the nail, and the removal of the kernel or seed is quite painful, though necessary.

The crust is usually thin, of a light yellowish-brown tint, but slightly adherent, and is shed or picked off without discomfort. The spot where the crust has been is of a deep purplish hue, and the many little stains here and there give the patient a peculiar spotted appearance, which in time disappears, except where the ulceration has left a pit or cicatrix. The pit soon loses its color and becomes of a whitish hue.

As dessication proceeds the constitutional symptoms decline, the appetite returns, and the patient gains strength.

Complications.—Sepsis is the one generally to be expected, and this may assume any form from a local affection, such as a furuncle, to a general septicæmia. Furunculosis is frequent and is often annoying, and no sooner is one boil healed than others follow. Bed-sores are also frequent if proper care is not used to prevent them. Bronchitis from the affection of the mucous membranes may occur. When simple, this can be handled easily; but when general pneumonia results, death is inevitable in the weakened condition of the patient. Ulcers and opacities of the cornea, laryngitis and croup (the latter generally fatal), zoster, sciatica, nephritis and gastritis, are all frequent complications, especially in severe cases.

Confluent Smallpox.—In this form the vesicles coalesce or run together, forming variously shaped and sized blisters, which as pustulation proceeds are usually ruptured in some manner and become infected, forming large, thick scabs with extensive ulceration underneath. The inability to properly cleanse such cases causes a very fetid odor to be given off and makes the patient an exceedingly difficult one to treat.

In the mild confluent form the disease is similar to the discrete form only that several lesions coalesce. In the severe confluent form the coalescence is extensive and large blisters are formed. The swelling about them is intense, and with the extensive sepsis the patient rarely survives. The swelling of the face and extremities is sometimes enormous, and the suffering is so severe as to make death a welcome visitor.

Confluent smallpox runs a course similar to that of the other forms, except that it is not as rapid as the third and is usually more severe than the first.

Hemorrhagic Smallpox.—This is recognized as the malignant form of variola, and is rapidly fatal in most cases. It runs its course precipitately, and at times most unexpectedly,—sometimes killing the patient in a few hours and in other cases not completing its career until the fourth or fifth day. Hemorrhages may come on suddenly and the patient expire before any rash appears. In one case an efflorescence appeared and so closely resembled scarlet fever that it was mistaken for it. Suddenly hemorrhages set in, and within six hours the patient was dead. There was a question at the time as to whether the case was malignant scarlet fever or malignant smallpox. Later a room-mate came down with a typical case of smallpox and helped to clear the doubt. The hemorrhage usually occurs as the disease changes from vesiculation into pustulation.

The severity of the hemorrhagic form of the disease is shown by the rapidity with which it passes through the various stages. Macules appear, and within a few hours rapidly change into papules, which almost as rapidly change into pustules; and before pustulation is complete hemorrhage occurs, and death quickly follows. It is not unusual in these cases for the disease to run its course in from twenty-four to thirty-six hours. In many, severe constitutional symptoms mark the onset, hemorrhages occur immediately, and death results before the rash appears. The hemorrhages are from the mucous membrane of the eyes, nose, and mouth, and from the anal, vaginal, and urethral orifices, the membrane swelling enormously. Hemorrhage occurring in the skin causes it to become raised and of a livid purple or bluish tint. The eyes seem to bulge as if about to drop from the orbital cavity. On the abdomen the hemorrhage is beneath the skin, causing raised lesions with a sharp border and a flattened top, feeling dense and firm to the touch. In the peritoneum the hemorrhages are extensive.

The constitutional symptoms in this severe form are typhoidal in character. The mind appears at ease, quietly passing into a comatose state. The countenance is pinched and sunken, and the skin is dusky and purplish. The eyes appear bloodshot and listless. The breathing is rapid and superficial. The delirium is of a quiet character, and death comes as a most welcome termination.

Through the courtesy of Dr. A. H. Doty, the following cases may be quoted. They were reported to the Health Department of New York City with a diagnosis of malignant hemorrhagic smallpox.