic. The hemorrhagic kind

appears as a spotted erythema, resembling the eruption of scarlet fever. It is due to capillary hemorrhage, and the spots do not lose color under pressure. The nonhemorrhagic kind produces small spots of color, and

although they look like measles they are not elevated from the skin.

They vary in size from mere spots to lentils, and turn pale under digital pressure.

The hypogastrium, the inside of the thigh or Simon's thigh triangle, the side of the trunk to the axilla, the upper arm, the patella, etc., are regarded as the most likely parts to show the initial exanthem.

The initial rash lasts from 1 to 3 days. The nonhemorrhagic kind usually remains from 12 to 24 hours, and the hemorrhagic kind 3 or 4

days, until the appearance of the typical eruption. The smallpox eruption proper fades in color, yet shows no scaling;

on the parts where the initial eruption has appeared, smallpox eruption seldom comes forth.

From June, 1917, to May, 1918, 103 patients with smallpox were treated at the Dairen Isolation Hospital, and 39 patients had an initial exanthem. This figure should not be taken for anything like the ratio of the appearance of the initial exanthem, as there is reason to suppose that the actual number was larger, for the patients were admitted mostly after they had developed the characteristic pustules. In such cases, the initial exanthem had already disappeared, and the patients were asked

Received for publication Feb. 18, 1921.

The Dairen Isolation Hospital, Dairen, Manchuria



110 M. TSURUMI AND S. ISONO

whether the initial exanthem had appeared and, if it had, as to its

progress, but even in cases in which the answer was in the affirmative, it was difficult to ascertain if it really concerned the initial exanthem or the first stage of the smallpox eruption. Therefore, only such cases as were determined by us are given here.

Form.?In most cases the eruptions were of the size of the head of a pin, of a rosy color. In some cases there was erythema of irregular shape ; the spots lost color under digital pressure, but at times there was capillary hemorrhage when the spots did not turn pale under pressure.

In a word, the shape closely resembles in some cases the scarlet fever eruption and in other cases the measles. For this reason, the initial exanthem is sometimes mistaken for scarlet fever, and the latter for the former, and the patients are hospitalized accordingly. However, on closer inspection it will be found that there are really three kinds, one like the scarlet fever eruption, one with hemorrhage, and one that resembles the measles rash.

Hebra and others say that the exanthem that resembles scarlet fever is attended with hemorrhage and does not turn pale under digital pressure. But, as a matter of fact, what resembles scarlet fever is not always attended with hemorrhage. On the contrary, cases accompanied with hemorrhage were few, there being only 4 cases in which the major portion of the eruption was hemorrhagic, and all were of a serious kind. Therefore, we are of the opinion that it is proper to classify these eruptions into 3 kinds. Yuhki, also, in his classification has made men- tion of the mixed type.

Localization.?The localization of the eruption is most characteristic, and often serves as guide to the diagnosis of the exanthem. The distribution of the initial exanthem is given in table 1.

The part in which the eruption is likeliest to appear is the outer side of the upper arm; next comes Simon's thigh triangle. Looking over the records available so far, no reference has been made to any close relation between the smallpox eruption and the outer side of the upper arm, except in four instances reported by Yuhki in Chugai Iji Shimpo, No. 718.

As a matter of fact, in almost every case of smallpox, eruption appears on the outer side of the upper arm. One noteworthy point is that a thicker eruption appears on the vaccinated side, even when the eruption appears all over the body, the eruption making its appearance first of all usually on the outer side of the upper arm, then spreading



TABLE

1

Distribution

of

Initial

Exanthem

Vaccination

Distribution

of Exanthem

Nature

Marks

Times

Time

Since

No.

Sex

Age

of

Left

Right

Simon's

Abdo-

Lower

Vacci-

Last

Vaccina-

Attack

Left

I Right

Arm

Arm

Thigh

men

Chest

Back

Extrem-

nated

tion

;

Triangle

.

ities

1

F

20

Light

6

5

4-4-4-

4-

4-

..4-4-

4-

4

1 month,

left

2

F

22

Light

4

5

4-4-4-

4-

..

..

..

..

..

5

1 month,

left

3

M

40

Medium

....

0

0

4-4-

4-4-

4-4-4-4-4-

2

5 yrs.,

left

and

right

4

F

22

Light.

0,2

4-4-

4-

4-

|

..

....

I

3

7 months,

left

5

F

30

Serious

33

4-

'

4-

4-

' 4-

4-

' 4-

4-

!

2

10 years

6

F

24

Medium

3

4

4-4.4.

4-

4-

4.4.

-|-

|

2

5 yrs.,

left

and

right

7

F

40

Serious

3

3

-h

1 H- -*--h

4-4-

4-14-

4-14

1 yr.,

left

and

right

8

F

!

26

Light

2

4

4-4-4-

'4-

4-

..

..

I

,.

\

3

1 year,

left

9

M

44

Death

0

0

4-4-

4-

4-

|

4-

4-

4-

I

2

10 years

10

M

I

32

Medium

3

2

4-

4-4-14-

4-

!

4-

!

4-

4-

3

7 mo.,

left

and

right

11

M

1

39

Light

;

3

1

1

4-

, 4-4-4-

..

1

..

i

..

I

,.

..

3

i 3 years

12

F

22

Light

2

2

4-4-4-

+

..

..

|

..

|

..

-!-

i

5

1 year,

left

13

M

41

Death....

|

8

6

-4-4-

-I-+

4-

4-

4-

i

4-

4-

5

2 yrs.,

left

and

right

14

F

25

Light

3

2

4-4-4-

l

..

..

..

..

I

..

..

4

7months,

left

15

M

34

Serious

5

i

3

4-4-

I

4-4-

4-4-

4-

4-4-

4-

5

10 years

16

F

17

, Light

1

4

3

4-4-4-

..

4-4-

..

.

..

i \.

4-

5

6months,

left

17

F

24

Death

1

1

4-4-

4-4-

4-4-

4-14-14-

4-3

10 years

18

F

54

Light

0

0

4-4-4-

..

..

..

j

4-

i

..

,

.-

I

2

1 year,

left

19

F

14

Light

5

24-4-4-4-

4-4-

I

4-

-.

..

..

I

3

1 year,

left

20

M

46

Serious

3

2

4-4-

4-4-

4-

4-4-4-

4-

I

5

1 yr.,

left

and

right

21

M

36

Serious

4

4

4-4-4-

4-4-

4-4-

4-

4-

'

4-

4-141

3 mo.,

left

and

right

22

F

21

Light

3

2

4-4-

4-4-

..

..

4-

'

..

..

5

16 days,

left

23

F

25

Light

0

0

4-4-4-

..

..

..

..

..

..

2

11 days,

left

24

F

25

Light

2

2

4-4-4-

4-

4-

..

..

1

..

4-

5

22 days,

left

25

F

22

Light

0

0

4-

..

..

..

..

4-

'

..

I

3

29 days,

left

26

M

22

i Death

0

0

4-4-

4-4-

4-

j

4-

4-

4-

|

4-

'

2

j 8 years

27

M

28

Light

0

4

4-4

4-

|

4-

..

..

..

I

..

|

3

3months,

left

28

F

37

j Light

1

0

4-4-4-

4-

j

4-

,

..

4-

;

..

1

..

I

5

30 days,

left

29

F

43

Light

2

2

4-4-4-

-f-

..

4-

4-

..

..

5

9 days,

left

30

M

47

Medium

4

2

4-

4-4-

4-

4-

..

..

4-

2

2 yrs.,

left

and

right

31

F

36

Medium

334-

4-4-4-

-f

4-

4-

4-

3

1 yr.,

left

and

right

32

M

25

Light

2

4

4-

4-4-4-

4-

..

-.

..

4-

3

2 years,

right

33

M

24

Medium

3

5

4-4-

4-4-

4-

4-

4-

4-

4-

5

2 months,

left

34

M

36

Light

6

6

4-4-

4-4-

4-

..

..

4-

5

2 years,

left

35

F

30

Medium

4

0

4.

4-4-

4-

..

4-

1 ,

..

,.

4

1 year,

left

36

F

35

Light

2

1

4-4-4-

4-

\

..

..

,.

5

10 days,

left

37

M

23

Light

354-4-

..

..

..

j

4-

,.

5

28 days,

left

38

F

26

Medium

2

j

5

4-4-

4-4-

4-

4-

4-

..

4

2 yrs.,

left

and

right

39

F

i

26

Light

0,0

4-4^

4-

!

4-

4-

..

..

3

7 days,

left

Totals

39

34

27

19

22

16

j

21

4-4-4-

13

4

Degrees

in density

of exanthem

-j

4-4-

14

16

5

l

4-

12

4

22

19

22

16

j

21



112 M. TSURUMI AND S. ISONO

to other parts. Even when the eruption appears simultaneously on both sides or all over the body, it is remarkable that the part vaccinated not

long before shows a thicker eruption than elsewhere. As regards the cause of the initial exanthem, it is not yet known,

but it may be inferred that there exists some relation between the localization of the eruption and vaccination. In 2 nonvaccinated babies, although the eruption appeared all over the body, that on the outer side of the upper arm was not any thicker than elsewhere. In order to put the point to test we picked out 3 young white rabbits and shaved the hair off on both sides of the back, vaccinating each at 3 points on one of the sides. We waited about a fortnight until the local inflammation had faded, and then mixing vaccine lymph with salt solution at a certain ratio, a small quantity of the mixture was inoculated underneath the skin. It was noticed that in one of the 3 rabbits the vaccinated part became flushed.

To sum up: It seems a peculiar phenomenon in those that have been vaccinated once that the initial exanthem appears on the outer side of the upper arm. On this account, in case of doubt as to the nature of an eruption looking like scarlet fever or measles rash, if the localization is limited to the outer side of the upper arm, or the eruption makes its first appearance here, or is particularly thick here, the case may with reasonable certainty be regarded as one of smallpox.

Relation to Pock Marks.?From the table we note that in 7 of the 39 cases the eruption appeared conspicuously in parts on which there were few pock marks. The presence of many vaccination marks on one side did not prevent the same side from showing comparatively few eruptions. On the other hand, the eruption came out thick on the other side. There were two such instances in our cases. Hence the number of vaccination marks and the extent of the initial exanthem do not necessarily coincide, indicating that there is no direct relation between the eruption and vaccination marks.

Relation to the Last Vaccination.?Supposing that while the initial exanthem bears some relation to vaccination it has no direct relation to smallpox marks, we must take note of the time that elapsed after the last vaccination, in other words, the relation between the last vaccination and the initial exanthem must be studied.

The table shows that in almost every case the part newly vaccinated showed a greater density of eruption than elsewhere, or was the spot of the first appearance of the eruption, followed by eruption on the other side.



Initial Exanthem of Smallpox 113

However, in cases in which ten years had elapsed after the last vaccination, this relation could not be ascertained; indeed, it is indicated that there is no relation. Among the cases under our treatment there were only 3 or 4 such instances, hence no conclusion may be drawn. However, considering the fact that the eruption was remarkably thick on the vaccinated side (especially when the vaccination was recent), it

might be said that the initial exanthem is apt to break out in the vaccinated part for some time, this tendency decreasing as time passes until the vaccinated part reacts as do other parts.

Relation Between Nature of Disease and Prognosis.?The initial exanthem appears oftenest in cases of varioloid, and cases with initial exanthem generally give light symptoms. Of the 39 cases under our treatment, 9 were serious, 8 less serious, and 22 light. Still it must not be concluded hastily that all the cases showing initial exanthems are light ones, as especially those attended with hemorrhage had an

extremely unfavorable prognosis, 4 of 9 in the table terminating fatally. Even among the less serious cases there were some in which the characteristic eruption thickly covered all the body, taking a good length of time for recovery. In other words, the appearance of the initial exanthem cannot always be taken as a reliable guide to prognosis.

CONCLUSIONS

Close observation seems to warrant the classification of the initial exanthem in smallpox into the hemorrhagic, the scarlet-fever-like, and the measles-like.

The eruption appeared on the outer side of the upper arm in all the cases in this series.

There is no direct relation between the initial exanthem and the pock marks.

In the vaccinated the eruption is most marked about the place of vaccination. However, if ten years have elapsed since the last vaccination, no such tendency is apparent.

An initial exanthem does not necessarily guarantee a light attack. This is true especially if the exanthem is hemorrhagic.



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The Initial Exanthem of Smallpox