and the morning of the second day of the eruption is then called erroneously the first day.

The eruption comes out first on the face, then on the neck and wrists and on the trunk of the body, and lastly on the lower extremities. Such is the rule; so that (as is specified in the definition) it does not cease to come out till the fifth day and it keeps a-head, in that order, throughout the disease. There are, indeed, some exceptions to this rule. Occasionally the spots appear first upon the extremities, but this is very rare. In some instances straggling papulæ continue to spring up after the main crop is fairly completed; but these stragglers seldom arrive at the same size with the others.

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The pimples, or papulæ, ripen gradually into pustules, the puration being complete by their eighth day; and on that day the pustules generally begin to break, and crusts or scabs to form. In four or five days more the scabs are falling off. There are some variations in all this also. In children, the crusts are sometimes visible on the seventh day and in adults, when the disease is severe, they sometimes do not begin to form till the ninth day. In all cases some of the pustules are liable to be prematurely broken, by accident, or by the patient's scratching; and these will crust over earlier than they otherwise would have done. So that in fixing the period of incrustation, you are to regard those pustules only, of which the natural progress has not been interfered with.

All that I have hitherto been saying, applies with more or less exactness, to the disease in all its varieties. But its severity differs exceedingly, as I have already hinted, in different cases. Its severity, in truth, is almost always in direct relation to the quantity of the eruption. The number of pustules indicates, in the first place, the quantity of the variolous poison which has been reproduced in the blood. In the second place, it is also a direct measure of the extent to which the skin suffers inflammation. Sometimes there are not more than half a dozen pustules; sometimes there are many thousands. If all these were collected into one, it would be an enormous phlegmon. For both these reasons the system suffers commotion, distress, and peril, in proportion to the quantity of the eruption.

When the pustules are very many, they run together: when they are few, they are separate from each other. And this affords a broad line of distinction, which can neither be overlooked nor mistaken, into the variola discreta, and the variola confluens. In

the one, the pustules are distinct, and of a regularly circumscribed circular form. In the other they coalesce, and their common outline becomes irregular. Now the discrete form of the disease is scarcely ever dangerous; the confluent form is never free from danger. The distinction therefore is of the highest importance and interest. For its full estimation, each form must be considered separately.

In the discrete variety, in which the disorder may be presumed to run its most natural course, the eruption is at first, according to the phraseology of Willan, papular. The pimples gradually increase in magnitude, but it is not till the third day of their appearance that they begin to contain a little fluid on their summits. For two days after this they increase in breadth only, and a depression is observable in the centre of many of them. The cuticle is bound down there somehow, for a time, to the cutis vera. It is the eighth day of the disease, or the fifth day of the eruption, before the pustules become perfectly turgid and hemispheröidal. During the time in which they are thus filling up, the face swells; often to so great a degree that the eyelids are closed; and the natural aspect suffers a complete and hideous change. The skin between the pustules on the face assumes a damask red colour. About the eighth day of the eruption, a dark spot makes its appearance on the top of each turgid pustule, and at that spot the cuticle breaks, a portion of the matter oozes out, and the pustule dries into a scab. When this crust at length falls of, it leaves behind it either a purplish red stain, which is still very characteristic of the disease, and which very slowly fades; or a depressed scar, which is indelible. In the latter case the patient, or more properly his skin, is said to be pitted with the small-pox, or pock-marked. The swelling of the face begins gradually to diminish after the eruption has become thoroughly pustular.

This is the course which the eruption pursues on the face, where the pustules, even in the discrete form of the disease, are usually thicker set than on any other part of the surface. And it pursues the same course, only two or three days later, upon the extremities, where it also begins later. The feet and hands swell just as the face swelled, but they begin to tumefy as the features begin to subside. Some of the pustules, especially on the extremities, do not burst at all, but shrivel up.

In this, the distinct variety of the disorder, the fever generally ceases entirely upon the coming out of the eruption: the headache, the pain of the back, the vomiting, the restlessness, abate and disappear, the pulse resumes its natural force and frequency,

and the skin its natural temperature. About the seventh or eighth day of the eruption there is commonly for a day or two a recurrence of fever. This is called the fever of maturation.

You are to observe that we judge of the eruption as it appears on the face. The disease is of the confluent kind, when the pustules are confluent there, whether they are so or not upon the trunk and extremities. Sometimes they are neither strictly confluent nor strictly separate, but stand just thick enough to touch each other, without absolutely coalescing; every pustule preserving its circular outline. In that case the disease is said to be of the cohering form. When the pustules are confluent over the whole body, their number is often prodigiously great, and their progress is less regular than in the discrete and milder variety of the complaint.

In the first place the eruptive fever itself is usually more violent and tumultuous in the confluent disease: the disturbance of the sensorial functions is more common and more decided, the sickness more distressing, the pain of the back and loins more severe. The eruption comes out earlier, and more confusedly; the pimples being at first very minute, and crowded together in patches, and not seldom accompanied by a rash like that of scarlet fever, or erysipelas: whereby the diagnosis, in so far as it depends upon the appearance of the skin, is rendered for a while uncertain. I have at present in the Middlesex Hospital a patient in whom the papulæ of small-pox were, at the outset, so intermingled with the appearances and sensations of urticaria, that I doubted, for twentyfour hours, what the true character of the eruption might be. It is sometimes like that of the measles; but the similarity and the uncertainty are soon at an end, for the pimples soon begin to exhibit a fluid on their summits. They do not, however, as they advance, and pass into pustules, fill up so completely as in the distinct form; they are flatter, less plump, more irregularly depressed, and even of a different colour; being at first whitish, and then of a brown tint, and seldom of the yellow purulent hue which is seen in the variola discreta. Sometimes they are even bluish, or purple. In the confluent form there is commonly some abatement of the febrile distress upon the coming out of the eruption, but the remission is much less decided than in the discrete. About the fifth or sixth day fresh rigors are apt to occur, marking the fever of maturation. Most of these points of distinction between the two varieties of the disease are well set forth in Cullen's definitions. The distinct form he defines thus: "Variola (discreta) pustulis paucis, discretis, circumscrip

tione circularibus, turgidis; febre, eruptione factâ, protinus cessante." And of the confluent kind his definition is, "Variola (confluens) pustulis numerosis, confluentibus, circumscriptione irregularibus, flaccidis, parum elevatis; febre post eruptionem perstante."

But the most important difference between the two forms is in what is called the secondary fever, which sets in about the eleventh day of the disease, or the eighth of the eruption, just when the maturation of the pustules is complete, and they begin to desiccate. This secondary fever is slightly marked in the distinct small-pox, and very intense and perilous in most instances of the confluent. It is at this period of the disorder, that death, in the fatal cases, oftenest occurs. Of 168 such cases, recorded by Dr. Gregory, the deaths happened in twenty-seven (nearly one-sixth of the whole) upon the eighth day of the eruption. That, therefore, is the most perilous day, as the second is the most perilous week. Thirty-two died in the first week, ninety-nine in the second, twenty-one in the third. The early occurrence of death denotes a peculiar malignancy in the disease. The nervous system appears to be overwhelmed by the force of the poison. During the second week the disorder proves fatal chiefly in the way of apnoea; from some affection of the respiratory passages. After that period the characters of asthenia commonly predominate. The patient sinks under some casual complication, or the powers of life are gradually worn out by so much irritation of the surface, and so large an amount of suppuration.

So much for the ordinary course of small-pox, and of the symptoms that are essential to that disease. There are, however, other concomitant circumstances, with which you ought to be acquainted and these I will endeavour to specify at our next assembling.

861

Small-pox, continued.

LECTURE LXXXVII.

Inoculation. Vaccination. Their compa

rative advantages. Treatment of Small-pox.

IN the last lecture I brought before you, in a rapid sketch, the ordinary course, and the essential symptoms of small-pox; both in its distinct and in its confluent form. I have yet to mention some other circumstances that are very frequently to be noticed in connexion with that disease.

Both kinds are accompanied by sore throat; the tonsils and fauces are tumid and red: and with this sore throat there is associated, about the period when the face swells, sometimes in the discrete variety, and almost always in the confluent, more or less salivation, which lasts for several days. At first the discharge is thin and plentiful: but, towards the period of maturation, it often becomes viscid and ropy, and is with difficulty got rid of by the patient. This salivation is of some importance as a prognostic symptom. If it cease abruptly, and especially if at the same time the swelling of the face suddenly and prematurely subside, the peril is great. Besides this, Sydenham regarded the ptyalism as a diagnostic circumstance; as a mark which identified with true. small-pox a fever called by him the variolous fever, the variolæ sine variolis of De Haen and others. "The resemblance (says he) which this fever bore, in its symptoms, to small-pox, induced me to give it the title of variolous fever, which seemed indeed so much the more appropriate, as the fever raged at the same time with small-pox, and got well under the same treatment. The two diseases belonged evidently to one family, and there was no difference between them, saving that in small-pox the morbific matter was directed towards the skin, in the shape of an eruption; while in the variolous fever this matter was expelled from the system by the salivary glands." Notwithstanding this statement, it is difficult to believe that any such disorder as variolæ sine variolis ever proceeds from the contagion of small-pox.

This affection of the salivary glands does not so often occur in children; but diarrhoea appears sometimes to take its place.

The soreness of the fauces often depends, in great measure, upon pustules there situate. You may see that the tongue, the roof of the mouth, the inside of the cheeks, the uvula, and the