THE CHARLOTTE MEDICAL JOURNAL.
their way of living. They could spend
much less than they do and save more by a
careful adaptation of vs^ays and means. In
very many instances it would be possible to
carry an endowment policy of insurance,
falling due at the age of 50 or 55, which
would go a long way towards enabling one
to give up routine practice at the time
mentioned.
But the second objection is more formid-
able. It IS the hesitancy of many men to
ask for a consultation for fear the consultant
will retain the patient. It is natural for
the patient or his relatives to consider the
"professor" who is called in, to have more
skill than the regular attendant, and there-
fore the tendency is to call him in on the
next occasion. Instances have occurred in
which the consultant has acted in such a
way as to arouse the just suspecion of the
regular attendant. This state of affairs,
more than anything else, perhaps, has pre-
vented many consultations, and has been
productive of much bad feeling and hard-
ships.
Of course this obsticle may be overcome
by a righteous observance of the code of
ethics, which is based on the Golden- Rule.
No physician, who is called in consultation,
should allow himself to be persuaded to
attend that family, or should he visit them
socially if thus introduced. Confidence
being thus established between physicians
consultations will become more usual and
mutual benefit will result.
In the last analysis, however, the actions
of physicians in this and all professional
relations, are matters of character and
character is a matter of religion.
SmaH Pox and Vaccination.
At the present time we are all interested
m small pox and vaccination.
A very exhaustive editorial in the Medi-
cal and Surgical Bulletin is worth reading.
By consulting the best medical literature
in regard to this subjest, we have reason to
believe that small-pox was first developed
in the earliest ages of which the human
family has any record. The disease proba-
bly originated in China, India and the ad-
jacent countries of the Asiatic continent,
then spreading over Europe and America
along the lines of commerce and popula-
tion.
Perhaps the earliest account of its rava-
ges can be traced to the writers of the latter
half of the sixth century, but it was not
until the ninth century that it was accurate-
ly described by an Arabian physician of
Bagdad. His description, however, clearly
set forth the views of an Egyptian physi-
cian, named Ahron, who wrote in the sixth
century.
During the tenth and eleventh centuries
the remarkable political and social changes
in Europe resulting in the Crusades, con-
tributed" largely to the spread of the disease
and to the occurrence later of decimating
epidemics, which became veritable scourges,
sometimes destroying the entire population
of the largest cities.
Small-pox is believed to have been intro-
duced into America by the Spaniards early
in the sixteenth century.
As to the primary origin of this disease,
probably the most virulent of all the con-
tagia in its effect upon the unprotected sub-
ject, we have no historical knowledge; the
first cases of the disease must, therefore, be
classed with those of spontaneous cow-pox.
At the present time it is regarded as be-
ing directly or indirectly transmitted from
individuals affected with a similar disease,
but as yet no bacteria or germ has been
proven to be the cause of the disease. It is
conveyed in the secretions and excretions
of the body. The pus of the pustule is the
most fertile source ; the dust coming from
the dried pus scales is the more common
medium of its distribution, it being inhaled,
therefore the lungs are the most frequent
avenue of inoculation.
Small-pox is an acute, febrile, contagious
and systemic afTection, preceded b/ an in-
cubation period, and especially character-
ized by an eruption wiiich passes through
the successive stages of papule, vesicle,
pustule, desiccation and desquamation, and
terminating either fatally or by complete
recovery, with or without sequelaa in the
form of multiple, circumscribed and super-
ficial cicatrices.
The contagion is very tenacious, some-
times remaining dormant for months in
clothing or hangings. It affects all ages ;
even the foetus in utero may acquire it from
the mother. No sex or race is exempt.
The negro is particularly prone to the dis-
ease.
Small-pox is more prevalent during the
winter months. One attack as a rule con-
fers immunity.
The essential morbid anatomy of small-
pox is that of the eruption in all its various
stages and modificatio.is. The pustule be-
gins in the rete mucosum, the center being
a focus of coagulation necrosis ; the reticu-
lar spaces about it are filled with serum,
lucocytes and fibrin ferment. If the process
does not go deeper recovery takes place
without pitting. But in the more severe
cases the papillee of the true skin are in-
volved, causing a loss of tissue, and result-
ing in the formation of a scar.
THE CHARLOTTE MEDICAL JOURNAL.
Incubation is said to last from seven to
fifteen days. The patient may feel perfect-
ly well or may suffer from malaise, anor-
exia, languor, insomnia and allied symp-
toms. If observed closely during this stage,
the face will be seen to present a peculiar
pallor resembling sallowness.
The symptoms which characterize the
stage of invasion, which usually lasts three
days, and is the time between incubation
and the appearance of the first cutaneous
lesion on the surface, or chilliness, accom-
panied by a sensation of creeping, usually
intense headache, violent aching pain in the
back, the temperature rises rapidly to 103
deg. or 105 deg. F., the pulse is rapid, hard
and strong at this stage, and in children
delirium may be present.
The prodromal rash occurs about the
second day, and is a diffuse, scarlatinous
rash, dark red in color, paling under pres-
sure, but does not leave a white line if the
finger nail is drawn quickly over the skin,
as in the scarlatinal rash. It is usually con-
fined to the abdomen, inner surface of the
thighs, or the lateral region of the thorax
and axilla.
Upon the subsidence of the stage of in-
vasion, the exanthem of the disease, as a
rule, appears. This is usually on the fourth
day. The distinctive eruption first appears
in the shape of small red spots, first on the
forehead and wrists, but becoming general
in the first twenty-four hours. The erup-
tion is pin-head size, firm, conical, discrete,
coherent or confluent reddish papules. At
this stage it resembles very much the rash
of measles, but in another twenty-four hours
papules have become very much harder, and
feel not unlike shot imbedded" in the skm.
When the eruption appears the fever
falls, and the patient feels comfortable.
The pock mark is usually mature by the
sixth day of the eruption. It is pea-sized
and globular in shape, and is umbilicated,
this being the most characteristic feature of
the eruption. At first it is filled with clear
or slightly turbid serum. By the eighth
day it becomes pustular and the umbilica-
tion disappears.
Upon the appearance of the pustule the
secondary or suppurative fever begins, rang-
ing between loi deg. and 105 deg. F., and
is accompanied by the usual signs of fever.
During its continuance, from the eighth or
ninth to the eleventh or twelfth day of the
disease, the patient is in a deplorable and
critical condition. Pain, aue to the tension
in the inflamed parts, is severe, and the pa-
tient usually lies conscious, but in a stolid
apathy, listlessly accepting the services of
his attendant. In more severe cases deli-
rium of a low or high grade may be present.
On the eleventh or twelfth day of the
disease the pustules become dry. By the
fourteenth day they are converted into
crusts, which drop off, leaving in mild cases
only a simple discoloration. In severe cases
an ulcer is left which, when healed, leaves
a pit.
The most severe variety of small-pox is
the hemorrhagic form, of which there are
two varieties, the purpura variolosa and the
variola hamorrhagica pustulosa. Of these
forms we see very little, as the patient dies
in from two to six days, sometimes before
the eruption makes its appearance.
A third variety is varioloid, which is
small-pox modified by vaccination or a pre-
vious attack of small-pox. All symptoms
are rendered very much milder.
We now come to a very important sub-
ject, one that should be of interest to every
practitioner, that of vaccination for the pre-
vention of small-pox. The local and gen-
eral symptoms resulting from the introduc-
tion into the blood of man of the contents
of the vesicle of kine-pox, or small-pox as
occurring in cattle, is called vaccinia, or
vaccine disease.
The. communication of small-pox to pre-
vent the same reaches back into antiquity.
In the Sanscrit Vedas we find mention of
the fact that the Brahmins employed this
method for the prevention of small-pox.
They employed pus procured from small-
pox vesicles a year previous. Their method
of inoculation was not dissimilar to our
method of the present day. They first
rubbed the place selected for operation
until the skin was red, then made several
scratches with a sharp instrument, and laid
upon the freshly prepared place cotton
soaked in the variolus pus, moistened with
water from the sacred Ganges. Careful
hygienic regulations were also carried out.
Among the Chinese "pock-sowing" was
practiced. As far back as ten centuries
before Christ the Celestials saturated pled-
gets of cotton with variolous pus and
introduced them into the nasal cavities of
children.
The Circassians and Arabians used need-
les for inoculation. In some parts of
Northern Africa inoculation by means of
incisions between the fingers was practiced.
And among some of the negroes the inocul-
ation was done in or upon the nose.
In 1 7 14 Timoni of Constantinople re-
ported that the custom had long been
naturalized in that city, and was practiced
by old women, instructed in the art, who
regarded it as a revelation of Saint Mary.
In 172 1 Lady Mary Wortley Montagu,
wife of the English embassador to Turkey,
returned to England, being the first to in-
THE CHARLOTTE MEDICAL JOURNAL.
troduce the practice there. Her son was
inoculated in Constantinople by Maitland,
and later her daughter was also inoculated.
At this time Maitland experimented upon
criminals. It proved very satisfactory, and
after this the procedure was looked upon
with more favor. The Prince of Wales and
his sisters were inoculated by Mead, and
the practice of vaccination was speedily
adopted in America as well as in England.
It met with general favor in Germany, and
a little later was practiced in France.
The first inoculation with cow-pox was
performed in 1774 by an English farmer of
Gloucester, named Benjamin Jesty. It
seems to have been a common practice,
especially among the dairy people.
However, the man that subjected the
popular impression in question to the test
of scientific investigation, proved the truth
and demonstrated its value to the world
was Edward Jenner, an English country
physician. He performed the first vaccina-
tion in 1796, upon a boy, using matter from
the hand of a milkmaid, who had been pre-
viously infected by cow-pox.
The first vaccination done in the United
States was performed by Dr. Waterhouse
of Harvard, in 1800, upon four of his own
children. .
The transmission of humanized virus
through the system of the cow, and its
subsequent employment in vaccination of
human beings, was first practiced by Troja
(1747-1827) of Naples. At the present
time it is almost the universal practice to
use the lymph from the cow. The chief
reason for using animal Ivmph is the fact
that all danger of communicating other
affections, especially syphilis, is avoided,
and it is also believed that protection is
more certainly assured. In this country
the more usual method of preparing the
lymph for use is to allow it ts dry on ivory
points or quills, or it is collected in capil-
larytubes and sealed.
After vaccination a slight redness ap-
pears, but rapidly subsides. About the
third day a red elevation occurs, developing
into an umbilicated vesicle filled with a
transparent- viscid fluid, surrounded by a
red areola.
By the six day the vesicle presents a
shiny, silvery appearance, and by the
tenth day the pock has reached its full
development, being umbilicated, as in
genuine small-pox. Itching is intense, and
in adults it produces an almost irresistable
desire to scratch, while in infants it pro-
duces fretfulness.
The disease begins to decline on the
eleventh or twelfth day, and by the four-
teenth day tl.e vesicle is covered by a dry.
brown scab, which drops off about the
twenty-fifth day, leaving a pitted scar,
very distinct at first, but gradually be-
coming paler than the surrounding tissue.
That vaccination really does protect a-
gainst small-pox observation has taught the
whole civilized world. No one need be
left in the dark in regard to thfs point, as
the statistics are so plain it is impossible to
mistake their true meaning.
In Sweden the average number of deaths
from small-pox per annum, per million in-
habitants, was, before the introduction of
vaccination, 1,973: during the period of op-
tional vaccination, 479. After vaccination
was made compulsory this frightful death
rate declined to 189 per 1,000,000.
During forty-two years of duty at the
London Small-pox Hospital Dr. Marson
has never observed a single case of small-
pox in the officers and attendants of the
hospital, who are compelled to be revacci-
nated when they enter the service, and who
are constantly exposed to the infection.
In the Bavarian army, where vaccination
was compulsory, there was not a single
death from small-pox nor a case of unmodi-
fied small-pox from 1843 ^^ ^^57-
In the State of Michigan, by making a
comparison between the five years preceding
the establishment of the State Board of
Health with the fourteen years (1874
to 1887) since its existence, allowing for in-
crease in population, shows the death rate
of small-pox has been reduced 6.63 persons
per year 100,000 inhabitants. Vaccination
in Michigan is not compulsory, but vacci-
nation is done without cost, being paid for
by the city, village or township, as the case
may be.
In New York City much the same plan
has been carried out since 1876. Before
this date the deaths from small-pox aver-
aged 59.57 per 100,000 per year. Since
this date they have averaged 8.38 per 100,
000 per year, and this average is yearly be-
ing reduced.
From the foregoing facts it is not hard to
see that with compulsory vaccination it
would be only a short time before small-pox
would be a rare disease, but unless such
measures are universally adopted and en-
forced by suitable legal enactments the di-
sease must from time to time threaten the
lives of our citszens, and the medical pro-
fession will have no other alternative than
to fight it with the best means we have at
hand.
When small-pox appears in a community
the chief aim should be to prevent its spread-
ing. This is best accomplished by isola-
tion of the patient. This can be done in
only one way, and that is by removing the
302
THE CHARLOTTE MEDICAL JOURNAL.
patient to a hospital especially appointed
for such cases. In every city a permanent,
well-equipped institution of this kind is an
absolute necessity. It should be located re-
mote from the thickly settled parts, but at
the same time it should be easy and ready
of access.
The hospital should be provided with
closed ambulances for the transportation of
patients. Private or public conveyances
should not be used for this purpose.
When a case of small-pox occurs in a fami-
ly, all the members of the family should be
vaccinated at once, and the patient remov-
ed to the hospital. All persons known to
have been exposed to the disease should be
quarantined for fourteen days. If the pa-
tient is to be treated at home he should be
isolated as much as possible. Usually a
room on the top floor is preferable, and no
one should be admitted except the nurse or
attendant, who has been previously vacci-
nated. The clothing of the attendant
should be of such material as can be readily
boiled. He should not come in contact
with any one while engaged with the case,
and when leaving he should bathe thorough-
ly and don new clothes. The physician
should take every precaution to prevent be-
ing the means of communicating the conta-
gion.
Another means of preventing the spread
of small-pox is to apprise the public of the
particular locality where the disease exists.
Thorough disinfection of all articles used
about the small-pox case is a highly impor-
tant prophylactic measure, and should be
scrupulously carried out.
Bodies of persons who have died of
small-pox should be wrapped in a sheet
saturated with corrosive sublimate i to 500,
or with a solution of chloride of lime, and
be buried at once.
After the sick chamber has been vacated
by the patient, either by recovery or death,
every article of no value should be burned,
the others should be rigidly disinfected, and
the entire house well fumigated. One can-
not be too careful in trying to prevent the
spread of this dreaded disease.
Fresh Air and the Death-Rate of the
Plague.
In view of the possibility that the plague
may become a well-known disease in Europe
and America before many years have passed,
some figures published by Weir, one uf the
officers of the Sanitary Service of Bomba}^
are full of interest, says the Medical News.
He hit upon the idea that the mortality
was greater among patients who live on
the ground floor than among those living in
higher stories. By establishing cases ac-
cording to the story in which they occurred
he found a striking decrease in the death-
rate with each additional flight of stairs.
Thus the mortality among patients living
on the ground floor was 84.7 per cent. For
each successive story the mortality was as
follows. First, 75.5 percent.; second, 67.3
per cent. ; third, 59.7 per cent. ; fourth,
58.1 per cent. ; fifth, 45.4 percent. Build-
ings in Bombay are not so constructed as to
permit an investigator to extend his obser-
vations above the fifth story. Proceeding,
however, along the same line, the mortality
in the tenth story would be 22.7 percent. ;
in the fifteenth, 11.4 per cent., and in the
twentieth story, 5.7 per cent.
Who will dare to guess the amount of
rent which the owner of the tallest build-
ing will receive for his top story, if the
plague reaches Chicago !
In the densest portion of Bombay the
houses are built on narrow streets and are
surrounded by broad, low verandas, which
permit scarcely any air or light to penetrate
into the lower stories of the central part of
buildings. This decreased mortality for the
residents of upper stories held good not
only in such houses, but also in better built
ones. Moreover, people living in separate
houses, as in the country districts, recover
from the plague in a far greater proportion
than those living in close quarters. The
Indian government is considering the ad-
visability of tearing down and rebuildingf
the houses in the worst district of Bombay,
so that the tenants shall have a reasonable
amount of light and air. If the new build-
ings are to be put on a paying basis, how-
ever, the rent necessary charged will be en-
tirely beyond the reach of the inhabitants
of the present structures which they aim to
replace.
In this connection may also be mentioned
the plan proposed by Pierre Apery of Con-
stantinople to rid an infected ship of rats.
It is a well-known fact that rats are capa-
ble of spreading the plague ; hence to fumi-
gate a ship and leave a horde of rats in its
hold is a comparatively useless procedure.
Apery's plan is to tow the ship 'a mile or
more from land. Cheese and fragments of
food are scattered in the most accessible
portion of the hold in order to bring to-
gether all the rats. A generator of car-
bonic acid gas is then set to work to form
enough gas to displace the air in the lower
portion of the ship. Owing to the weight
of this gas it sinks slowly to the botton and
gradually displaces all the air. As a mix-
ture of one part carbonic acid gas and two
parts of air is sufticient to suffocate an ani-
mal it will not be long before the diffusion
THE CHARLOTTE MEDICAL JOURNAL.
303
of the gas will kill all the rats. As the gas
has no unpleasant odor or taste animals are
not frightened by it and even if a few should
jump overboard the distance from land is
so great that they will be drowned. The
upper level of the gas may be determined
by lowering a lighted candle into the hold.
When the gas is reached the candle will be
extinguished. When the rats have been
killed the carbonic acid gas may be pumped
out of the ship. The bodies of the vermin
are then collected, disinfected, and destroy-
ed. This method of procedure is simple,
easily carried out, and inexpensive in com-
parison with the effects it accomplishes.
Open Air and Tuberculosis.
The open air treatment of consumption
is up for consideration very frequently
now. In commenting on the discussion by
the Royal Medical and Chirurgical Society
of London of the open air treatment of tu-
berculosis, the Hospital says that the gen-
eral result may not unfairly be summed up
by saying that there is no "open air" treat-
ment in the popular sense of the words.
Tuberculosis depends on the invasion of
the body by a bacillus, which flourishes
chiefly in badly-lighted and badly aerated
localities, and languishes, comparatively
speaking, when exposed to fresh air and
sunshine. These agencies, although detri-
mental to the invaders, are eminently ad-
vantageous to the invaded, and their proper
application will suffice, in a large propor-
tion of cases seen at a sufficiently early
stage, to turn a nearly balanced scale in
favor of the forces of resistance. In other
words, the bacilli will die out instead of the
patient, and, after the lapse of a period,
measurable more often by years than by
months, the effects of the invasion will be
so far recovered from as to permit a resump-
tion of the occupations, and, to some ex-
tent, even of the freedoms, of health.
It is obvious that the conditions thus laid
down are beyond the reach of all but the
comparatively wealthy, and that the neces-
sity which would generally compel members
of the industrial classes to resume remuner-
ative occupations as soon as their strength
would permit must in every case present a
formidable impediment to the real and per-
manent usefulness of special "sanatoria"
maintained by the charitable as hospitals
for the tuberculous poor. It is less obvious,
but is rendered none the less clear by the
discussion, that the rich will not be likely
to derive benefit from resort to so-called
"sanatoria" in which the medical supervi-
sion and control are insufficienc. or in which
inmates are allowed to please themselves
with regard to matters on which it is
necessary, if good is to be done, that they
should submit implicitly to the directions
of the physician. The temperature to which
they should be exposed, the kind and
amount of food which they should consume,
the extent to which they should mix social-
ly with others, and the degree in which
they should be kept at rest or permitted to
be active, are all questions which require
individual determination for each patient ;
and in respect of which the laxity of a
"dividend-earning" establishment would
frequently be fatal to every prospect of
improvement.
These, unfortunately, are among the very
points as to which silly and obstinate in-
mates would persist, we will not say in
judging for themselves, but in acting on
their own inclinations without the pre-
liminary of a judgment which it would be
beyond their power to form. The discus-
sion further afforded interesting evidence,
in the speeches of Pearce Gould and of the
President, how much earlier the value of
fresh air in tuberculous affections was re-
cognised by surgeons than by physicians ;
and reminded us of the way in which the
late Mr. Solly, when St. Thomas's Hospital
was in occupation of temporary premises in
which the separation of the medical from the
surgical wards was incomplete, used to
complain of the difficulty of securing pro-
per ventilation for his cases. "The physi-
cians," he said, "think foul air is a specific