A Practical Treatise on Smallpox 2
There are various clinical forms of smallpox, which may be conveniently
described as (1) discrete, (2) confluent, and (3) hemorrhagic, or
malignant; and then, according to intensity, as (_a_) very mild, (_b_)
mild, and (_c_) severe. The few purpuric spots seen in the severe
discrete and the confluent forms are not of great significance, as they
are generally due to a peculiar diathesis, and as a rule the patient
recovers. The malignant form is almost invariably fatal.
The term discrete implies that the lesions are separate and distinct,
not coalescent. If the lesions coalesce and form patches of various
shapes and sizes, the eruption is called confluent. For the purpose of
differentiating the various forms above mentioned, it is convenient
to first trace a normal, unmodified case of smallpox from the initial
symptoms to recovery, and then to consider the severe forms, and
finally the rare and obscure forms of the disease.
*Period of Incubation.*--This extends from the date of exposure to the
occurrence of clinical symptoms, a period usually lasting from twelve
to fourteen days.
*Period of Invasion.*--The disease is usually ushered in by fever,
with a distinct chill or chilly sensations, headache, neuralgia, and
a general malaise. Frequently the first symptom is a distressing
backache. This is located in the lumbar region, but it may be as
high up as the lower angle of the scapula, or it may be sacral and
extend down into the thighs. The backache is an important symptom when
present, but it is not always on hand to help one out in the diagnosis.
The backache of smallpox is not peculiar or distinctive, but it is its
severity which attracts attention.
The headache is usually frontal and is an ache that is constant in
character. The neuralgia is about the orbits, but may be facial, and is
of a lancinating character.
The fever may precede the backache or it may follow. It may be at first
a rise of only a degree or two, or it may jump to 104° F., or as high
as 106° F. The latter is most frequently seen in neurasthenic subjects
and in children. The pulse rises in frequency and in tension.
In children a convulsion not infrequently ushers in the disease. At
this time convulsions are of little significance, but late in the
disease they are of serious import. There are other constitutional
symptoms, such as loss of appetite, vomiting, muscular pains, a dry,
coated tongue, and at times an active delirium.
The face is congested and swollen. The eyes are injected and present a
bleared appearance, but the watery or weeping condition seen in measles
is usually absent. The nose is dry, and a sore throat is not uncommon.
Epistaxis is frequent.
A very important symptom which sometimes occurs in this stage is a
cutaneous efflorescence, which may resemble urticaria, scarlet fever,
or measles. This latter resemblance is very close and often leads to
diagnostic error. The efflorescence occurs most frequently in the
young, and also in vaccinated adults. In some epidemics it is not at
all uncommon, but as a rule it is rare.
The duration of the stage of invasion varies from two to four days.
Usually it is about three days.
*Period of Eruption.*--Late on the third day or early on the fourth the
eruption makes its appearance, and the constitutional symptoms subside
to a certain extent.
The rash appears first on the confined and moist portions of the skin
or in irritated parts,--under a blister, for instance, which may have
been applied for the backache. Normally, it is first seen upon the
forehead at the hair-line, then behind the ears and down the tender
part of the neck. It gradually extends down the trunk and arms, the
hands and lower extremities being affected last. The eruption generally
takes from twenty-four to thirty-six hours to cover the entire body.
The best location to observe the rash for diagnostic purposes is on the
back, where it cannot be obscured by scratching and where the warmth
of the body causes the mildest congestion to appear at its best. The
exposed parts are usually ill adapted for study of the rash, being
obscured by the swelling and congestion of the face and by more or less
dirt or staining of the hands.
The rash consists first of small round or oval, rose-colored macules,
which seem to be in the skin, coming up from beneath it, as it were.
They disappear readily on pressure or on tension of the skin. When
coalescence occurs, the lesions may resemble the blotches of measles.
The macule at this stage is about from one-eighth to one-fourth of an
inch in diameter, and its color is of an intense red which shows well
at night, even by the light of a match. In less than twenty-four hours
the centre of the macule becomes hard; and as this hardness increases,
the lesion gradually rises above the skin. It is now changing into
the papular stage. The macular stage lasts usually from eight to
twenty-four hours.
The papules continue to increase slowly in size, the apex becoming
flattened or indented in some lesions. While this change is going on
the redness of the macule forms an areola about the hard portion or
central papule. This areola tends to get smaller as the papule gets
larger, and at last is completely lost.
If the pulp of the finger is passed over the papule, especially in its
early stage, the latter seems to roll beneath it, giving the sensation
of a small shot buried in the skin. When the papule is fully developed,
the surrounding skin is put on the stretch, and the rolling sensation
is lost, but the papule is so dense and hard that it is frequently
described as “shotty.” The papule of varicella and of acne is not so
dense and resisting as the papule of variola. The fully-developed
papule in smallpox is rarely surrounded by a halo of congestion as
it is in varicella, but in the modified form of smallpox this is not
infrequently the case. The papule always arises from the centre of its
halo like a bull’s eye, whereas in chicken-pox it arises from within
the circumference, but not always in the centre. The halo of congestion
in chicken-pox is always very broad and extensive, and is best seen
upon the back. When a halo is present in smallpox it is very narrow and
insignificant. The papule is usually fully developed in twenty-four
hours.
At the end of another twenty-four or thirty-six hours the apex of
the papule shows a further change. It appears to be transformed from
a solid to a fluid. The color also changes as the fluid increases,
and the lesion appears bluish or purplish. The fluid continues to
increase in amount until the papule is converted into a little blister
or vesicle. As the change is going on, the height of the papule grows
less and less, and when vesiculation is complete we have a broad,
flat, umbilicated vesicle with a firm, dense base. To the touch these
vesicles are firm and resisting, and the membranous covering is not
easily broken, unless macerated by the perspiration due to heavy
flannels.
The vesicle is divided irregularly by little bands, or septa, which
permit only a portion of the fluid to escape when one is punctured.
Vesiculation is usually complete about the third day, and the stage
generally lasts three days. It may be stated here that the reckoning
in smallpox is usually from the appearance of the rash. The period
of incubation and invasion are considered in reckoning the length of
illness, but in descriptions of smallpox it is considered best to state
the day of the eruption, and not of the disease.
There is an old and oft-repeated statement that a uniform rash is a
characteristic of smallpox and that a mixed rash indicates chicken-pox.
This deserves to be promptly refuted. It is most unusual to find a
case of smallpox with its eruption all in one stage. While it is
a well known fact that chicken-pox runs a hasty course,--so that
in from one to two days we may have macules, papules, vesicles,
and even crusts,--in smallpox this is not likely to occur, as the
disease never runs such a rapid course. In the early stage we may see
macules changing into papules on the head and the neck, while there
are simply macules on the trunk. Later in the disease the eruption
may be vesicular on the head while still papular on the body. When
vesiculation is complete, we have the distinct umbilicated appearance
that has long been recognized as a characteristic of smallpox. The
vesicles are broad, firm, flat, and hard, and are invariably indented
or umbilicated.
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.
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