1488 



COSMOPOLITAN FEVERS 



the face, arms, back of the wrists and hands, and, later, on the trunk and 

 limbs ; and at the same time on the mucosa of the mouth, nose, and throat, and 

 more rarely on the vulva, vagina, and rectum . Generally it is more marked on 

 the extensor surfaces of the limbs than on the flexor surfaces, and is often most 

 marked in areas where there has been pressure. The papules are' bright red 

 in colour, but this may not be very evident in the dark skin, 2 to 3 millimetres 

 in diameter, and have a hard, shotty feeling. As the rash comes out the 

 temperature falls, and the initial symptoms improve. On the fifth to sixth 

 day the papules become umbilicated vesicles, which turn into pustules when 

 the umbilication disappears, and a surrounding areola of injection appears. 

 During the maturation of the pustules the secondary fever appears, and the 

 eyelids become swollen and closed. In the discrete form the fever disappears 

 by the tenth to eleventh day, and convalescence sets in. 



The confluent type of smallpox is more severe than in the above, and presents 

 much less difficulty in its recognition, and need not be described. 



Varieties. — There are, however, two varieties which are of im^portance in 

 the tropics — viz., variola haemorrhagica and varioloid — and these must be 

 mentioned at greater length. 



Fig. 679. — Smallfox. 

 (From a photograph by Balfour.) 



Variola Haemorrhagica. — Haemorrhagic smallpox is, or was, by no means 

 rare in Africa, and is met with in Asia, though by no means so frequently. 



There are two varieties: Purpura variolosa and Variola hcsrKorrhagica 

 pustulosa. 



Purpura Variolosa. — This variety commences with the same symptoms as 

 ordinary smallpox, but they are much more severe. The fever is not con- 

 siderable, and may be below 100° F., but the pains in the body, especially the 

 backache, is very severe, and the vomiting may be very persistent and asso- 

 ciated with severe epigastric pain. The pulse and the respirations are both 

 much increased in frequency. At the end of the second or the beginning of 

 the third day an erythematous rash appears in some part of the body, very 

 often in the groins and flexure of the joints, but it may be absent, or it may 

 extend and become general. At the same time and in the same places appear 

 red and purple petechise, and about the same time subconjunctival hemorrhages 

 in one or both eyes, while purple spots appear on the forehead, eyelids, and 

 face, and ecchymotic areas in various parts of the skin, and also on the tongue 

 and pharynx. The patient now becomes pale and anagpiic, except where the 



