600 ACUTE INFECTIOUS DISEASES. 



and the highest fever and most severe disturbances usually precede 

 confluent small-pox. But this is not always the case; sometimes a 

 Bevere prodromal stage is followed by a scanty eruption; in other 

 cases, a very mild prodromal stage precedes a confluent eruption. 

 Deviations in the duration of the prodromal stage are rarely observed, 

 and still more rarely it is entirely absent, and the eruption is the first 

 symptom. 



The second stage, stadium eruptionis, almost always begins with 

 the appearance of the first papules in the third exacerbation of the 

 fever. If the eruption be very copious, the red points lie close to- 

 gether, and unite at some places, as they do in measles, or by a general 

 confluence they cause a regular redness, and granular swelling of the 

 face ; if the eruption be scanty, the different nodules remain isolated, 

 and are separated by more or less extensive patches of normal skin. 

 The next day the eruption usually spreads from the face to the neck, 

 breast, and back, and on the third day to the extremities. The num- 

 ber of papules on the body and extremities is proportionately far less 

 than on the face ; so that, even when the disease is confluent on the 

 face, the pustules on the body and extremities usually remain discrete, 

 or at most would be called variolae cohaerentes. The points gradually 

 become large, blunt conical nodules ; the second or third day these 

 change to vesicles, and the third or fourth to pustules, the contents 

 becoming cloudy and purulent. The pocks appear late on the extrem- 

 ities ; they also develop late ; on the face, the papules have become 

 larger, and changed into vesicles, or their contents have become 

 cloudy when the first nodules appear on the extremities. The erup- 

 tion on the mucous membrane begins at the same time it does on the 

 skin ; but we do not generally notice it till later, as it at first causes 

 little trouble. The pocks in the mouth induce increased flow of saliva ; 

 those in the pharynx, difficulty of swallowing ; those in the air-passages, 

 hoarseness and cough ; those on the conjunctiva, lachrymation and pho- 

 tophobia. The fever, the severe pains in the sacral and lumbar re- 

 gions, and the constitutional disturbance, which attain their height 

 toward the end of the prodromal stage, always remit when the erup- 

 tion icomes out, decrease still more as it extends to the body and 

 limbs, and toward the end of the eruptive stage the patient usually 

 feels quite well. He is then encouraged because he thinks he has 

 passed through the worst. A few years since, a patient with conflu- 

 ent small-pox presented himself at my clinic, who, after lying in bed 

 lor three days at Esslingen, with severe fever, had walked the five 

 miles from Esslingen to Tubingen without difficulty. In confluent 

 small-pox the eruptive stage is usually shorter, the exanthema spreads 

 :>ver the l>ody more rapidly, the contents of the pocks become purulent 



