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'Che Conservative.
though less frequently than is the rule ,
with pain in the back. With almost
mathematical precision an eruption ap
peared on the end of the third or begin
ning of the fourth day , and was nearly
always observed first on the face. It
then spread over the body , to bo most
marked , after the face , on the fingers.
It showed itself also , distinctly , upon
the palms of the hands and soles of the
feet.
4. The eruption presented the appear
ance of smallpox. It was papular , to
become later vesicular and then pustu
lar. It was at times and in places um-
bilicated ; it was in severer cases con
fluent. The eruption dried up to form
crusts and leave pits , which were quite
pronounced in the severe case described
as having occurred in June. As I saw
the cases twelve to fourteen days after
its first appearance , the eruption pre
sented the condition characteristic of
this period in the history of smallpox.
5. The eruption ran a characteristic
course also over the body. It appeared
on the face , to extend gradually over the
trunk and be most distinct , next to the
face , on the fingers and feet. As the
eruption became vesicular on the ex
tremities and trunk it became pustular
on the face , and as it became pustular on
the body it dried up on the face. The
eruption showed , therefore , its regular
advance and the various phases in regu
lar sequence characteristic of smallpox.
The question arose at once , as it al
ways arises under similar circumstances ,
as to what other disease might bo mis
taken for variola. The opinion had
been expressed in. some quarters that
this disease was an aggravated chicken-
pox. Against this view speak the facts
that :
1. The disease was preceded by pro
dromes , chill , fever , headache , dizzi
ness , nausea , etc. , the eruption appear-
t ing on the third day , whereas in chiokou-
r < i pox the disease , without prodrome , is an
nounced at once by the eruption on the
first day.
3. The eruption of chicken-pox ap
pears as vesicles containing a clear fluid ,
looking in many cases like drops of
water. Only individual cases may be
come pustular. In this case most of the
vesicles became pustules , and in some of
the cases the pustules became confluent.
8. The eruption of varicella appears ,
as a rule , upon the neck and chest
( though sometimes upon the face ) to the
number of ton to fifty , or sometimes , but
very rarely , as many as two hundred or
more over the whole body , and always
irregularly , never uniformly. It is only
an individual case which shows as many
spots as two hundred in an epidemic.
Most of the cases show only ton or
twelve spots , one or two of which may
become pustular and only one or a very
fdw of which may leave a scar. There
is never any such accumulation on the
fingers as was manifest in this epidemic ,
and there is never the uniform spread
from the face downwards as in a real
variola.
4. The vesicles of chicken-pox vary
in size from a pin-head to a pea , excep
tionally from a dime to a dollar. The
large vesicles are always lax , never full
and distended. The vesicles and pus
tules in this epidemic were remarkably
uniform in size , except , of course ,
where they had become confluent. The
non-umbilicated sacs were fully dis
tended.
5. The constitutional symptoms , ma
laise , headache , fever of varicella , slight
in degree , disappear with the disappear
ance of the eruption. They last thus ,
as a rule , buf a few hours , and rarely
extend to a few days. These patients
whom I saw wore now convalescent , but
had been ill for the greater part of two
weeks.
( i. A point iipon which I lay great
stress chicken-pox is a disease of child
hood , smallpox of all ages. Chickenpox -
pox is rare after ten , and is extraordi
narily rare after the age of twelve.
In drawing these lines I am not un
mindful of the fact that certain author
ities still obstinately adhere to the belief
that varicella is only an attenuated or
hybrid variety of variola.
Measles , which some of the people
hold this disease to be , could not bo
considered for a moment. There was
no preceding coryza. The eruption of
measles shows neither vesicles , pustules
nor scars. There could , of course , bo
no question of drug eruption , syphilis
or herpes assuming such epidemic pro
portions.
The diagnosis was facilitated by the
fact of the duration of the disease
that is , by the period at the time I
.saw it. It is always more difficult at
the start. Individual or isolated cases
require at the beginning the considera
tion of many diseases. Thus Manson
says of his experience in a London hos
pital that upwards of twenty diseases
have been mistaken in the last few
years in the early stages of the disease as
smallpox , and the patients have been
sent as having smallpox to the small
pox hospital.
I had the same good fortune in being
able to recognize , in the same way , I
might say at a glance , a genuine case
of smallpox at Huntingtou , W. Va. , a
few years ago , where there had been
previous to my visit some difference of
opinion among the physicians. The
town was hero also in a state of consid
erable excitement , and watchmen had
been placed at the doors of the infected
houses. But by the time I saw the case
the whole body was covered with vesi
cles and pustules , some of which wore
umbilicated and some of which had be
come qonfluont on the extremities , bo
that the diagnosis was easy enough.
The diagnosis was made easier in
these cases also by the fact that the in
dividuals had not been vaccinated.
They therefore had not the protection
which is given by vaccination ; and , fur
ther , the cases did not show the anomal
ous forms which are seen after vaccina
tion , in that , as Morrow tells us , "vac
cination denaturalizes deranges
smallpox , - j >
ranges the original order of the di&oaso '
and effaces its most distinctive features. "
I suggested to the citizens the neces
sity of thorough vaccination of the en
tire community , assuring them that the *
disease was mild , but that it would be
come dangerous with accumulated cases ,
and that with systematic vaccination no
now cases would occur after the end of
a week. I learned afterwards that the
health officer had reached the same con
clusion , and had ordered a house-to-
house vaccination after subdivision of
the town into sections. In reaching
this opinion wo wore both of us sup
ported by a majority of the local phy
sicians. I would lay stress iipon this
point , because in the reports which have
been made in the newspapers and in one
of our medical journals the impression
was made that the local physicians had
diagnosticated the disease as chicken-
pox. Now the truth is , I heard no such
opinion expressed. On the contrary ,
the disease was regarded as variola , and
so positively had this opinion been expressed -
pressed in one case that the name "small
pox" had been tacked up in big letters
on a house , about which a rope had
been drawn and at which an officer was
stationed to secure isolation. This case ,
one of those which I have reported , was
of exactly the same character as the
rest. The physicians whom I saw had
fully appreciated the character of the
disease. Thus , wo were able to impress
upon the citizens the necessity of imme
diate vaccination of all unvaccinated
members of the place , and to give them
the assurance that the epidemic would
cease so soon as general vaccination was
secured.
While there was no great objection
to the isolation of cases , such confine
ment seemed to mo entirely superfluous.
It entailed hardship and harm also upon
a great many unaffected members of
these various households. I took occa
sion to repeat what I have said before ,
that the maintenance of a pest-house for
the isolation of cases of smallpox is a
superfluous expensQ , and is a reflection
upon the intelligence of a community.
In fact , in civilized centres cases of
smallpox have become so rare that the
pest-houses are more profitably used for
the separation and treatment of cases of
consumption. In protection against
smallpox it is only necessary to practise
vaccination , for vaccinia is smallpox , the
smallpox of the cow. Vaccination pro
tects exactly as does a previous attack of
smallpox. It is the variola maxiine
benigna , and , although it is severe
enough to secure protection for a long
time , it is unfortunately not severe
enough to secure protection for all time , * "
so that re-vaccination becomes a neces
sity. It is the alphabet of our know-