The eruption does not appear all over the body at once. It begins on the face and neck, spreads to the upper part of the chest, arms, and hands, to the rest of the body later, and to the legs last. In the course of two days it will have spread over the body. But those on the face having appeared first, will always be in advance of the others, and thus those on the face may be dried up while those on the legs are only fully ripe. The eruption is also pre sent on the lining membrane of the throat and mouth, and causes pain in the throat, felt from the commencement of the rash. It is also some times present on the lining membrane of the eyelids (the conjunctiva, p. 447), and may lead to serious injury of the eyes. The pocks on the body have often a depression in the centre, not seen in those on the face. Pocks showing this are said to be umbilicated.
The final stage of small-pox is that in which the pustules dry and form scabs. The scabs begin to fall from the face between the fifteenth and twentieth days, and a little later from the body. A red prominence is left, after the fall of the scab, on which scales form, and from which they fall for, it may be, several weeks. Finally, after some months the redness dis appears, and a white scar is left, below the level of the rest of the skin. If the pocks have not been large, the marks may be very slight.
Such is the history of distinct small-pox. It is one of the least fatal forms of the disease, except in unvaccinated children below one year of age. Nevertheless it may prove fatal even in grown-up persons. When death occurs from distinct small-pox it happens about the eighth or ninth day. According to the French phy a fatal issue is to be feared when the eruption does not come well out by the Iftliiiiisth:Oi seventh day, when the pus tules are irregularly formed, when the sweating ceases suddenly and cannot be recalled, and when delirium occurs with dry cold skin and a weak, sharp, irregular pulse. Profound uncon sciousness and twitchings of the tendons are signs of approaching death.
Confluent Small-pox.—The confluent form of the disease, in which the pocks run together, is a very fatal form. The symptoms of its com mencement are similar to, but more severe dm, those already described. The pains are more intense, fever more decided, and vomiting con tinuous. The eruption comes out earlier than in the ordinary case, appealing on the second day instead of the third, though in very bad cases the rash may be delayed. The fever is
not only very high, but it does not fall for any time between the period of the rash appearing and the period of the pocks ripening, as it does in distinct small-pox. It is almost continuous till the pustules have become yellow with matter. The eruption, which, as already stated, appears early, and may at first be mistaken for measles because of the general redness of the face, consists of small pimples extremely close set. As they grow in size great swelling of the face is produced, and when they grow into blebs they so run together that large patches of raised skin are produced, like that caused by a blister. The swelling of the face is accom panied by swollen eyelids, swollen jaws and ears, and there are constant flow of water (saliva) from the mouth, and harsh cough. The ball of the eye may be fiercely attacked and vision de stroyed. The swelling of the face and the flow from the mouth should begin to diminish by the eleventh day. At the same time there occurs great swelling of the hands and feet, due to the pustules, and the swelling is ac companied by pain. When the pustules have become ripe, full of matter, which occurs be tween the eleventh and thirteenth day, they give out a most disgusting stench, and the patient's skin is in a most serious condition, with the leaking pustules, ulcers formed from them, and often boils and abscesses, due to some extent to the irritation of the decomposing matter of the pocks. (Plate XXVIII.) Delirium, in confluent small-pox, is apt to con tinue from the fifth day of the disease till the thirteenth or fourteenth day, when it should cease. But the fever has not such a defined period, for it may be maintained beyond the third week by the formation of boils and ab scesses in the skin, and also in deeper parts.
At this late period attacks of shivering, with high fever, indicate the formation of deep boils.
In confluent cases death is very common, and usually occurs between the eleventh and four teenth days. Excessive delirium, or deep un consciousness, great prostration, much difficulty if breathing, and anxiety—these are all bad iigns. Death sometimes arises from suffocation 3y swelling and the formation of membranes n the throat. Inflammation of the lungs may »listen a fatal termination. But even should he patient survive this period, prostration and leath are too apt to be the result of the pro longed formation of boils, &c., in the skin and ieeper parts.