The eruptive stage lasts about eight days—from the third to the eleventh of the illness. The appearance of the rash is usually the signal for a remission in the fever, and in the symptoms of general constitutional disturbance ; but there is seldom a notable fall in the temperature until the eruption is fully out. If the pyrexia remain high after the papular stage is completed, the disease is severe and unmodified, or some compli cation is present. In confluent small-pox the remission is very imperfect and transient, the reduction of temperature is inconsiderable ; and whereas in a mild discrete case the patient feels almost well at this time, in the severer form of the disease the alleviation to the distress is much less complete, and even at this early stage of the illness photophobia, saliva tion, pain in deglutition, and hoarse cough may be the source of great discomfort. In an ordinary case of discrete small-pox when the eruption is fully out, the temperature, although still above the normal level, is com paratively little raised ; nervous symptoms are no longer noticed ; and except for the local inconvenience of the state of the skin, the condition of the patient is greatly improved.
When the pustular stage is reached and the process of maturation be gins (about the sixth day of the rash, eighth or ninth of the disease), the temperature rises again, and what is called " the secondary fever " begins. The intensity of this later pyrexia varies according to the severity of the attack. In mild cases it may be slight or even absent ; but in severe cases, especially in the confluent form of the fever, the temperature rises to a higher level, perhaps, than in the earlier stage ; the child is stupid or de lirious, and often wakeful at night ; his tongue is furred and often dry ; his pulse gets quick and feeble ; his weakness is great ; and tremors, subsultus tendinum, with other symptoms of prostration, may be noticed. In not a few cases the disease has. ended in death before the period of secondary fever is reached. In the severe cases, if the patient do not die at this time from the violence of the disease, he is very apt to succumb to an in flammatory complication.
The secondary fever lasts until the maturation of the pustules is com pleted on the eleventh or twelfth day of the illness. The disease then en ters into its latest period, that of desiccation and decline. In the course of two or three days the pustules discharge their contents ; the redness and swelling of the skin subside ; the odor from the child's body becomes extremely offensive ; and yellowish-brown, thick scabs form from caking of the purulent secretion. Nearly at the same time—unless some febrile complication arise—the pyrexia begins to subside and the tongue to clean ; the painful symptoms connected with the mucous membranes disappear in the order in which they occurred ; the pulse slackens and the appetite im proves. The falling of the crusts is accompanied by some itching of the
skin. It takes place earlier in some parts than in others, and is delayed in proportion to the amount of ulceration which is present in the cutis. If this be great, the scabs become very thick and horny, and remain attached for a long time. Sometimes successive crops of scab are thrown off before the underlying surface has become healthy. The size of the fallen crusts is also subject to variety. If the pustules have been thickly set, the edges of the neighbouring scabs may unite, so that large pieces of dark brown, horny crust become detached at the same time. The separation of the scabs is often very slow on the scalp in children ; and often new crusts continue to form after old ones have been removed with wearisome persist ence. When the crusts have all fallen, the surface is left mottled with slightly elevated red spots, which eventually either disappear leaving no trace, or, if there has been ulceration, change into depressed white deep scars with inverted edges and an irregular floor.
Complications. —In severe cases, even if the child survive until the pe riod of the secondary fever, he is very apt at that time to be carried off by some one of the many complications which are liable to come on in the third or fourth week of the illness. The severe forms of small-pox, espe cially the confluent variety, are most commonly attended by these acci dents ; but they may also follow the milder forms of the disease.
Boils are very frequently seen ; and the intense inflammation of the cutis which occurs in the severer attacks may pass into partial mortification of the tissues. Spots of gangrene are thus formed in the skin,, and the same thing may be observed in the genitals. If a scrofulous child who suffers from vaginitis be attacked by small-pox, there is great danger lest gangrene of the vulva supervene. Such cases, it need not be said, are very dangerous.
Abscesses and acute cellulitis may occur. Deep-seated collections of matter often form and may reach a considerable size. They are slow to heal. Sometimes the joints are the seat of suppuration.
Erysipelas and pywatia are common in small-pox hospitals—less com mon in private houses, although they may be met with anywhere when the disease is confluent or very severe. The latter of the two sometimes suc ceeds to the former and is very fatal.