A Practical Treatise on Smallpox

by George Henry Fox

It is not until the stage of vesiculation that the constitutional symptoms diminish to a marked degree. In fact it is considered one of the landmarks of the disease for the fever curve to show a decline at this time.

Late in the fifth or early in the sixth day the vesicle begins to assume a cloudy or yellowish hue, which denotes the commencement of pustulation. The fluid continues to grow more yellow, and about the time that it has assumed a dense straw color the umbilication begins to disappear, so that in from one to three days the pustule loses its indented appearance and becomes globular in form. To the touch it appears to involve as much of the skin below the surface as it is high above it. It is during the stage of pustulation that the surrounding skin becomes swollen and œdematous, with an area of redness about the pustules giving the appearance of a bull’s eye. It is also during the pustular stage that the constitutional symptoms become more intense and the fever rises in proportion to the severity of the attack. The pustules are fully matured about the eighth day of the eruption.

During the pustular stage the affection of the mucous membranes reaches its height. The eyelids, lips, and nose are often tremendously swollen. The tongue swells and deglutition becomes impossible. The voice is husky, and is sometimes lost, owing to the swelling of the glottis.

About the ninth or tenth day of the rash another change appears in the pustule. In mild cases this change sometimes takes place several days earlier. In the centre of the pustule is observed a small, darker spot, which gradually grows larger. The membrane of the pustule becomes shriveled, and the little, dark spot continues to get larger and darker until it involves the entire area of the pustule. This is the drying stage, during which the fluid part of the pustule is absorbed, leaving the solid part behind to be exfoliated in the form of a crust. It is during this stage that, owing to the softening of its membranous covering, the pustule is broken by the movements of the patient or the contact of rough bed-linen. The pustules of the face are usually the first ones broken, and an ulceration frequently occurs which destroys the true skin and results in a pit or scar. Pustules do not rupture spontaneously and discharge their contents. Dessication lasts usually from five to twenty days, the exposed parts being the first to dry and shed their crusts. On the palms and soles the dessicated débris is left deeply buried in the skin, and often has to be removed by the aid of a lancet or other instrument. Sometimes there is a pustule under the nail, and the removal of the kernel or seed is quite painful, though necessary.

The crust is usually thin, of a light yellowish-brown tint, but slightly adherent, and is shed or picked off without discomfort. The spot where the crust has been is of a deep purplish hue, and the many little stains here and there give the patient a peculiar spotted appearance, which in time disappears, except where the ulceration has left a pit or cicatrix. The pit soon loses its color and becomes of a whitish hue.

As dessication proceeds the constitutional symptoms decline, the appetite returns, and the patient gains strength.

Complications.—Sepsis is the one generally to be expected, and this may assume any form from a local affection, such as a furuncle, to a general septicæmia. Furunculosis is frequent and is often annoying, and no sooner is one boil healed than others follow. Bed-sores are also frequent if proper care is not used to prevent them. Bronchitis from the affection of the mucous membranes may occur. When simple, this can be handled easily; but when general pneumonia results, death is inevitable in the weakened condition of the patient. Ulcers and opacities of the cornea, laryngitis and croup (the latter generally fatal), zoster, sciatica, nephritis and gastritis, are all frequent complications, especially in severe cases.

Confluent Smallpox.—In this form the vesicles coalesce or run together, forming variously shaped and sized blisters, which as pustulation proceeds are usually ruptured in some manner and become infected, forming large, thick scabs with extensive ulceration underneath. The inability to properly cleanse such cases causes a very fetid odor to be given off and makes the patient an exceedingly difficult one to treat.