ACUTE INFECTIOUS DISEASES. 



tion of the skin, the mere intense is the fever; the dermatitis and the 

 fever attain their height together, and the decrease and disappearance 

 of the eruption go hand in hand with the decrease and subsidence of 

 the suppurative fever. In many cases the suppurative fever becomes 

 dangerous, because the bodily temperature rises so high as to induce 

 the symptoms of adynamia and fatal paralysis (asthenic, nervous, 

 typhous small-pox). In such cases, just as in asthenic measles and 

 scarlatina, the symptoms of adynamia are not unfrequently accom- 

 panied by those of an acute haemorrhagic diathesis ; the contents of 

 the pock become bloody, and petechiae appear between the pocks. 

 Occasional!}^ also, there is profuse epistaxis, more rarely haematem- 

 esis, bronchorrhagia, or metrorrhagia (haemorrhagic or septic small- 

 pox). In some rare cases, during the excessive adynamia of the sup- 

 purative stage, the inflammation of the skin increases to partial morti- 

 fication of the inflamed tissue ; gangrene of the skin results, and the 

 pocks fill with a discolored ichor. Such patients almost always die 

 early with the symptoms of excessive prostration (gangrenous small- 

 pox). Besides the adynamia induced by the high fever, and besides the 

 occurrence of a haemorrhagic diathesis or of cutaneous gangrene, which 

 favor the threatening paralysis, the suppurative stage is especially 

 dangerous on account of the localization of the variolous process on 

 the serous membranes and in the parenchymatous organs, which occurs 

 most frequently during this stage, and from the frequent increase of 

 the affection of the mucous membrane to croupous and diphtheritic in- 

 flammations. Thus, in many cases, increased dyspnoea, sharp pain in 

 the side, tormenting cough, bloody expectoration, as well as the phys- 

 ical signs of condensation of the lung, show the occurrence of pneu- 

 monia. In other cases the subjective and objective signs of pleurisy 

 accompany the above symptoms of the stage of maturation. The 

 symptoms of the disease are also variously modified by the occurrence 

 of suppuration of the joints, suppurative periostitis, subcutaneous, and 

 intermuscular abscesses, inflammation and suppuration of the lym- 

 phatic glands, panophthalmitis which begins as a hypopion and may 

 be readily overlooked, as well as by the symptoms of pericarditis, 

 meningitis, or of pyaemia from absorption of ichor. It is chiefly in 

 confluent small-pox that the fever assumes an asthenic character during 

 the suppurative stage, and that unusually dangerous local diseases of 

 the internal organs occur. Moreover, in confluent small-pox, during 

 the stage of maturation, the eruption on the mucous membrane of the 

 pharynx and larynx readily becomes complicated with croupous exuda- 

 tion and oedema of the glottis. Hence, this form of the disease is 

 correctly considered very malignant ; and confluent small-pox is often 

 regarded as identical with malignant. 



