The eruption at first consists of reddish spots, closely resembling measles. The spots soon become hard, feeling like shot beneath the skin, and then minute vesicles appear. These vesicles, becoming infected by the bacteria normally present in the skin, become pustular. The pustules may remain separated, or they may he so close together that the entire skin is covered by their disfiguring presence. Following the eruption, the fever usually subsides for a few days, and is then followed by a new rise in temperature, the so-called suppurative fever. This fever, which is due to the pus in the pustules, lasts about io to II days. During this period of very severe suffering, the entire body—the skin, the mucous membranes, the eyes, the ears, even the throat and the sexual organs—may be covered with pustules. The intestines, kidneys and joints may be affected also.
After the suppurative stage of the disease, the fever and the inflammation subside. The pustules dry and form crusts, which fall off about 35 to 40 days after infection took place, usually leaving disfiguring scars. A great many patients succumb during the second period of fever. They die with symptoms of delirium or from weakness of the heart ; or occasionally they choke because of intense local inflammation. Some patients become deaf or blind ; some remain crippled ; others are paralysed ; and still others become so debilitated that they later succumb to the slightest affection. The accompanying illustration (Fig. 43o) shows a mild case of smallpox at the beginning of the suppurative stage. It is more than probable that the patient will recover, but his face will show many disfiguring scars.
Black smallpox, or bleeding smallpox, is the name applied to an extremely severe form of the disease. This runs a very rapid course, and is always fatal. The symptoms are especially severe in cases where the pus
tules develop in great profusion ; whereas cases in which the pustules remain more widely separated are apt to run a milder course.
Before the introduction of vaccina tion, only children were attacked by smallpox. At present the disease affects chiefly adults, in whom the immunity obtained by vaccination during child hood has run out because they have neglected to have themselves re-vaccinated. Such cases, however, run a much milder course than in persons who have never been vaccinated. It is self-evident that unvaccinated children are subject to the severe forms of the disease. If small pox ever affects the vaccinated—which it does occasionally, for the immunity is relative, not absolute—the disease almost invariably runs a very mild course. There may be slight fever for 3 or 4 days, with eruption ; or an eruption may occur which is very scant, and not apt to be disfiguring. For facts concerning the length of time of immunity, and the needs for re-vaccination, consult the article on VACCINATION.
Patients affected by smallpox at once feel so sick, and the symptoms are so severe, that medical assistance is probably called at the beginning of the disease in every instance. Coolness, rest, subdued light, pure air, cool_ ing beverages, and washing of the mouth are the first requirements, in addition to lukewarm ablutions. If no physician be present, the friends or relatives of the patient should at once notify the medical officer of health ; for only when the authorities are informed in time will it be possible for them to counteract a spread of the affection, and to do what is necessary to protect the patient's surroundings. To hide a case of smallpox from the knowledge of the authorities is a very serious crime.