110 SMALLPOX The invasion of the disease is announced by chills followed by fever ; this is apt to be at- tended with pain in the back, particularly in the loins, and with nausea and vomiting. If the fever runs high, with violent pain in the back and much delirium, the disease commonly assumes a severe form. In children the inva- sion is often announced by an attack of con- vulsions. The eruption begins to show itself on the third day of the fever. As a rule, it appears first on the face, then on the neck and wrists, then on the trunk, and finally on the extremities. On the fifth day the eruption is complete, and after this few or no new spots appear. It at first consists of minute rounded papules or pimples of a characteristic solid consistency, feeling like small shot beneath the skin. It is by this peculiar solidity of the spots that smallpox at this period is distinguished from other papular eruptions. By the fourth day from their first appearance the papules are converted into vesicles filled with a thin lymph and having a depressed centre, whence they are termed umbilicated. The vesicles begin now to be surrounded by an areola, or circular flush upon the skin, which soon becomes dark crim- son ; the lymph, at first colorless and transpa- rent, is gradually converted into pus, which increases in quantity and distends the vesicles until they become hemispherical. About the eighth day of the eruption a dark spot makes its appearance at the centre of the pustule, and gradually dries up and is converted into a scab. When this scab falls it leaves either an indelible cicatrix or a purplish red mark which fades very slowly, and which long exposure to a cool atmosphere renders very distinct. In passing away, the eruption follows the course which it took on its first appearance, the scabs first falling from the face, then from the trunk, and last from the extremities. When the pus- tules are comparatively few, they ar6 separated, sometimes widely, from each other, and the disease is termed discrete (variola discreta); when they are very numerous, they touch each other and run together, and then it is termed confluent (variola confluens) ; and between the two a third variety, the semi-confluent or co- herent, is often spoken of. In the discrete form the fever commonly subsides on the ap- pearance of the eruption, and when the pus- tules are few it may not return; but where they are at all numerous, their maturation is commonly attended with more or less fever. With the appearance of the eruption on the surface, more or less sore throat is complained of ; the fauces and tonsils are red and swollen, and pustules make their appearance upon them, upon the roof of the mouth, and the inside of the cheeks; the patient at the same time is commonly troubled with salivation. When smallpox is confluent, the subcutaneous cellular tissue seems involved in the disease, the swell- Mjtli Tery great, and by the fifth day the patient is commonly unable to open his eyes. The eruption on the face sometimes coalesces into one huge sore ; it is attended with a tor- menting itching, and the fever is of the ty- phoid kind, the debility being extreme, and the patient restless, sleepless, and often delirious, while the pulse is small, frequent, and feeble. In such cases the accompanying inflammation of the mouth, nasal passages, pharynx, and larynx adds greatly to the distress of the pa- tient and the danger of the disease, sometimes even producing suffocation. The disease is always attended by a peculiar odor, but in confluent cases this is nauseous and offensive to an excessive degree. In this form the fever, which commonly abates on the coming out of the eruption, is aggravated as the eruption ap- proaches maturation. The eighth day of the eruption or the eleventh of the disease is com- monly the most fatal day, while more patients die during the second week of the disease than either earlier or later. A second attack, even after free exposure to the contagion, is very rare. Only widely separated instances have been known. When patients recover from severe attacks of smallpox, blindness from an intercurrent inflammation of the conjunctiva is an occasional result, and before the general introduction of vaccination blindness from smallpox was common. Besides inflammation of the eyes, glandular swellings and abscess- es, bed sores, and phlebitis are occasional com- plications. It is also sometimes complicated with a diseased condition of the blood, produ- cing hemorrhage from various organs, togeth- er with petechise. These cases are always at- tended with great debility ; the accompanying fever is typhoid, and the eruption itself does not come out freely. They are almost invari- ably fatal. Pregnancy is a serious complica- tion. Abortion or premature delivery with the death of the child is commonly produced, but the mother frequently recovers. Some- times the child presents the characteristic eruption of the disease, but this is rare. Still more rarely a mother whose system has been protected by vaccination or a previous attack of the disease, communicates it, after exposure, to ihe foetus in utero, while she herself escapes. Confluent smallpox is always dangerous, and the danger is aggravated if the patient be still in infancy or over 45 years of age, or of a feeble or strumpus constitution. The mortality from smallpox is estimated at one fourth or one fifth of all who are attacked ; that of the Lon- don smallpox hospifoal has long averaged 30 per cent. Like many other contagious diseases, it is subject to epidemic influence, and when it prevails epidemically it seems to be severer and more fatal. It is remarkable that when it is communicated by a minute portion of the virus being inserted under the cuticle by inocu- lation, as it is termed, the disease is far less violent than if communicated through the at- mosphere ; and yet a second attack in such a case is as improbable as in any other. When patients are inoculated the mortality is rarely greater than 1 in 600 or 700. Inoculation was
