SMALL. POX. 



appears, or they uflier in a very confluent and malignant 

 fmall-pox. 



The eruption appears more early than in the benign fmall- 

 pox ; commonly early on the third day, or on the evening 

 of the fecond, and fcarcely ever fo late as the fourth day ; 

 except, as Sydenham remarks, in a few rare cafes, where it 

 appears to be delayed by fome violent fymptom, fuch as an 

 acute pleuritic or rheumatic pain, or a violent pain in the 

 ftomach, with ficknefs and vomiting, which manifeftly indi- 

 cate the confluent and dangerous nature of the forthcoming 

 difeafe. The eruption too is often preceded by an extenfive 

 erythematous efllorefcence, like a commencing eryfipelas ; 

 and fometimes it comes out in little irregular clufters, like 

 the meafles, confifting of many crowded red points or pim- 

 ples. The pimples are always mofl: numerous on the face, 

 and at the fame time fmaller and lefs eminent. The little 

 veficles which form on the tops of the pimples, appear 

 fooner than in the diftinft fpecies, and while their diameters 

 extend, they do not retain a circular form, but are of very irre- 

 gular figures. Many of them run into one another, forming 

 a flat irregular furface, fo that the face very often appears 

 to be covered rather with one extended veficle, than with a 

 number of puilules. And when there is any diftinft fepara- 

 tion of the puftules, they do not rife to a fpheroidal form, 

 but remain flat, and their circumference is not bounded by 

 an inflamed margin, the part of the flcin that is free from 

 puftules being commonly pale and flaccid, and not exhibit- 

 ing the damafl< hue of the diltinft fmall-pox. The fluid in- 

 cluded within the puftules changes about the eighth day 

 from a clear to an opaque appearance, being firft whitifh 

 and now brownifli, but never acquires the yellow colour and 

 thick confiftence that appear in the mild fpecies. 



In the confluent fmall-pox, the fwelling of the face, which 

 is fometimes abfent from the diftinft fpecies, but is generally 

 prefent when the puftules are numerous, never fails to ap- 

 pear, and it comes on more early, and arifes to a greater de- 

 gree, fometimes annihilating every appearance of the features. 

 It abates, hovi'ever, on the tenth day, and on the eleventh 

 ftill more. At this time the puftules or veficles, or rather 

 the extended pellicle, which from the eighth day had 

 become rough and brown, is ruptured ; and, fhrivelling, 

 pours out a fluid, which concretes into brown or black 

 crufts, which do not fall oft^ for many days, even till after 

 the twentieth day ; and, in confequence of the ulceration 

 which takes place under them, pretty certainly leave the 

 furface of the face confiderably pitted. On the other parts 

 of the body, and on the extremities, efpecially the hands 

 and feet, ftill more than on the trunk, the puftules of con- 

 fluent fmall-pox are larger and more diftinft than upon the 

 face ; but they never acquire the fame maturity and confift- 

 ence of pus as in the properly diftinft kind. 



The confluent fmall-pox is attended by two other fymp- 

 toms of confiderable importance, the one in adults, the other 

 in children. The former is falivation, or exceflive fecretion 

 of faliva, which never fails to accompany the confluent form 

 of the difeafe in grown perfons, and is fometimes feen in 

 a flight degree in the diftinft kind. It fometimes begins as 

 foon as the eruptions appear ; and fometimes not till a day 

 or two after. The faliva is for fome time thin and copious, 

 and eafily difcharged, having very much the appearance of 

 the ptyahlm excited by mercury, except that it does not 

 fmell fo offenfively ; but about the eleventh day it becomes 

 thick and more vifcid, and is expeftorated with great diffi- 

 culty. The patient is very thirfty, and coughs while he 

 attempts to drink, expelling the liquor through his noftrils. 

 The affeftion of the throat is alfo generally aggravated at 

 the fame time. The falivation often ceafes after the eleventh 



day, about which time the hands commonly fwell (or at 

 leaft, Sydenham fays, eught to do fo) ; but fometimes, after 

 a complete ceffation for a day or two, it returns again. 



In children, a diarrhoea occurs frequently in the place of 

 the falivation ; but it does not feize them fo early as the 

 falivation attacks grown perfons. Whenever it begins, how- 

 ever, unlefs it be checked by art, it attends the difeafe to 

 its termination. 



In the diftinft fmall-pox, as we have already ftated, the 

 fever commonly ceafes with the completion of the eruption 

 on the fifth day ; but it is not fo in the confluent fpecies. 

 In the latter, the febrile fymptoms only fuffer a remiffion at 

 the time of the eruption, which continues to the period of 

 complete maturation, that is, to the eleventh day, in the 

 latter part of which day it is often renewed with confider- 

 able violence, conllituting what has been called the fecondary 

 fei)er, which is the fource of much danger, and is of vari- 

 ous duration. The pulfe quickens, the heat of the body 

 increafes greatly, much thirft, with great anxiety and reft- 

 leftnefs, fevere head-ache, ftiort and confufed flumbers, de- 

 lirium, and fom.etimes coma, enfue. Tliefe fymptoms, in- 

 deed, are often fo fudden and violent, being accompanied 

 alfo with fuppreflion of the falivation, and a difficulty of 

 breathing and of deglutition, that, if nothing has been done 

 to alleviate the early inflammator)' aftion, death foon fol- 

 lows. Whence Sydenham fpeaks fo often about the dan- 

 ger of the eleventh day. In other cafes, however, this 

 fever is protrafted to the fourteenth and feventeenth days, 

 and fometimes even later, and yet terminates fatally. In 

 fome inftances, thefe fevere forms of confluent fmall-pox are 

 accompanied by fymptoms of great malignancy or putref- 

 cency, as it has been called : purple fpots, or petechia, ap- 

 pear in the interftices of the fl<in between the puftules ; and 

 fometimes fmall black fpots, fcarcely fo large as pins' heads, 

 arife on the top of the eruptions in different places : or a 

 difpofition to gangrene under ferous veficles ftiews itfelf : 

 or laftly, various fpontancous haemorrhages take place from 

 the internal parts, as from the kidneys and bladder, whence 

 bloody urine is difcharged ; or from the lungs, in bloody 

 expeftoration ; and fometimes from the inteftines, in bloody 

 ftools. 



From a confideration of the preceding detail of the various 

 circumltances which accompany the different forms and itages 

 of the fmall-pox, the degree of danger under the various 

 fymptoms, and the probable event in particular cafes, may 

 be eilimated. The following points of prognofis will be 

 obvioufly inferred. In general, the more exaftly the dif- 

 eafe retains the form of the diltinft kind, it is the fafer ; 

 and the more it approaches or takes the form of the con- 

 fluent kind, it is the more dangerous. It is only, indeed, 

 when the diftinft kind exhibits a great number of puilules 

 in the face, which are contiguous or coherent, that it is 

 attended with any danger : for it muft be obferved, that it 

 is chiefly from the crowd of puftules on the face, and not 

 from thofe on the body, that the danger of the difeafe is 

 to be apprehended. Particular fymptoms will enable us to 

 anticipate particular occurrences. Thus, if the previous 

 or eruptive fever be very violent in its attack, and be ac- 

 companied with great proftration of ftrength, anxiety, and 

 lownefs of fpirits, with fevere head-ache, weeping and red- 

 nefs of the eyes, great pains in the back, a burning heat 

 of fliin, and a quick hard pulfe ; — the occurrence of a con- 

 fluent eruptien may be expefted. The more early the 

 eruption, the more danger is to be anticipated ; but a re- 

 tardation of the eruption beyond the fourth day, alfo im- 

 phes a probability of a confluent difeafe. The more gra- 

 dual the eruption of the puftules, the more favourable ; pro- 

 vided 



