A Treatise upon the Small-Pox/Part1-Section2

by Richard Blackmore

Sect. II.

Of the several Sorts or Species of the Small-Pox.

HE lowest and most favourable are those of the distinct Sort, which are cast forth upon the Face and Body in broader red Spots, with considerable Spaces between them, and are for that Reason call’d the distinct Sort, to discriminate them from others of a more dangerous Nature, that shall afterwards be accounted for, and not being accompanied with violent Disorders, they make their Appearance most commonly on the fourth Day: And therefore it has been a great Mistake in Judgment, and a pernicious Error in Practice, by warm and cordial Medicines, to hasten and drive out the Small-Pox, and by that Means, to precipitate Nature’s Intentions, and disturb her regular Progress; which Custom too much prevails at this Time among many ignorant and injudicious Persons, especially in the Country, who by giving at the beginning Venice-Treacle, Sack, Mithridate, Saffron, and other Medicines of like active Quality, design to promote their coming forth speedily, by which inconsiderate Conduct, they will not suffer the operative Principles of the Blood to do their Duty in their own orderly Way, but spur them on, and force them to expel the Matter of the Disease before its due Time, and so often make a harmless Distemper dangerous, and a dangerous one fatal. It is certain, that the longer it is before this Disease appears in Spots, the safer and more favourable it proves; for I never saw a Patient miscarry by the coming forth of the Pustules too slowly, though Multitudes have been lost by their coming out too soon. The Reason of the different Event is this; the diseasy Matter being neither of a malignant Quality, nor in great Quantity, the active Principles of the Blood are not provok’d and excited to throw it off immediately, for fear of being oppressed by it, and therefore have Time and Room to labour, prepare, and qualify it for a due Separation and Expulsion. And Nature generally finishes this Stage in the Space of four Days, as I have said before, by which Time it has subdued and conceded the crude Seeds of the Distemper, and made them fit to be separated from the Blood by the Strainers of the Skin, where they are compelled to stay and slick fast, not being able to pass through the Pores, by Reason of their improper and unequal Size and Figure. The Matter of the Disease being thus intercepted and entangled in the outward Glands, usually appears first in the Face, the Lips, Neck, and Breast, in small red Spots of the broadest Kind in this Distemper, which rise above the Surface of the Body, and gradually encrease in Bulk, by the constant Accession of new Matter prepared by the Blood, and excluded thence to their new Settlement in the Glands of the Skin; so that by fresh Supplies, continually poured on and determined to the Places where the first Matter was lodg’d, the little red Spots swell to minute Boils, and like them are painful and inflammatory, and gradually proceed to a mature or ripe State. There is therefore no Reason that can support the Distinction, which Surgeons lay down between Swellings or Tumours by Congestion, and others to which they give different Names; for all are caus’d by Congestion, that is, the Accumulation or heaping on of fresh Matter, whether that Matter be deriv’d and communicated gradually from the Blood or from the Nerves, whether they arise to a Maturity in a shorter or longer space of Time, and whether accompanied with a Fever or not; for all acquire their Growth and Augmentation, whether by a swift or slow Progress, from the continual access and flowing of new Particles on the obstructed Places, where the Matter of the Swelling was at first laid down: Those indeed, that at first arise and are after fed from the Blood, arrive sooner at their Maturity, than those that receive their Supplies and Reinforcement from the Nerves, and which are very slowly, if at all, ripen’d; but in the manner of their Generation and Increase, there is no Difference, all being form’d by Congestion, that is, the gradual Addition or Afflux of new Matter, from what Sources soever it is deriv’d.

In a short Time after the Appearance of this milder Kind of the Small-Pox, of which we are discoursing, the previous Symptoms are in a great Measure mitigated, that is, the Pains in the outward Parts; Headach, Thirst, labouring Pulse, and disturb’d Imagination or Delirium: 'Tis observable, that in Children convulsive Motions, a harmless Symptom, often usher in the Eruption of this Distemper, which confirms what I have before asserted, that the Nerves and animal Spirits are first affected by this Disease; and when the Matter or Principles of it are cast off from the Nerves into the Blood, and are thence after a due Preparation and Digestion thrown out into the Surface of the Body, the Symptoms which before that Time afflicted the Patient in a very great Degree, are removed. Things now having taken another Turn, the Fever is greatly abated, and the Blood and Spirits restored almost to a State of Quiet and Tranquillity; and now Nature as fast as it has concocted and dispos’d the noxious Parts for Exclusion, drives them out to feed the Seeds of the little Swellings or Ulcers, till at length it has entirely freed the Blood, and produced a compleat Harvest, which it usually accomplishes in three Days.

And now the noxious Matter being subdued and entirely expelled from the Blood, Nature, as said, is more at ease, and seems to revive and triumph, as conscious of its own superiour Strength, and the Weakness of its Enemy, which clearly presages a happy Event. During this Stage of the Disease, while all Things are in a greater Quiet and Repose, the Small-Pox being constantly recruited by new Supplies from the Blood, swell to a larger Size, if compared with that of the worst Sort, and continue red and separated from each other by intervening Spaces: But after three Days, which forms the second Stage from their Invasion, or the first from the Eruption; on the eighth Day begins the third, when the small Swellings or Boils begin to acquire a State of Maturity, which appears by their whitening Heads, the Mark of Suppuration; and at this Time the Patient undergoes much Pain: for the greatest Part of these little Boils, as well as the Skin about them, continuing red, fiery, and crude, an extraordinary Effort of the active Principles of the Blood is required to digest them; for as Nature in the first Stage of this Disease, by exerting her Force and Vigour to concoct in some Measure, and dispose the putrid Particles for Separation, was during that Labour and Conflict in a feverish State; so now, when she undertakes to ripen and digest entirely these numerous little Boils, her Attempt must be accompanied with the like feverish Symptoms, which arise from her Strife and Contest with the Matter as yet crude and not mastered by Suppuration; and if the ripening of one common Boil demands so great a feverish Ferment, it is no Wonder that such a mighty Number, though of small ones, dispersed over the whole Body, should be attended with so much Heat, when they grow to Maturity.

This is called the Fever of Maturation, or the second Fever. It must however be acknowledged, that there is but one and the same continued Fever from the Beginning, though under various Appearances of Heat, sometimes greater, sometimes more moderate, according to the several Stages of the Distemper, and the different Exigencies of Nature. The Small-Pox is allowed to be a Fever; and if that which accompanies their first breaking out, is a distinct Fever, as some have asserted, from that, which attends the ripening of them, then it is manifest, that every Small-Pox is two Diseases, which would be a very harsh and absurd Position. If a Fever, that is simple and not putrid at the Beginning, should by irregular Conduct, or by its own intrinsick Nature, after a considerable Time, degenerate into one that is Malignant, which often happens, attended with the worst Symptoms, could the different States or Stages of this one, be reckoned so many distinct Fevers?

It is the constant Property of this mildest Sort of Small-Pox, that the Pustules or Boils continue distinct and separate on the Face and Body, till their whole Course is compleated; and in some Cases they are very few, and large, not perhaps more than eighty or a hundred in all, and sometimes not so many; and they of this kindly Sort are generally judged fully ripened by the tenth Day from the first Illness, or the sixth from their first Appearance; the eleventh Day therefore is not justly fixed for the Completion of all of this Kind, as the eighth Day from the first Attack is not truly assigned as their most dangerous Season. By the continuing of this Sort so long, they are distinguished from the Chicken or Swine Pox, which as they are larger, and often full of Water, so they disappear before the eighth Day, though in that Space they sometimes stay long enough to leave Impressions or Prints in the Skin; and by this it may be known, that is, by their Continuance till the tenth Day, whether the Eruptions or Pustules were truly the Small-Pox or no.

But there are yet higher Degrees of the distinct Kind, of which the highest of all produces such a Number of Pustules or little Boils, that when they are ripe and full of Matter, they almost flow together, and become the Flux Kind; and this Sort proves sometimes fatal, by the great Quantity to be cast forth and digested, as well as by the ill Quality of the Matter, approaching too near to Malignancy.

As Nature begins with low and mean Productions, and arises by several Steps and various Degrees to Beings of the greatest Perfection, which Degrees are diversified by such nice Limitations, that it is difficult to determine where one Kind ends, and another begins; so she proceeds in like Manner, in the Unravelling and Dissolution of the Bodies of Men by Distempers and Diseases, which is not more remarkable in any Instance, than in this of the Small-Pox. The first Sort which I have mentioned is called Distinct; but even in this are found many different Steps or Gradations, as I have suggested above; before you arrive at the worst of this Sort, some consisting of very few Pustules, some of more, and that in various Degrees till you come to the highest; and when you are gotten thither, you do not presently step into the Confluent or Flux Kind, as some have asserted, who make but two Sorts of Small-Pox, the Distinct, and Confluent. For Nature, according to her Custom, does not proceed so fast and hasty; but before it arises to the Confluent Species, it produces a middle Sort between both, that is, when in some parts of the Face and Body the Pustules are Distinct, and in others Confluent; and sometimes it happens that while all in the Face are Distinct, many in the Body shall flow together in Patches, like a redish scorbutick Tetter. If these confluent Patches appear at the Beginning, it is an Argument of an ill-conditioned Distemper, but if they run together and break in upon one another only at the latter End, when the Boils ripen, swell, and want room to spread themselves, then their Nature is more favourable, and the Danger less; and therefore it is from Inadvertence and Want of Attention, that those Physicians, who have wrote the History of the Small-Pox, have not taken Notice of this middle Sort as a different Kind from the other two, having the same Grounds and Reasons for doing so, as they have to make a Division between the Distinct and Confluent Species.

As a simple continued Fever consists in the irregular Disposition, and shattered Frame of the Blood, while the sulphurous Particles are exalted to an excessive Power, and an unnatural Dominion over the rest, and so have ruffled and disordered the Mass, which however suffers not any Degree of Putrefaction, that is, any minute Division of its Parts, that destroy their Coherence with each other, and their Union with the whole; so in the distinct Kind of the Small-Pox the Blood is in the like irregular State, but yet free from the Corruption before described: But in the middle Sort, which is partly distinct and partly flowing together, there is a considerable Degree of the Putrefaction which I have mentioned before, and have more fully explained in my Discourse of the Plague and malignant Fevers; yet it must be acknowledged, that sometimes, though very rarely, it happens, as I have seen, that great Putrefaction accompanies even the distinct Sort, which shews it self sometimes in scarlet, and sometimes in blue Spots, dispersed over the Body in great Numbers; and then the Distemper, though it appears favourable in Respect of the Distinction of the Pustules, yet by Reason of the Malignancy and Corruption discovered by the other Marks, it is no less fatal, than the worst of the confluent Kind; and had not those malignant Particles, by some extraordinary Way been separated from the Matter of the Pustules, no doubt the Distemper had been of the worst confluent Sort.

I shall here make only this farther Remark, that in the mildest Sort of the distinct Species there is not any Danger, and the worst of the Confluent are as much incurable, as the Plague it self; and therefore as the first does not require the Attendance of the Physician and the Use of Medicines; so in the last they are unequal to the Disease, and altogether insignificant; whence it follows that the only Province in which the Physician is useful, must be the intermediate Degrees, that is, the most favourable Sort of the confluent Kind, that of a middle Nature, and that of the worst of the distinct Sort.

By orderly Steps we are now advanced to the confluent Species of the Small-Pox, that is, when the Eruptions or Pustules, that appear upon the Skin, break their Partitions and run into one another; this Conjunction often happens in the Face, while the Pustules in the Body are separate and disjoyned, and therefore they are denominated Confluent from the Face only, which is chiefly affected by this Disease: For if in several Parts of the Body many Pustules flow into one, while in the Face they are parted and divided, this is not the Confluent, but the middle Kind; and on the other Hand, if the Pimples run together in the Face, though they are ever so distinct in the Limbs and the Body, this is reckoned in the Class of the Confluent: And in this Kind also are found many Gradations, before we ascend to the most terrible and malignant of all. The least dangerous Sort of these is when the Eruptions appear on the third Day after the first Illness; for the longer they stay before they break out, as I have observed before, the milder and safer they are; for then Nature is allowed longer Time to digest the noxious Matter, and dispose it for Exclusion; whereas it is an Argument of the highest Putrefaction, when Nature, that is the active Principles of the Blood, are forced to attempt a too hasty Separation or Expulsion of the Matter as yet crude and unconcocted, to ease her self of the vast Oppression of the poisonous Ferment, under which she is ready to lye down and dye. Thus the mildest Sort of the Confluent, that approach the nearest in Nature to the distinct Sort, come nearest to them likewise in the Time of their Eruption, which is in the fourth Day after the first Attack, as in this Sort on the third.

The Symptoms, that attend the confluent Kind of all Sorts are as before enumerated, but in an higher Degree, cold Shiverings or Rigours, great Pains commonly in the Back, sometimes in the Side or Limbs, an inordinate, labouring, and swift Pulse, Sickness in the Stomach, Vomitings and Strainings to vomit, Thirst, Aching and Lightness of Head, excessive Heat, Oppression of Spirits, and great Inquietude, till the Time of their Appearance. If this happens on the first Day, the Case is deplorable, and eludes all the Art and Care of the Physician; and that Sort is likewise very dangerous, which breaks out on the second Day after the first Seizure; for herethe Matter of the Pustules being expelled to the Skin, before sufficient Time is allowed for their Digestion, rarely proceed in a regular Manner to a safe Maturity, but continue crude and unconcocted so long, that it protracts the Fever, and extinguishes the Spirits by its malignant Quality, till exhausted Nature is at length subdued and yields to the Enemy. Tho’ this fatal Event sometimes happens on the seventh or eighth Day, where the Putrefaction is found in a very high Degree, and next to pestilential; yet most commonly the Distemper is prolong’d to the eleventh, and often to the thirteenth, seventeenth, twenty first, and twenty fifth Day, and sometimes yet farther, so that the eleventh is not the decisive Time in this worst Sort.

The Fever in this Species that accompanied the Eruption of the Pustules, and was necessary for that Purpose, is not reduced and mitigated to that Degree, as it is after the breaking out of the Matter in the Distinct Kind, but continues, tho' with Abatement of Symptoms, in a considerable Degree thro' all the Stages of the Distemper; which confirms what I asserted before, that there is no first and second Fever in the Small-Pox, but it is one and the same from the Beginning to the End, and only varied in the different Stages of the Disease, as it is accompanied with greater or less Symptoms; and in their State of Maturation the Fever is more painful and intense in finishing the Small-Pox, as it happens in the Ripening of all inflammatory Tumours; but therefore must not be called a second, that is, another Disease.

It must be here observ'd that tho' the Confluence of the Pustules in the whole Face or at least the greatest Part of it, diversifies this from the distinct Kind; yet the chief Difference lyes in the intrinsick Nature of it, which consists in its malignant Property; for in the mild Sort there is no Putrefaction or destructive Separation of the Parts of the Blood, but only a Violation and Discomposure of their natural and healthful Order and Disposition, while their Connexion is not ruin'd and destroy'd, but is still preserved, though weakened, and and continued under the Animal Oeconomy; but in the Confluent Small-Pox it is a great deal worse, for in this Case many Parts of the Blood undergo such a Solution and Division, that the natural Structure is not only impair'd but in a great Measure broken, and many of the integral Parts are so far separated and putrefied, as to be cast out of the Animal Government, and are so corrupt and lifeless that they cannot be restored to their former Station and Union with the Blood, but must be digested and expelled into the Skin by the sound and active Principles, or Nature must be overcome and fall in the Combat; and this I call a State of Mortification in the Blood. And it is to be observed, that in the worst Kind of Small-Pox, as in the Plague and high malignant Fevers, the Patients feel little Pain or Sickness, and are insensible of their Danger, and wonder when they are told they have so short a time to live; which is the Case of those that die of Gangreens or Mortifications in the solid Parts, either external or internal; for when the Mortification begins, the Pain ceases, and the Patient is actually dying, when on a Sudden he is at Ease, and looks upon himself as in a better Way of Recovery. It is remarkable, that when a Toe or Finger, especially of Persons advanc'd in Years, mortifies from an inward Cause; tho' the Surgeon takes them off, yet the Parts next above, from which they are severed, will soon undergo the same Fate, and so on; the Reason is because the cutting off the Member could not free the Blood from the putrefied Parts, that fed the Gangreen, and therefore it still continues to discharge and lay down in some other Place the corrupt Materials, till it has destroyed the Fabrick. This Observation makes it evident that corrupt and lifeless Particles may be contain'd in the Mass of Blood; which I therefore call a State of Putrefaction or Mortification, as said before; for as I have elsewhere asserted this Notion, so I still believe it is just and well founded upon Reason and Experience.

The Confluent Kind then are diversified from the Distinct externally by the running together of the Pustules and copious Spitting or Salivation at the eighth or ninth Day, and internally by the Corruption of some Parts of the Blood, which in the last Sort is unbroken and entire, tho' flutter'd and disorder'd in its Texture and Symmetry. There are also various Steps and Gradations to be observ'd in this Species of the Small-Pox arising from the different Degrees of Putrefaction, which constitutes this Kind; the lowest and most favourable come out on the third Day distinct at first, and almost as large, as the Sort of that Denomination, but after some Time they run together, when in their Growth they swell, and by enlarging their Borders, they break the thin Fences that separate them from one another, and shew themselves to be of the Confluent Sort. In this Species the Pustules are often more elevated and bold, and being constituted of less noxious or malignant Matter, they are not accompanied with violent or threatning Symptoms, and they generally compleat their Course with good Success, which most commonly is done on the eleventh Night after the first Attack, when many likewise expire; that Period of Time then is only properly assigned as commonly decisive in the lowest Degree of the Confluent Sort.

The next Gradation in the Confluent Kind is, when the Eruptions are smaller and more numerous, which proceed from higher Degrees of Corruption; that is, when many more Ingredients of the Blood are divided and ruin'd than in the former Degree. In this Case the Pustules are so small, so many, and so contiguous, that they soon flow together, and in a shorter Time than the former; and this is the Sort that is indeed dangerous to the Patient, and most tries the Skill and Judgment of the Physician; for now there appears a great Variety of grievous and formidable Symptoms, violent Vomitings, great Head-achs, Delirium or Suspension of Reason, obstinate Wakefulness, excessive Heat, great Inquietudes, and often laborious and short Breathing. The ninth Day from the first Invasion the Pustules rise higher, and the Face swells and grows redder, the Fever that continued all along, is now augmented, and without Reason, as I have said, is called the second Fever, it being the same with the first, only higher rais'd. The Pustules usually in their State of Maturation swell the Face very much, and turn by degrees to a dark brown Crust or general Scab, which often continues undigested and unseparated from the Skin many Days: So that in this Case, which is the chief Province of a Physician, it is an Error to assign the eleventh Day as decisive of the Event; for it often happens that this is not the determining Period in this Kind of Small-Pox; for all Practisers must know that the Small-Pox of this Sort are most frequently carried on beyond those Limits for many Days; and after the Face is altogether, or almost, clear'd of the Pustules, the Fever will often survive and maintain its Ground a great deal longer,, and till that be reduc'd, and the Pulse restor'd to their natural Standard, the Distemper cannot be looked upon as judg'd and concluded; for after the eleventh Day the Fever proves often fatal, sometimes by terminating in Convulsions, sometimes in a hectical and consumptive Wasting; and it is absurd to say, that the Patients in such Cases did indeed escape the Small-Pox, but dyed of Convulsions, or, a Consumption, after they were recover'd from the other Disease whence those Symptoms proceeded.

Sometimes the Confluent Crust, or general Scab on the Face is of a dull, leaden Colour, which it acquires from the great Crudity and ill Condition of the Matter, of which they are form'd; and I have known that the Confluent Pustules of this Aspect have continued on the Face more than three Weeks, before they have been fully digested and separated from the Skin.

Sometimes on the ninth, tenth, and eleventh Day, during the Maturation, the Face, from the Colour of the digested Matter, beneath the Skin, grows pale, and sometimes white as a Sheet, with little Swelling or Elevation of the Cheeks, Lips or Nose, which is a Case always very dangerous, and most commonly fatal; tho' I acknowledge I have seen some escape in a very wonderful Manner, when not only the Face has had this Aspect, but even the Arms and Wrists have turned white by the purulent Matter, and the Confluence has been so great, that the concocted Contents have hung down in Bags like Bladders rais'd by Blistering Plaisters, which Bags being cut to discharge their purulent Matter, the Muscles were left all raw and uncover'd: But it sometimes happens that there is little or no Protuberance, or Swelling of the Confluent Eruptions, but the Face lyes flat and equal, while the minute, and scarce distinguishable Pustules growing dry only turn the Skin into the Likeness of an old Piece of Parchment, or dull Russian Leather, and even then the Patient has sometimes recover'd.

Another important Discriminating Property of this Kind of Small-Pox is the Spitting or Salivation that Nature raises usually about the eighth or ninth Day from the first Invasion, and this is so constant and so necessary, that it seems equally required for the Recovery of the Patient with the ripening of the Eruptions it self; and this Evacuation by the Glands of the Mouth is more or less copious, and continues a less or greater Space of Time, according to the different Degrees of Putrefaction in the Blood, a considerable Part of which is destin'd to be excluded by these Sluices; for tho' the greatest Portion of the corrupt or mortified Particles of the Blood and Humours are expelled by the sound and active Principles into the external Parts of the Body, yet a great Quantity of it, which is not by Reason of its disproportion'd Bulk and Figure capable of being determined and transmitted to the Surface of the Body, is drain'd through the Salival Glands, and carried off by copious Spittings; as Nature as well as Art in some other Cases discharges the noxious Humours that cause Distempers by a Flux of Humours issuing from the Glands of the Guts; so by this inverted Purgation, performed by the Strainers of the Mouth, the Blood is freed in a great Measure from the Matter of the Disease mingled and diluted with the ejected Serum. This Evacuation, I have said, begins usually about the eighth Day, and continues according as the Exigencies of Nature require, that is, till that Part of the purulent Matter which is communicated to it, is discharged: But sometimes this Province of Salivation is executed in an irregular Manner both in respect of its Rise and Appearance, and also of its Continuance; for sometimes the Salivation is suspended, even till the Scabs on the Face are dry, and sometimes longer. I remember an extraordinary Case of a Lady, that had no Spitting till the fourteenth Day, and till she was recovered and sat up, and then the Salivation began and continued about a Week; and I have observed likewise, this Salivation in some others, that appeared at its usual Season, has after the fourteenth Day been greatly augmented, and continued many Days.

The Swelling of the Face, which usually begins on the eighth Day in the distinct Kind, happens most commonly on the ninth in this Sort; and the greater the Swelling is, the greater Prospect there is of the Patient’s Recovery. This Swelling arises from the inflammatory little Tumours that flow together: It is the Nature of all Inflammations, to cause Prominence in the Parts affected: A Boil, a Phlegmon, an Erysipelas, or St. Anthony's Fire, Anginas, Rheumatisms, or scorbutick Inflammations, are all accompanied with Swellings in the Places where they happen; which Tension, that is, the Stretching of the Fibres beyond their Staple, creates Pain; and the Swelling is produced by an afflux of Humours to the Part, from the Vellication of the Muscles, or Tendons, by the sharp and crude Matter of the Distemper; and the immoderate Heat is occasioned in the solid Parts affected, as it is in the fluid; for as an unnatural feverish Heat is raised by the Conflict in the Blood, while the active Principles labour to digest, and exclude from the Mass, the degenerate and corrupt: So in the solid Parts there follows excessive Heat, as well as Pain, while those sound and active Parts strive to concoct, and bring the Matter of the Distemper to Maturity and Suppuration; and when this is compleated, the Heat in the inflamed Member, and the Fever in the Blood, quickly disappear. It is not only the Face that swells and continues so, till the Suppuration is compleated, but wherever the inflammatory Pustules are Confluent, they swell the Part in the fame Manner, and for the same Reason, as they do in the Face: This happens in the Hands, and Feet, and other Members, whenever the Quantity of the Pustules is very great, and their Quality malignant. The Hands begin to rife, when the Swelling in the Face begins to subside, which usually happens on the eleventh Day; for the Pustules in the Body, the Hands, and Feet, coming out about thirty Hours after those of the Face, they are in Proportion, as slow before they reach Maturity. An eminent Physician, that has deserved well of the Profession, by his History of the Small-Pox, and his Method of Cure; though as all human Works are, it is imperfect; observing, that as the Swelling in the Face abated, that in the Hands began; imagined that the Matter which caused the first, was in some Measure translated to the last, and so was the Cause of it; and this Opinion has generally obtained among the Gentlemen of the Faculty. But this I look upon to be a great Mistake; for though the Swelling of the Hands immediately follow the sinking of the Face, yet it follows not as an Effect from a Cause, but as a Consequent succeeds an Antecedent; for that Swelling necessarily arises from the inflammatory Pustules in the Hands themselves, which at that Time come to Suppuration, as those in the Face swelled by their own Heat thirty Hours before, and not from any Matter communicated to it from the Face: For when the Digestion is fully, or almost compleated, and the Inflammation ceases, the Swelling does of Course subside; as it plainly does in all Kinds of inflammatory Cases whatsoever, that come to Suppuration; as in Boils, Phlegmons, scorbutick Tumours, &c. and when the Feet swell, as they often do, if the Number of the Pustules is great by the Anguish and Pain affecting the Fibres, this Symptom does not proceed from the Matter translated from the Face, or Hands, to the Feet, but from the Suppuration of their own Pustules, as the Face and Hands swell by the ripening of theirs; If a Boil is digested and ripened in the Arm, and another, that rose two Days after in the Thigh, begins at this Time to swell to a greater Degree by the Pain and Suffering in the Maturation; will it not be absurd to say that the Matter which caused the Swelling of the first, even after it is concocted and ripened, is translated to the last? And the like may be argued from other inflammatory Tumours, that should in Time succeed one another.

And as there is no Need to fetch any noxious Humours from the Face, to furnish out Materials for the Tension of the Hands, the Heat and Anguish of their own Pustules being abundantly sufficient for that Purpose, as well as those in the Face were able to cause the Protuberance or Elevation there, so no Manner of Conveyance, no Road or Passage, can be accounted for to favour this Supposition: For the Matter must of Necessity retreat from the Cheeks into the Blood, and then the Consequence will be, that the Blood must suffer a new feverish Conflict, while Nature struggles with these returning malignant Particles, and exerts its Force to exclude and send them to the Skin, which Event however does never happen, for the Fever at this Time is generally abated: And why should the Blood expell it, to augment and raise the Pustules in the Hands, rather than those in the Breast, or any other Part of the Body? But to put it out of Doubt, that Confluent Pustules may swell and ripen of themselves, without any Communication of Materials from the Face; I have known in the middle Kind of Small-Pox, which I have described before, that the Pustules in the Face have continued all Distinct, through their whole Course, with little or no rising; and at the same Time one of the Arms, on the Outside from the Shoulder almost to the Elbow, was covered with an infinite Number of small Pustules with the least Space imaginable intervening, which soon flowed together, and the Arm swelled in the usual Time, like the Face in the Confluent Sort; and other such Instances I have seen in those of the middle Kind, and no doubt other Physicians have observed the like. I conclude, that all the Pustules in whatsoever part they arise, whether they continue separate, or run into one Surface, rise, grow, ripen, and acquire Suppuration by their own native Heat and Activity, and swell, and are digested independently on one another, and without the Translation of any Matter, from those of one part of the Body to those of another.

But to return to the History of the lowest Degree of the Confluent Kind, where many Patients escape, and many miscarry; Besides the sad Train of Symptoms, which I have described before, that attend this Sort; there is another more grievous, that is sometimes added to this formidable Retinue, that is, scarlet, bluish, or purple Spots, sometimes in a small Number, which often disappear before the Maturation of the Eruptions, and then the Patient sometimes escapes; but if those Spots are numerous and of a deep Colour, as in spotted Fevers, they are usually fatal, and therefore I reckoned them among Symptoms of the most dangerous Nature.

The highest Kind of the Small-Pox, are those that appear on the Skin the first Day of the Attack, and the next in Malignancy are those that break out the Day following; the Symptoms peculiar to this dangerous and usually mortal Species, is a violent and unsufferable Pain most commonly in the Back, with grievous Vomiting, by which it imitates a sharp Fit of the Stone, and has sometimes imposed upon the Physician, as well as the Standers by, and made them conclude it was that Distemper: But sometimes this previous acute Pain is felt in the Side, and sometimes in the Limbs. Another discriminating Property in this Case, is the vast Number and minute Size of the Pustules, that are scarcely elevated above the Skin, and being continued and united for the most part, especially on the Breast, form the Appearance of a scarlet Fever, or St. Anthony's Fire, such is their redness and unequal rough Surface, like that of the Seal's Skin; and this Sort has often been mistaken by inattentive and undistinguishing Practisers, for the Meazles, the ranker Sort of which are more protuberant, or rise higher than this Kind of Small-Pox; this Profusion and enormous Quantity of Pustules, so small, that their inequality or unevenness is scarce perceptible, overspreading almost the whole Body, especially the Breast, as well as the Face, may at first Sight be pronounced fatal; their Nature being so malignant, and their Number so immense, that it is not possible for the active Principles to digest and bring them to Maturity, especially if at the same Time a Multitude of scarlet or livid Spots are interspersed and scattered over the Skin, particularly in the Neck and Breast, for this shews the Putrefaction to be in a very high Degree. This Symptom therefore presages the greatest Danger, for notwithstanding, as I have said, a few such Spots are sometimes consistent with Recovery, as well in the Small-Pox, as malignant Fevers; yet when they appear in great Numbers, they discover such a degenerate State of the Blood, as cannot be repaired by Nature, though assisted by the greatest Art. Another Symptom belonging to this Kind, is a Discharge of Blood by Urine, and sometimes by other Sluices, as by the Seat, by the Mouth, and by the Eyes; but as to bleeding at the Nose, it is sometimes very useful by preventing or abating the feverish Heat, and never so dangerous, as such Evacuations from other Parts, which is an Argument that the Frame and Contexture of the Blood is not only shaken and disordered, but dissolved and broken into minute Atoms; and being thus severed, and its Continuity ruined, it is ready to issue through the Glands, and pass thro’ any Strainers of the Body without Opposition, especially those of the Kidneys; and this is a Discovery of the greatest Putrefaction, or a state of Mortification in a great part of the Blood; and therefore the Small-Pox, as well as malignant Fevers, attended with such a Discharge, is generally incurable. It is true, if this Symptom happens at the Entrance of this Distemper, and that in a moderate Degree, it will sometimes gradually abate before the Time of the Suppuration, and the Patient may recover; and the same may be said of black or dark coloured Urine: This very ill Sort, from which some few however make their Escape, come forth upon the Skin on the second Day; but of those on whom the Pustules appear the same Day, that the Illness begins, I do not believe, as I have said, that any recover.

I have now done with accounting for the several Species of Small-Pox, but I must yet add one Sort, according to the Opinion of some, which is indeed very wonderful; and that is a Kind, which is not accompanied by any Spots, Pustules, or Eruptions whatsoever; when the wise Doctor tells the good People that it is the Small-Pox within, and would have appeared outwardly, if Nature had been strong enough to have thrown out the Matter; but she being defective and unequal to the Task, the Small-Pox without appearing destroys the Patient in a very clandestine Manner. This is certainly very surprising; for here is a Disease without Symptoms, which is somewhat extraordinary: The Doctor fancies it had a great Mind to have been the Small-Pox, but being disappointed of that Intention it kill’d the Patient in such a malicious and secret Way as no Body knew what did hurt him: But can any Man know this would have been the Small-Pox? why might it not more probably have been a very malignant Fever, that took off the Patient in so few Days? Besides, if it be considered, that Nature pushes out the word and most fatal Sort of Small-Pox in Spots or Pustules, even on the first or second Day; so hasty is she to expel the malignant and pernicious Matter; and why should it have such Patience as to linger three or four Days without casting out in Spots this pretended unappearing Small-Pox is unaccountable. Let this be tried in parallel Cases; how odly would it sound to say that a Patient died of a St. Anthony's Fire, that never scorched, or so much as appeared on any Member of the Body, or that he had a Boil, or Phlegmon, or a Scorbutick Inflammation, that never redened, swelled or pained any Part whatsoever, or a Cutaneous Disease, by which however the Skin was never in the least affected? Having now given an Account of the Nature of the Small-Pox and its proper Characters, and divided it into its several Species, and laid down the peculiar Properties, that discriminate and distinguish one Sort from another; I come to discourse upon the most proper and effectual Method of Cure in this great Distemper.