New York (State). Dept. of Health.

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Diseases With Which Smallpox is Confounded.

I will only mention some which come to our notice.

Measles. — This disease has an initial fever of similar duration
and eruption which at the beginning looks papular ; but the fever
increases rather than ends with the appearance of the eruption,
tind is always attended with coryza; the circumscribed blotches



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State Department op Hbalo^h. 741

of measles never have any suggestion of the hard papule which
soon forms in smallpox.

Erythema Mnltoform. — This may have an irregular fever prior
to eruption, but the dull colored blotches on the back of the hands
can only a few of them have anything suggestive of the bright
red macule of smallpox. In fact, I never knew of but one case
where these diseases were confounded.

Imfetigo centaposia is a name frequently given to an outbreak
of smallpox. While a disease of childhood, it, or what is prac-
tically it, is seen of late much upon the faces of adult men who
contract it in barbershops. But the flat vesico-postules scattered
over the face soon dry up to their yellow superficial crusts, and
have almost nothing to suggest the pock of smallpox to anyone
familiar with them.

Scabies. — The names of Cuban or other itch have been con-
stantly given to mild variola. Perhaps the postules appearing
on the hands and between the fingers sometimes suggest scabies ;
but scabies has always a history of itchiness, of prolonged and
indefinite duration, without fever, and the eruption is multiform,
is not seen on the face, and in fact has almost nothing about it
resembling that of smallpox.

Acne has sometimes variolaform lesions on the face; but the
history and concomitant lesions ought always to exclude it.

Poatular Syphilide. — This may sometimes be indistinguishable
from the pock of smallpox, and with an untrustworthy history
in the case of a tramp one may have to wait for developments
to make a diagnosis. A syphilitic person may take smallpox, but
generally the concomitant symptoms of syphilis may be trusted.

Chicken-pox finally, is the disease most often confounded
with smallpox. I will only repeat the points of distinction which
we have so often given.

1. Age of subject. — ^Without doubt adults have chicken-pox, but
it is so rare after the age of twenty-five that every suspected case
should be held for development.

2. Fever. — Careful inquiry will show that the initial fever has
occurred in smallpox, as already noted, and in chicken-pox it
will be lacking. One should make very careful inquiry of this.



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742 TWEXTT-FIVTH ANNUAL BBPOBT OT THS

Barring the chance occnrrmce of fever or malaise prior to the
developing of tme chicken-pox from some eztraneooB cause, there
need be no hesitation in tmsting to the initial fever of three days
in smallfiox, ending abruptly when ^uption comes, as diagnostic.

3. The lesion of smallpox is a papule. — ^The only confusion is
that Home lesions of chicken-pox by reason of tranma ( ?) possibly,
may be congested so as to resemble a papule; they will lac^ the
firm feel to touch. On the other hand, remember that on the
abdomen the lesion of smallpox may have little papular quality.
On the abdomen chicken-pox is vesicular from the very b^inning,
barring a transient macule sometimes found, and by the third
day some lesions may be found which never develop beyond the
macule.

4. Crops of leffions. — For three days lesions of all sizes and
HtagCH of development may be found in chicken-pox, and this is
much more marked than in smallpox to which I have already
referred.

5. Site of leision. — The body is the chief site of eruption in
chicken-pox ; it begins there and is most abundant there, and is,
more than any other part, on the shoulder blades part of the
back. But it comes on the mucous surfaces and palms and soles
just as in smallpox, but the contrasts of site are marked enough
to help in diagnosis between the two diseases.

6. Duration of the disease. — By the fifth day the chicken-pox
lesions will begin to dry up, some will soon scale off and nothing
but a light stain will remain. In smallpox, although the vesicle
may be ill-developed and soon dry up, the papular part of the
lesion remains and often continues ,to be appreciable for more
than three weeks. One should never be misled by apparent sub-
sidence of activity of lesion, failing to note this continued
induration.

7. Vaccination is a final test. I believe that no one who has or
has nearly had smallpox is susceptible to vaccination.

One has to count in all these elements secured by close observa-
tion, to make certain of a diagnosis.

We have so widely prevalent a mild, irregular type of smallpox
that only considei*ate scrutiny suflices. Severe, fatal smallpox



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State Department of Health. 743

may be taken from the mildest type of the disease^ and thie should
stimulate us to careful and intelligent scrutiny of every suspected
case of this disease.

Dr. Lewis — I would ask Dr. Sengstacken, of Stony Point, to
continue the discussion. .

Dr. Sengstacken :

Mb. Chairman, and Ladies and Gentlemen : I don't know
that there is very much that I can add to what Dr.
Cifrtis has said, except to say that in chicken-pox the vesicles will
always collapse if you puncture them. In smallpox they will not.
The stage of invasion as you all know, in chicken-pox is two days
before the eruption appears, and before the vesicle appears. In
smallpox, you have a vesicle on the fifth day, then the vesicles
until the ninth day, and then the pus. In chicken-pox, the vesi-
cle is either round or oblong in shape. In smallpox it is always
oval or round.

Down in Stony Point, as Dr. Curtis said, w^e have a number of
negroes that come to us broken out with what they call the
" bumps." In nearly every case we have been able to get the stage
of invasion, and they have headache and backache which lasts
four days, when the eruption comes on. The only trouble I find
is in the point of time. You have the vesicular stage, the stage
of invasion, four days, when some of them will have one or two
postules which do not vesiculate, but dry up and disappear;
and for the benefit of those here, I might give you the history of
a family that I treated last spring. There was a mother, father
and eight children, and I was called on the 10th of April and
found the mother with a high fever, backache, headache and sup-
posed she had the grip. While I was in the room I was told that
one of the daughters that had grip was covered with sores. I
saw the daughter and she was covered with postules. On the
fourth day there were about a dozen papules on the mother's
face and dried up and disappeared. The father was then taken
sick, with the same symptoms, — four days fever, headache and
backache, and he had two papules, one on the ear ( ?) and one on
the breast, w^hen they disappeared. Then a boy of ten was taken
down, and he had a well developed case of smallpox. One little
fellow of seven was sick four days, with a temperature of almost



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744 Twenty-fifth Annual Report of the

104, with headache and backache; on the fourth day he had one
papule on the forehead and one on the wrist, which dried up and
disappeared in three or four days. Two of the other children
escaped, — one of them a young man eighteen years of age, who
was vaccinated the previous February, and a daughter that came
home when the daughter was taken ill and was vaccinated as
soon as she reached the house.

Out of thirty -three cases which I have had since April 10th, last,
three were confluent, seven discreet, and ten of the abortive type.
Seventeen out of the thirty -three had never been vaccinated.

That I believe is all I can tell you, except what has already
been said.

Dr. Lewis — I wish you would all make a note of that last state-
ment of the doctor's and take it home and present it to your
boards of education.

Is Dr. Craig, the Albany health officer, present? I would like
to have him continue the discussion.

In the meantime. Dr. Johnson, the Secretary of the Depart-
ment, can fill up the time, if he will be so kind.

Dr. Johnson:

Mr. Commissioner, Ladies and Gentlemen — What I have to
say upon this subject will be somewhat in the line of what Dr.
Curtis has just stated to you, and in the line of experience. '

As many of you here present are aware, I have had the pleasure
of visiting your communities where smallpox has existed ; and I
desire to say that, oftentimes, it has not been discovered until
I visited you, and oftentimes it has existed in communities for
a period of three or four months before it was diagnosed as small-
pox, and then I may say because of more or less anxiety on
the part of relatives and friends who have thought it a very
serious case, — the existing case of chicken-pox, Cuban itch,
nigger itch, elephant itch, and other names that I cannot now
recall. Doctor Curtis has told you in regard to the different
symptoms presented in the different stages of the disease.

It is seldom that I have visited a municipality at the period
of invasion or initial stage. It is generally during the eruptive
stage; and I desire to say in this connection that, in visiting a



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State Department of Health. 745

patient; there is a great deal to be observed by inspection. I
think those of you who have had experience of this kind have
often gone into a room, and the room is somewhat darkened, with
but little light, the patient lying in bed, and you have not been
able to make a diagnosis of the disease by the appearance of
the eruption upon the patient.

I will cite measles. I think you will notice often those crescent
shaped wheels upon the face, that congestion of the eyes, which
will almost demonstrate to you what you have before you
before you have gone further, and when the light is more brilliant
you will be able to discover that it may be a case of measles.

Now, one of the first things that I generally do in a case of
this kind, where an eruptive disease exists, and it is rather
suspicious that smallpox may exist, is to discriminate as soon
as I can whether it is vasiculo sequense disease or a papulo vesi-
cular- one, and I ordinarily wash my hands and pass my hands
over the surface of the body, and soon can discriminate between
the two.

As Doctor Curtis has said, in case it is smallpox you can't
very well make a mistake in r^ard to the papular form of the
lesions. Oftentimes they are so far advanced that they have
aborted in the vesicular stage, and oftentimes you will find while
that has existed upon the face and the hands, and that portion
of the body which is exposed, if you will go a little further in
your examination, you will discover on the lower extremities
lesions in the vesicular or changing to the postular stage.

Now, I generally make it a point to make a very close examina-
tion and sit down and talk with the patient. First, I try to
discover the period of invasion,^ — ^the day that you were taken
sick; what you were doing on that day; and I write it out. The
physician in attendance is usually there, or the health officer.
I find recurrent chills, headache, backache, pains in the loins,
and sometimes nothing more observed than a cold, as the doctor
has stated; and oftentimes again they say that they have an
attack of grip.

If I can I try to get the temperature accurately, from the
physician in attendance or the health officer. I have often found
that many of those things are overlooked ; that the physician in
attendance does not get all the points that are presented, or



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746 Twenty-fifth Annual Report of the

they may be given in snch a loose way that his observations have
not been very close, and after prescribing he has gone away with
the idea that he will be called again in a few days, and he will
leave some simple remedy probably, suitable to the case. But
he is not called again in several days, and perhaps the next time
he sees the patient, he is out in the street, well, -and attending
to his accustomed duties.

In a short time other cases will follow, and they come along
with the chicken-j)ox, or whatever it may be called, for a period
of a couple of weeks or three weeks, and it will finally get into
the school; and it amounts to but very little until maybe the
teacher comes down with it, and after he has had his experi-
ence with it for a few da\*8, — oftentimes he does not find it neces-
sary to suspend his duties as a teacher, he remains in the school
and all the scholars are in attendance, and in a short time they
have an epidemic of chicken-pox in that vicinity, and the Depart-
ment is requested to send someone there, because they have a
very bad case of chicken-pox and are suspicious that it may be
smallpox. '

When making such a visitation, — I have described to you here
about how the first case was attended, — that it was overlooked;
no particular attention was paid to it, — and when I go to make an
examination perhaps in a family which has gone through three
or four weeks of it, the statement that is made to me does not
accord with the statement made to the attending physician, and
he has overlooked it by reason of the statements made to him.

It often occurs that the cases are of such a very light char-
acter that I don't wonder that many suburban physicians, those
in small municipalities, who have had very little experience in
smallpox, should know nothing about it except what they have
read upon the subject; and usually in those cases, if they are
suspicious relative to them, they make reference to their works
upon the subject, and examine the illustrations closely of typical
cases, beautifully penciled, so that they can make no mistake
in those cases which they make reference to, and will say to
themselves: "This is not a case of smallpox. It does not look
like any cases that I ever saw or that I read about." And in
that way the cases are often overlooked.



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Statb Department op Health. 747

Now, then, I may say that there la no mistake in regard to
its being, -first, papular, then vefciieuiar, and the postular. 1 have
in mind a case where I was called to see a patient with a health
officer, and there was no doubt about the diagnosis. In another
fv.::^]r T v?^':t(d vvth liin\ tho c:ise wis m extremely light that
i-eally no one could say what was the matter from his descrip-
tiuu of t':c c{i:;\\ :ind I v.allicd >virh him oiit upcm the porch, and
he said that the only thing the patient had upon his person was
a little bit of a pimj)le on the palm of the hand, over the cushion
part of the thumb, which is a very characteristic lesion of small-
pox. It was the only one he had upon his person he said, although
he tlouglit ho had had a few in his scalp.

Now, where such cases exist, of such a mild character, and the
few lesions that are exhibited, and the period of invasion scarcely
noticed by the patient, it is a very difficult matter for any man,
for a physician who has had no experience, to nmkie a diagnosis
of smallpox. ^

1 will go back and say that among those things that I give
particular attenti<m to is the period of invasion. As Dr. Curtis
said, three days is oi-dinarily and generally the period presented
of the invasion, although 1 have had persons say to me that it
is four days, and I don't know but five (gone beyond the three
days) but ordinarily it is but three days.

As I said before, as soon as vesiculation takes place, those
lesions abort.
A very marked feature in most cases, I may say here, is lesions
.in the palmer surface of the hand, and the interdigital spaces;
and sometimes they may be observed on the surface of the feet.
Frequently they aie of such a chaiactcr and the induration is so
related to the sub-adjacent tissue which is involved, that I have
seen several persons with a jack-knife attempting to cut out their
corns, which they have exhibited to me, which they thought were
corns, but were simply the result of the lesion of smallpox.

I will not talk much about chicken-pox, which it is generally
taken for, only to say this: That 1 think chicken-pox should be
quarantined; generally speaking, if chicken-pox is quarantined,
you will make no mistake about quarantining smallpox, for
ordinarily I find that it is taken for chicken-pox, and that the



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748 TWENTY-PIFTH ANNUAL BbPORT OF THE

neighbors and friends and physicians, in mild cases, are very
apt to make a diagnosis of chicken-pox.

I never saw bnt one case of chicken-pox in an adult. That
I saw last week, and I must say that the i)eriod of invasion
of course was of a very mild type, and he described quite clearly
the period of invasion of. smallpox, and yet there were only a
very few lesions upon his body and they were so very light and
filled with a light, limpid fluid, that when you touched them
they broke and the fluid escaped.

Another thing I give special attention to, which is worthy of
attention: After carefully taking down all the physical signs,
I look at their arms. " Have you ever been vaccinated?'* " Yes."
"Let me see your arm." Very, very many times I find upon
inspection of their arms, that there is no evidence of vaccina-
tion, — no scar whatever. I ask them more particularly about
it. They were vaccinated, but they don't remember whether it
took, or not. It is very evident that they have not been properly
vaccinated. If the result was not satisfactory, it was not a suc-
cessful vaccination.

I have very seldom seen a case of smallpox or varioloid, —
I have not seen any that carries a scar that has been made in
the past three years. I think it safe to say that any person who
has a typical scar upon his arm which is the result of vaccina-
tion, within two or three years, will not have smallpox, and in
a large majority of cases (I can say all the cases almost, that
I have vaccinated) we don't flnd any person who has had small-
pox, I may say, unless they haven't been vaccinated, — ^generally,
speaking, all those cases that have smallpox have not been vac-
cinated.

When that question comes up for discussion with other mem-
bers of the family, for their protection, I am astonished to
flnd the opposition there is to vaccination which is occasioned
by some peculiar individuals in the community who are opposed
to it, called anti-vaccinationists, who tell terrible stories about
loss of arms and loss of life, and a great many other ill eflfects
resulting from vaccination; and your Commissioner of Health
of this State sent me, a couple of weeks ago, to the northern
portion of this State where complaints were made to the De-



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State Department op Health. 749

partment o^ the ill effects of vaccination; and I visited those
people, and found there was, as usual, nothing in it.

Ordinarily, I think the bad arms which are the result of vac-
cination are due to other infection. There is no doubt but
that that is the case.

Now, then, I will go along a little further in regard to what
should be done with patients suffering from smallpox in a com-
munity. Health oflScera usually have a good deal of trouble, —
it is a very difficult thing for them to get along with a com-
munity, by reason of the opposition they have to contend with.
Some members of the board of health are opposed to vaccination,
— ^they are opposed to a great many things suggested by the
health officer; and I want to say that health officers generally
understand their business. They may have overlooked a case,
but they are capable of recognizing it after a short time, and
also use every effort for its suppression.

One of the most important things is isolation, and you know,
many of you, the difficulty that is attendant upon the isolation
of patients in the suburban districts. You will liave a family
of six, eight or ten persons in a house. You can't isolate them
very well, — not pleasantly at least. It is a difficult matter to
get a place where you can care for them, — an isolation hospital
or hospital of detention, — and as I said before, great difficulty
exists. It cannot be controlled, — the important thing is to put
them upstairs. Clean opt the room, remove the fabrics. Have
nothing but plain curtains and the most simple furniture that
it is impossible to obtain; put but one person in their care,
unless it is an aggravated case where that person must be relieved.

Ordinarily in the epidemics that we have throughout the State,
they are generally of a mild form; so much so that it is a
pretty hard matter for the people to become reconciled to the
fact that smallpox exists, and that by isolation from other mem-
bers of the family may exist in the same house only if they
are kept away from them; but treat them by one person, that
is nursing, and the physician should go there prepared for the
purpose of protecting the community and vaccinating the rest
of the family, if it is possible to do so, and at a certain period
of time, to fumigate the premises thoroughly.



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750 TWEXTY-FIPTH ANNUAL BbPOBT OP THE

One of the most important things in connection with it is
fumigation, and that fumigation should be conducted upon
scientific principles. It should be very thorough, and if it is
done thoroughly I think jou can suppress the disease in a short
time in that family, if those persons are vaccinated. If those
persons who have not been vaccinated are vaccinated immedi-
ately, the physician will get ahead of the smallpox, and not
another person be infected in that house.

Therefore, gentlemen, in regard to smallpox, which is a pre-
ventible disease, it may be suppressed in any community if
proper care is taken and rigid means exercised for its suppression,
by vaccination, fumigation and isolation. I think that will
almost cover the ground.

I think that is all that is necessary for me to say upon the
subject, in regard to the care of smallpox.

Dr. Lewis — Is there any further discussion of smallpox?

Dr. Mason (of Fishkill) — Dr. Johnson had just touched upon the
question of vaccination. I would say just a word. This ques-
tion of smallpox has already been pretty well threshed out this
evening, particularly the part relating to the diagnosis of it.
There is a general impression throughout the country among the
laity that a person who has been vaccinated unsuccessfully many
times is proof against the contagion of smallpox. I hold an
enlarged photograph in my hand of a boy ten years old who
had been vaccinated ten times without having it take a single
time. He got smallpox from his grandmother who had died in
his home, the case having been mistaken for a case of erysipelas,
with this result. The other inmates of the house were all vac-
cinated upon the death of the old lady, as well as the boy him-
self. The other vaccinations took promptly. His delayed, and
within the period of incubation he was taken sick and developed
a most typical case.

To get back to the original paper for discussion this evening,
of Dr. Curtis, and particularly upon the diagnostic features of
smallpox, I want to indorse every word that he has said, as
an experience of thirty years in the practice of medicine, twenty
of which has been in health officer's work, including a number
of cases of smallpox, has shown me that he is right.



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Statb Djbpahtmbnt of Health. 751

I want to say that, as to the diagnostic differences between
chicken-pox and smallpox, there are three points particularly to
be depended npon. The first is the mnltilocular postule of small-
pox, as compared with the single vesicle of chicken-pox. Sec-
ond, the hardness of the smallpox fill as compared with the
soft fill of the vesicle of chicken-pox, and third the appearance
of smallpox lesions upon the palms of the hands or upon the
soles of the feet, which never occurs in chicken-pox.

I have never seen a case of chicken-pox in an adult. We have,
of course, many of these abortive cases of varioloid. We have
had many of them down the river. It has been my duty to
care for no less than six cases of smallpox at Croton Point, and
I expect, although through no fault of my friend at Stony Point,
that the cases escaped and came from across the river. In these
cases of negroes, in the $rst stages of the eruption we have no
aureole, no redness, because you can't tell it in the darker col-
ored negroes, and the first thing you know the initial fever has



Online LibraryNew York (State). Dept. of HealthAnnual report → online text (page 59 of 74)