Otitis with suppuration in the middle ear is a not uncommon complica tion. The results which may follow from this distressing affliction are described elsewhere.
In all bad cases of small-pox there is conjunctivitis, which may come on as early as the fifth or sixth day of the eruption. If swelling prevents the lids from being opened, conjunctivitis may be suspected if the child complain of pain in the eyeball, increased by movement of the eye, and of a feeling of dirt beneath the lid. In very rare instances we meet with a development of small pustules on the mucous membrane of the eye ; but slight ophthalmia of this kind as a rule is easily overcome. The severe inflammation which leads to ulceration of the cornea and de struction of the eyeball sets in about the beginning of the third week (on the fourteenth day, according to Mr. Marson). An ulcer appears on the margin of the cornea, sometimes on both sides of the cornea at the same time. The various layers are quickly penetrated ; the aqueous humour es capes ; and often the lens and vitreous humour are discharged. The process is generally very rapid, and may be accompanied by no pain to the child. Sometimes, instead of ulceration, general sloughing of the eyeball may occur.
To some form of chest affection many deaths in small-pox are owing. Pleurisy is common and very fatal. Pneumonia may begin insidiously, and is also a very serious complication. Bronchitis is sometimes a cause of death ; and, according to Rilliet and Barthez, pulmonary cedema is occa sionally met with. Besides these, peri- and endo-carditis may supervene, and it is stated on the authority of Desnos and Huchard that acute fatty degeneration of the walls of the heart may be a cause of sudden death.
The laryngeal symptoms during the period of secondary fever may be complicated by oedema of the larynx. This, however, is seldom seen except in cases of confluent small-pox. In other instances a severe laryn gitis may be set up, leading to ulceration of mucous membrane, perichon dritis, and necrosis of cartilage with consequent chronic aphonia. Laryn
gitis may be one of the earliest complications, and is sometimes seen on the tenth or eleventh clay.
In the case of any of these complications the fever is high and the child, who is barely entering upon convalescence after an exhausting disease, is in a state of great weakness, which is instantly aggravated by the presence of the intercurrent lesion. So that, if the patient do not succumb to this new danger, his illness is seriously protracted and convalescence propor tionately delayed.
Varieties.—Many varieties of small-pox have been described ; but for practical purposes it will be sufficient to remember the special forms of Discrete, Confluent, and Malignant small-pox, and the modified form found in efficiently vaccinated persons which is called varioloid.
In the discrete variety the spots are separated from one another by healthy skin of normal tint. The general symptoms are usually milder, and the fever less high, especially the secondary pyrexia, which is much less severe. Still, even in this form serious complications may arise, and when death occurs, it is usually owing—unless the patient be a young in fant—to one of these secondary lesions.
The confluent form is attended by a very high mortality. From the records of the London Fever Hospital it appears that of those at tacked by this variety fifty per cent. die. In children probably the proportion of deaths would be much greater. The danger consists not only in the severity of the eruption, but also in the intensity of the general symptoms. The initial fever is very violent, and is often accompanied by high delirium ; there is little remission in the pyrexia when the develop ment of the rash is completed ; tremors and signs of profound nervous de pression come on early ; the swelling and inflammation of the mucous membranes produce great distress ; and the secondary fever is very vio lent. If the child survive to the third week, which rarely happens, a seri ous complication usually occurs, and this in his exhausted state proves rapidly fatal.