A system of practical medicine. By American authors. Vol. 1

by Unknown

The invasion stage of variola commonly occupies three days. Rarely it extends into the fourth, fifth, and even the sixth, day after the premonitory chill and fever.

Upon its subsidence the exanthem of the disease as a rule promptly appears. Simultaneously, the temperature abates, the rapidity of the pulse diminishes, and there is marked amelioration of the general symptoms. The patient, frequently deceived by the completeness of this defervescence, is apt to conclude that he is convalescent from his disorder, and is thus often astonished at the discovery of the exanthem upon the person, usually the face. In other cases, more commonly those of a grave character, there is failure of this defervescence, the febrile symptoms continuing or even increasing in severity.

The eruption first appears in the form of pin-head sized and larger, firm, conical, discrete, coherent or confluent, reddish papules, sometimes accompanied by mild sensations of a pricking or painful character, often exciting no subjective symptoms by which their presence could be declared. To the touch they are characteristically indurated, and suggest the hardness of small shot imbedded in the skin. They appear first and in greatest abundance upon the face and scalp, involving later and progressively the trunk, the extremities, and the palmar and plantar surfaces. It is at this moment that the eruption most resembles that to be recognized in measles (the distinction between the eruptive symptoms of the two diseases will be considered later). At times a reddish areola surrounds each lesion, especially those appearing upon the trunk. All are situated about the orifices of the follicles and glands of the skin.

On the first and second days of the eruption the papular lesions multiply in number, involve an increasingly large area, and individually augment in size; so they appear first upon the head, and are successively presented to the eye upon the lower portions of the body. The older lesions are usually recognized upon the scalp, face, neck, and shoulders; the more recent upon the extremities. By the third day of the eruptive stage there is usually evident at the apex of the older lesions a minute vesicle containing a drop of pellucid serum, which rapidly changes in character and size till a distinct vesicle is formed with cloudy or lactescent contents. Early in their career an apicial depression can be seen, which later deepens into a characteristic umbilication. This umbilication in the vesicular stage is somewhat peculiar. It is more than a mere depression of the summit, such as might be made by thrusting a blunt-pointed pin centrally and downward so as to carry the roof-wall before it. It is made clinically most distinct by the fluting or puckering of the peripheral part of the roof-wall, giving the lesion a crenated appearance which is not assumed by any other cutaneous efflorescence of multiple development. It may be regarded as pathognomonic of variola.

The pock is usually mature by the sixth day of the eruption. It is pea-sized and globular in shape; its umbilication has been usually quite removed by the complete filling of its chamber with distinctly purulent contents; it is often surrounded by a halo due to hyperæmia or exudation; and, the total number of individual lesions being then fairly determined, it is often closely set against its fellows, islets of unaffected integument having meantime become fewer and more contracted. The face, covered with this eruption, then exhibits a typical aspect. The entire integument becomes swollen and brawny or oedematous. The eyes are thus closed by the tumid lids, which are separable with difficulty, and this, too, even though they be the seat of comparatively few lesions. The nose, lips, cheeks, and ears are by similar processes deformed and given a most repulsive unsightliness. Mucus and puriform secretions gather and dry about the mucous outlets. The skin of other parts of the body (hands, feet, genitalia, and the entire extremities) is in a similar condition, merely most noticeable in the exposed and disfigured visage.

The fever of maturation or suppuration, or, as it is often called, the secondary fever, is lighted to activity with the onset of the suppurative process. The temperature rises to a point ranging between 101° and 105° F., the pulse-rate simultaneously rising to 100 and even 150 in the minute, varying of course with the age of the patient and the severity of the attack. During its continuance, from the eighth or ninth to the eleventh or twelfth day of the disease, the victim of the malady is in a deplorable and critical condition. The intense grade of cutaneous inflammation, with its resulting subjective sensations of burning pain and tension, the soreness of the mouth (tongue, pharynx, inside of lips, and palate), due to the existence of pus-filled pocks upon the buccal membrane, and, for similar reasons, the dysphagia and irritation of the larynx and tracheal membrane, are all sufficient to account for the general condition. In cases of mild grade the patient lies conscious, but in a stolid apathy, listlessly accepting the services of his attendants. In others there is delirium of low or high grade, often sufficient to demand constant surveillance, lest in consequence the patient do serious injury to himself.

The behavior of the pustules which appear upon the mucous surfaces accessible to the eye is modified somewhat by the heat, moisture, and friction to which these surfaces are exposed. Typical, fully-distended pustules occasionally persist upon the soft palate and the inside of the lips. Soon, however, the macerated roof-wall yields, leaving a reddish floor where the mucous membrane is exposed, denuded of its epithelial layer or covered with a new tender and hyperæmic pellicle. In grave and severe cases these pustular lesions may extend deeply into the mucous tracts, involving the trachea, bronchi, or alimentary canal. In an autopsy made by the writer on the body of a male subject dead of unmodified variola, there was no portion of the alimentary canal from the mouth to the anus which was not studded by thickly-set pustules. The urethra, vagina, vulva, external auditory canal, and conjunctivæ are, in severe cases, similarly involved. According to Kaposi, the tympanum is usually exempt.

The period of desiccation begins usually on the thirteenth or fourteenth day of the disease, and, according to the severity of the previous pathological processes, requires for its completion from one week to a fortnight. Its onset is characterized by a second marked but gradually developed defervescence. With a diurnal temperature successively less elevated above the normal standard there is a corresponding fall of the pulse-rate. As the disease has by this date taxed the vital resources of the system to the utmost limit, the exhaustion resulting may be declared by a pulse which is flagging, weak, and even in the matter of frequency much below the standard of health.

The cutaneous lesions now again undergo a change. Some of the pustules rupture, and their viscid contents, oozing forth, concrete into a yellowish crust which gradually assumes a brownish hue. Others desiccate en masse, the roof-wall first collapsing upon the contents, thus producing an appearance which again suggests umbilication of the lesions. This is sometimes termed a secondary umbilication. The desiccation en masse is doubtless due to the evaporation of a portion of the fluid exuded into the superficial strata of the integument, and the consequent inspissation of the pus. Often the face at this moment is totally concealed by a dense, dry, brownish or even blackish mask, composed of the crusts furnished by numerous individual lesions. At the same time the tumefaction of the skin subsides, and the subjective sensations to which it gave rise gradually disappear. Beneath the crusts cicatrization advances till the former are lessened, and finally, becoming detached, fall in quantity from the surfaces subjected to friction. Beneath them are seen brownish and violaceous blotches, the integument thus stained slowly losing its abnormal color. It is thus seen to be the seat of multiple, slightly depressed, shining scars of a dead white color, which in the course of time lose somewhat of their disfiguring prominence, but which when typically distinct persist for a lifetime. This exfoliation of crusts continues till the skin is completely rid of its pathological products, the process being completed with entire restoration to health about the conclusion of the fourth or fifth week of the disease. Meantime, in favorable cases, convalescence progresses pari passu. The patient has a returning appetite, decadence of symptoms originating in impairment of function of the mucous membranes, and gains in weight till the restoration to sound health is complete.

Such is the history in outline of what may be regarded as a typical form of uncomplicated variola. It should not be forgotten, however, that in different epidemics there are marked differences in the career and manifestations of the malady, and that even among the cases observed in a single locality visited by the disease the same divergence of symptoms is no less conspicuous. This diversity is due to several causes, irrespective of the remarkable modifications displayed in the variolous who have been previously vaccinated. Individual susceptibility is doubtless to be considered in this connection, as also the temperament, bodily vigor, and hygienic surroundings of those who are infected. It is possible also that the intensity of the poison may be subjected to occasional modifications in its transmission from individual to individual. In this way the following types of variola present themselves in clinical forms with divergent features: