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28th. The swelling of the face has disappeared; the pustules on the face appear arrested; they have considerably diminished in size; they no longer enclose pus, and are nearly desiccated. Those of the body are large, projecting, without the central depression, and filled with pus; there is a slight redness surrounding them. The hands are not swollen.

29th. The pustules on the body enlarge; there has not yet been swelling of the hands and feet; the pustules on the face are abortive.

30th. The pustules on the face are completely dry; the swelling has completely disappeared from the face; the eyes are open. On the body the pustules have begun to break and to be covered with crusts; on the limbs all the pustules are full of pus, not one is dry.

December 3rd. The pustules are entirely dry.

January 13th. The child left the hospital after having experienced a slight attack of ophthalmia.

[Collodion would appear to possess an abortive power over the eruption of small pox. M. Aran, at the Bon Secours, refers to a case which occurred in the wards in which the good effect of collodion was as decisive in confluent small pex as it had been before in the more simple form; it occurred in the person of an unvaccinated young man, and the collodion was applied to all parts of the face but the lips and ears. Through this transparent covering the progress of the pustules was observed to become at once arrested, while those uncovered continued enlarging. Moreover, a part of the covering having been destroyed without 'being observed for some hours, the pustules thus exposed immediately began to develop themselves uutil again arrested by a reapplication. The ears too were

now covered, and the progress of the pustules arrested there. In a few days the collodion peeled off, the skin looking as after erysipelas, but no cicatrices were to be observed, though in other parts of the body they existed in abundance, the eruption having been very confluent.-(Bulletin de Therapeutique; vol. xxxix, p. 369.)-P.H.B.]

The children may continue to suck, but the breast should be given them less frequently. If they are already weaned and well nourished, they should be restricted to diluted milk, which will serve them for a drink.

The cough should be treated by juleps of gum and emulsions, with the addition of from one to four drachms of the syrup of poppies, at most. If the breathing is much obstructed we must have recourse to an emetic composed of 3j of the syrup of ipecacuanha, and in case of bronchial and pulmonary inflammation, characterized by sibilant, sonorous, and subcrepitant râles, to one or two leeches at the pit of the stomach, and to a small flying blister at the sternum.

If convulsions or coma supervene, a leech should be applied behind each mastoid process.

After the detachment of the crusts, baths may be given without any inconvenience, and even, on the contrary, with every advantage. It is advantageous, also, to finish up by the employment of some mild laxative capable of relieving the bowels of the noxious matters accumulated during the course of the small pox.

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APHORISMS.

292. Small pox attacks those liable to it, enters into the blood, and breaks out by the skin.

293. The liability to receive small pox varies with age; rather great in the fœtus living in the womb of its mother, rare in infants, very great in childhood, it becomes lessened in the adult, and disappears. entirely in the aged.

294. Small pox is often congenital.

295. Intra-uterine small pox is an almost inevitably fatal disease. 296. Small pox is epidemic and contagious.

297. Small pox is regular or irregular, discrete or confluent, benign or malignant.

298. The small pox of young children is almost invariably discrete, but often irregular, which renders it very unfavourable.

299. A sudden convulsion, followed by fever and vomiting, in an unvaccinated child, would lead to the supposition of small pox.

300. The liability to receive small pox is neutralized by the inoculation of vaccine matter.

301. Decided small pox invariably follows the progress indicated by nature, and the eruption of the pustules on the skin can only be prevented to a very slight extent.

302. Broncho-pneumonia is a very frequent and a very fatal complication of the small pox of children.

303. The proper treatment of a simple, discrete, and regular small pox is to abstain from all energetic medication, and to content ourselves with prescribing rest and emollient drinks in the midst of a pure, mild, and temperate atmosphere.

304. The pustules of the face should be always made to become abortive by mercurial ointment or softened Vigo plaster.

305. The complications of small pox alone require the immediate and energetic interference of the practitioner.

CHAPTER III.

ON VARIOLOID.

The term varioloid is applied to a pustular and contagious cutaneous eruption, of the variolic nature, without secondary fever, originating from small pox, and able to produce it, and the duration of which is from one to two weeks.

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Three sorts of varioloid must be admitted; pustular centrally he depressed, globular, and conoid varioloid. All the three are developed

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in vaccinated individuals at the time of epidemics of small pox, and sometimes, also, when these epidemics are not observed. The centrally depressed varioloid is the most important to recognize, for it presents great analogies with the eruption of small pox, and it is often difficult to distinguish the one from the other.

Varioloid does not appear until two or three days after the precursory symptoms, which are characterized in young children by fever, uneasiness, an unaccustomed restlessness, and sometimes by gastrie disturbances, as vomitings, for example. Some children first present an eruption of roseola, and it is only at the end of twenty-four hours Feuer may themselves. that the pustules peculiar to the disease we are now considering manifest

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be quiete Red spots are at first perceived on the forehead, on the limbe, and

lastly, on the body. They often make a considerable projection, and sh, then put on the pustular character which is proper to them.

Their

number is never very considerable. In some patients they remain Theke acuminated, or more or less rounded off; in others they present a

central depression similar to that of the pustules of small pox.

AppThese pustules enlarge and acquire the maximum of their development towards the fifth or seventh day. They are then surrounded by a small areola of inflammation, without swelling of the skin as in small pox. Suppuration is imperfectly established in their interior, or is not established at all, and desiccation commences towards the eighth

implumday, at the same time that the inflammatory areola disappears. In

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some patients the desiccation is not effected until at a more advanced period of the disease. The crusts have nearly all fallen at the twentyfirst day, that is to say, at the end of the third week.

The general symptoms of the eruptions of varioloid do not sensibly increase in children even by the fact of the eruption. The symptoms are very much the same in the course of the disease as at the period of its invasion. The fever persists at the same degree for some days, Az and diminishes at the time of the desiccation of the pustules. There is not, as in small pox, a primary fever, which momentarily ceases during the development of the pustules, and which reappears with such intensity at the period of their suppuration. In a word, there is no secondary fever. The state of uneasiness, wakefulness, and agitation of the children is the same. There is loss of appetite, and vomitings are sometimes observed. Convulsions are uncommon; however, they may be explained by the intensity of the fever in young children. It fact, it is known that in them it is by convulsions, and pet & not by delirium, that the cerebral disturbance is betrayed. How can "they have delirium, since their intelligence is not yet developed? Juall for The pustules of the centrally depressed varioloid last a little longer

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than the pustules of globular and conoid varioloid.

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is often similar to that of variolic pustules, and they sometimes

completely suppurate before they become cicatrized. However, at the emulsi. period of suppuration, there is no secondary fever as in small pox. A. The symptoms of this kind of varioloid are also more severe.

It is

in this variety that vomitings and convulsions are especially observed. The only case of convulsions which I have remarked in varioloid, occurred in a child who had been previously vaccinated, and in whom all the pustules were depressed in the centre.

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Varioloid is not a serious disease; the children are readily cured; however, varioloid with the centrally depressed pustule is sometimes more serious than a discrete small pox. It is related than in an 2. The epidemic of small pox at Marseilles, twenty of the vaccinated died, and in them the disease presented all the characters of pustular as varioloid.* This disease is never followed by the eruption of boils

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and by the hæmorrhages which are sometimes observed in small pox. for reale. From the period of the commencement of desiccation fresh symptoms hardly ever supervene, and unless complications which are quite special ex and unforeseen occur, the children may be regarded as cured.

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The course to be followed in the treatment of varioloid is very evident. The eruption should be watched and allowed to accomplish its necessary phases. The children should be dieted and placed in a properly warmed apartment, sheltered from the action of cold and damp (€ air. They should not be covered too much, so as not to increase the fever, or to bring on abundant perspirations and the erythema which accompanies the sudorific secretion. Lastly, emollient and warm drinks should be administered until they may be again suckled.

In the case of complications referable to the alimentary canal or to the head, the appropriate means should be employed to vanquish these symptoms. Ipecacuanha powder may then be useful to empty the stomach completely, and magnesia to neutralize the acids which it contains. As to convulsions, as they are not dependent upon a change in the brain, there is nothing to be done for them; they cease naturally, and antispasmodics can only be given, of which we have spoken in the chapter devoted to the history of these symptoms.

CHAPTER IV.

ON CHICKEN POX.

Chicken pox is an epidemic and contagious disease, characterized by the presence on the skin of vesicles, more or less numerous, filled with

* Rayer.

a colourless and limpid serosity. This disease must not be confounded

in dial with varioloid, the nature of which is very nearly identical, but the

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character of which is essentially different. In fact chicken pox is a

vesicular affection, and the varioloid, on the contrary, a well characterized pustular disease.

uded Chicken pox is preceded by a slight fever which lasts from twelve to forty-eight hours at most. The febrile state is often scarcely to be appreciated, and as M. Rayer has pointed out, it does not prevent the children following their usual games. In some rare instances, the invasion of the chicken pox is preceded by abdominal pains, vomitings, &c.; but these instances must be very exceptional, for I have collected twenty-three cases of this disease, and in not one of them were any of these symptoms observed.

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"Chicken pox is either discrete or confluent. It is characterized by small red slightly prominent spots, circular when they are isolated, irregular on the contrary when many are observed on the same spot. On the next day a prominent vesicle filled with a colourless or pale Disteles yellow perfectly limpid humour, which readily escapes when the

vesicle is pricked, is formed in the centre of most of these elevations. On the second day this vesicle is about one line and a half in diameter; it either projects to a point or assumes a rounded form. On the third day the colour of the lymph is yellowish, but this is the only change which the vesicles have undergone. On the fourth day, those which have not been accidentally broken, diminish in size, and become shrivelled at the circumference. The fifth day, a small crust adherent to the skin is formed in their centre, and a small quantity of opaque lymph is enclosed in their circumference which sometimes gives them an appearance of central depression. On the sixth day, small yellowish or brown crusts occupy the place of the vesicles. On the seventh and the eighth, the crusts become detached and leave small red spots without depression on the skin, which remain for several days.

"During the course of this eruption, many of the elevations appear to become abortive; some remain in the state of simple spots or of popular elevations, and become gradually effaced; the others are only surmounted by a very small vesicle which is easily broken, or vanishes very quickly."*

The vesicles of chicken pox are not always preceded by a red spot on the skin; they are then true bullæ which become developed without a precursory local symptom. If I can form an opinion of this from the cases which I have collected and which are rather numerous, the vesicle becomes primarily formed in the majority of these cases without any previous alteration of the dermis. Thus, I have many times observed, in the midst of the ordinary eruption of chicken pox, vesicles, or rather * Rayer. Art. Varicelle. Dictionnaire de médecine et de chirurgie pratiques; t. xv, p. 556.

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