SMALLPOX 



513 



Generally speaking, the severity of the disease is 

 proportional to the number of pocks ; and when 

 these are so numerous as to run together on any 

 part of the body, the disease is said to be confluent. 

 This form differs in many important respects from 

 that already described. The eruption is necessarily 

 modified : the individual pocks are smaller, but by 

 their coalescence they give the skin of the face an 

 appearance ' like a mask of parchment,' and gener- 

 ally lead to much more scarring of the skin. 

 Severe laryngitis and bronchitis, and ulceration of 

 the cornese, with consequent impairment or destruc- 

 tion of sight, are of frequent occurrence ; and sali- 

 vation is a usual symptom. But most important 

 of all is the difference in the course of the fever. 

 The remission described above in the first stage is 

 slight, if it occurs at all ; ami the secondary fever, 

 ul t hough on this account less conspicuous, is more 

 severe, and much more dangerous to life. 



Malignant smallpox is characterised by the 

 severity of the onset, but particularly by the occur- 

 rence during the first few days of haemorrhages 

 tinder the skin, and from the various orifices of 

 the body. Such cases are almost without exception 

 rapidly fatal, sometimes HO early that no sign of 

 the characteristic eruption appears at all. 



Modified smallpox, sometimes (but not happily) 

 called varioloid, is the name applied to cases of 

 the disease in which the eruption runs a less severe 

 course than usual. They may be at first discrete 

 or confluent ; but the pocks abort either at the 

 papular or the vesicular stage, or if they become 

 pustular are small, and dry up with unusual 

 rapidity. The constitutional symptoms are corre- 

 spondingly less marked. This form of the disease 

 with rare exceptions occurs only in those who 

 have been vaccinated, or have had a previous 

 attack of smallpox. The form of the disease which 

 follows Inoculation (q.v.) has a shorter incubation 

 period (usually ten days), and a shorter and milder 

 course ; and the mortality is very much less than 

 when it is contracted by infection. 



The cause of smallpox is universally allowed to 

 1>e a specific contagion, of whose nature we are in 

 the most profound ignorance. There is probably no 

 disease so contagious as this. Dr Haygarth stated 

 (in 1793) that, during his long attention to this 

 subject, not a single instance had occurred to prove 

 that persons liable to smallpox could associate in 

 the same chamber with a patient in the distemper 

 without receiving the infection. The contagion 

 acts either through the air, or by contact with the 

 skin, or by inoculation ; and the disease may be 

 caused by the dead body, even when it has not 

 been touched. What products of the diseased 

 body are contagious is not exactly known, but the 

 contents of the pustules and the dried scabs cer- 

 tainly are so. Opinions are divided as to the 

 period at which the disease begins and ceases to 

 be contagions. It is safest to maintain that it is 

 capable of self-propagation as soon as the febrile 

 symptoms have exhibited themselves. How soon 

 the patient ceases to be dangerous cannot be 

 decide*} with accuracy ; but the stability of the 

 contagions principle may be inferred from the fact 

 that clothing win retain it for months, and it is 

 said for years, when confined. Like nil the con- 

 tagions exanthemata, smallpox appears in an epi- 

 demic form, at irregular and, in our ignorance, it 

 would almost seem capricious intervals. After an 

 extraordinary exemption, perhaps for years, a dis- 

 trict is suddenly invaded by it, and continues to 

 suffer for a longer or shorter period, after which 

 the disease spontaneously disappears dies out, as 

 it were and does not reappear perhaps for years. 

 Different epidemics vary very much in their severity, 

 and isolated cases are usually milder than those 

 occurring when the disease is epidemic. Race has 

 449 



much to do with the severity of the disease ; the 

 constitution of the dark races, especially the Negro, 

 being singularly susceptible of the contagion, and 

 exhibiting very little power of resisting the fatal 

 tendency of the disease. 



It is generally admitted that the discovery of 

 Vaccination (q.v. ), by which smallpox is deprived 

 of its danger, is the greatest triumph of modern 

 medicine. Inoculation (q.v.) protected the indi- 

 vidual, but, by spreading the disease, increased 

 rather than diminished the total number of deaths, 

 while vaccination has the advantage of protecting 

 both the individual and the community. 



With regard to prognosis, it may lie stated gener- 

 ally, it is a very fatal, and was formerly an ex- 

 tremely destructive disease one death occurring 

 in every four or five cases. Modified smallpox is 

 very seldom fatal, although instances of death are 

 occasionally reported. Smallpox is more fatal at 

 the two extremes of life than in the intervening 

 period, and is especially dangerous in pregnancy. 

 In olden times it was believed that the eruption 

 was an effort of nature to get rid of the noxious 

 matter, and hence heating and stimulating 

 measures were adopted with the view of promoting 

 the eruption. To Sydenham belongs the credit 

 of first recommending an entirely opposite or 

 cooling mode of treatment ; but his suggestions 

 met with the most strenuous opposition, anu it was 

 not till long after his death that the cooling treat- 

 ment was fairly established. In mild cases, and 

 in cases of modified smallpox, the physician has 

 merely to guard the patient against hurtful influ- 

 ences, such as stimulating foods or drinks, too 

 hot a room, or improj>er exposure to cold, and to 

 prescribe cooling drinks during the fever, and 

 occasional laxatives if they shall be required. In 

 more severe cases the fever may be combated by 

 saline purgatives, prescribed so as to produce two 

 or three liquid stools daily, and by free ventilation 

 of the surface of the body. When the eruption is 

 all out, if the pimples on the face are few and dis- 

 tinct the danger may be regarded as over, and no 

 further treatment is required. If, however, the 

 disease assume a confluent form, wakefulness and 

 restlessness are apt to come on about the eighth 

 day, and opiates in free doses may be prescribed 

 with benefit. If the pustules are abnormally torpid 

 in reaching their maturity, it may be expedient to 

 administer strong broths, or even wine ; and when 

 the pustules are livid, and intermixed with Petechise 

 (q.v.), bark and acids must be additionally ordered, 

 although the patient is then too often beyond the 

 reach of help. During the secondary fever the 

 bowels must be kept gently open, and opiates 

 should lie prescribed once or twice each day. A 

 more nourishing diet is now called for, and wine 

 should be given if the pulse is very weak. The 

 external itching* is partly relieved by the opiates, 

 but local applications are also employed : cold 

 cream, or a mixture of equal parts of olive-oil and 

 lime-water, may be thus used with advantage. 

 Numerous special methods have been devised for 

 the purpose of preventing the pitting or seaming 

 of the face, which is often a hideous permanent 

 disfigurement to the patient, but there is not yet 

 sufficient evidence that any of them is uniformly 

 satisfactory in its results. 



During the period of desquamation an occasional 

 warm bath may l>e prescribed with advantage; and 

 the patient should always resort to this measure, 

 as a precaution against carrying the contagion 

 about with him, before again mixing in society. 



The history of this remarkable disease is clothed 

 in considerable obscurity. Its original habitat is 

 quite uncertain ; but there seems no doubt that it 

 has been prevalent in India from a remote period, 

 and in China since at least 200 years before the 



