New York (State). Dept. of Health.

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begun and passed through its stages, and the fifth day probably
the negro says he has got the "bumps." I had six cases in a
camp at Croton Point. The original case was discovered upon
the brick yards, — ^a man who was at work handling the same
piles that the other colored workmen handled. He had been sick
some ten days previously with what was supposed to be chills
and fever, for which he had been treated by the local physician.
The original fever had subsided, but the postular fever drove
•him to his bed and brought the case to the surface. Previous
to that time he had been in tlie village of Croton and had played
cards in the saloon with other colored men and went back to
Croton Point to the brick yard, and was discovered, put in camp,
and five other cases in the same locality followed each other
successively.

Now, the jieculiar feature: The abortive type or very mild
form of varioloid that hap developed in the village of Croton
since the original negro, can be traced directly from him down
to the present day, and in that village today there exist six or
eight cases of varioloid of a mild type and two severe cases of
smallpox, which have been sent to the pest house outside of the
village.



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792 TwEHTT'PiiTH Annual Bbpobt or thk

From the day that the negro played cards, on Saturday nig^t
before the Monday on which his case was discovered, the dif-
ferent people who contracted the contagion can be snccessiyelj
followed, right down to the present day.

Many cases of varioloid have been mistaken tor chicken-pox.
Many of these cases in the village of Croton were mistaken for
chicken-pox, and one or two developed severe symptoms, and the
people themselves were frightened, because the children, half-
grown children, were so sick. It was not the mistake of the
physician, but of the families themselves; they had supposed that
they had chicken-pox, until the postular fever made its appear-
ance. Then they were so sick that they had to go to bed, and
then the physician was called in and the true state of affairs
was discovered.

The few cases which exist there now are well under control,
through the efforts of Dr. Miller, the health officer of the village
of Croton. I have had the pleasure of assisting him in as many
ways as I can, and have taken care of the severe cases, which
have been removed outside the village but within the town
limits, to the pest house. I thank you.

Dr. Goler, of Rochester:

Mb. Chairman — I feel that I know a great deal less about
smallpox than I did some years ago. That is after an experience
with some eight hundred cases and making diagnoses in some one
or two thousand cases.

I think that we all owe Dr. Curtief our sincere thanks for what
he has so clearly placed before us, and I do not think I can
add very much to what he has so clearly set forth; but there
are one or two things that occurred to me in this discussion
that I certainly think ought to be cleared up, in the light of
my own practical experience.

One thing is that the eruption of chicken-pox does not appear
upon the palms of the hands. I think it does occasionally occur
upon the palmer surface of the hands although it is very rare
indeed.

The other is tlie difficulty of making the diagnosis sometimes
between syphilis ( ?) and smallpox. I think the case that Dr. Curtis
referred to was a Rochester case, and that case perhaps deserves



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Statb Depabtmbnt of Hbai:;ih. 753

a word or two of comment, because it was rather a remarkable
case. •

A man who came to the city had been going around the coun-
try a good deal and he was accompanied by a woman who trav-
eled with him. The man had been sick for a few days, two or
three days, I think, with the initial fever. He had a papular
eruption upon his body, and the woman who accompanied him
had a similar attack of fever and a very similar papular erup-
tion upon her body. Those were the two points that made the
diagnosis in these cases rather difficult and they were, I think,
the only cases out of a great number of cases that were under a
cloud for more than twenty-four hours, perhaps.

I don't believe that it is very difficult to make the diagnosis
in ordinary cases of smallpox, but in those abortive forms when
but one or two postules or papules occur, and those postules
do not go on the papulation, I think those cases, especially to
men who have not had a wide experience in the diagnosis of
smallpox, are very difficult of diagnosis indeed.

Dr. Peck — I feel that I ought to say a few words. Of course,
almost anyone can diagnose a typical or well-marked case of
chicken-pox. That is not where the difficulty comes iA; it is in
the obscure cases.

The health officer runs up against a case long after the initial
fever very likely, and in many cases you cannot get any history
of the fever whatever, but you have got an eruption that is won-
derfully like the smallpox eruption. Perhaps these people have
had no physician, on they may have had. I think that, in almost
all cases, and perhaps in every case, there is a fever of a few
days perhaps; but you can't get the history of it. Where you
have these abortive eruptions, it is very, very difficult, and no
physician I think ought to be blamed, in many of these cases,
for not making a correct diagnosis.

There is one thing which has not been dwelt upon very much,
that I think a great deal of, and that is the halo surrounding
the postule, if it goes as far as the postular stage. For about
two days the halo will be very bright and very distinct. I have
seen, I think, in a case of chicken-pox, something that is very
like a halo, but it is pale, and not characteristic at all of it.
48 • .



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754 Twenty-fifth Annual Bepobt of thb

Now we come to the age. Of course, chicken-pox is very rare
in adults, but I know that they do have it I have seen several
cases of my own, of people over thirty years of age.

A case came to my knowledge within the last three months,
of a woman, a mother of a family, thirty years of age and more,
and T was unable to say for a long time whether she had chicken-
pox or smallpox. She had a physician but once, and he reported
the case to me, and I quarantined the family, because I was in
doubt. I think that is the proper way to do. She had some
eruption on her face and some eruption on her body, and some
erni)tion on her limbs, and I was very suspicious of the caae;
but it happened that there were two girls, one of eight and the
other of ten, in the family. One had been vaccinated and the
other had not, — the other had had chicken-pox, but had not been
vaccinated. The girl who had never had chicken-pox, in the
course of fifteen or twenty days came down with the chicken-pox,
and the other girl did not have smallpox, so I concluded it was
chicken-pox-

It is sometimes very diflScult, too, to distinguish a case from
measles. A case occurred with us a year ago in which a man
forty years of age had a high fever, a temperature of 104 or 105,
for two or three days, and it was reported as a case of smallpox;
but in three or four days the man came out with measles in
good shape. We had him quarantined all right; so it was not
very bad after all.

Another case in my experience, — I don't want to take up too
much time, but to show how very difficult it is sometimes to
make a diagnosis, and how, many times, no diagnosis is made
until it is too late, and perhaps not at all, — ^a year ago we had
a little smallpox in our place, and two boys in a family had been
vaccinated, — in fact the whole family, consisting of two boys
and three girls, were vaccinated by myself several years ago.
They are grown now. With the girls the vaccination was suc-
cessful, but with the boys it was not. The two boys both had
smallpox and the girls escaped.

I saw a case last spring, where a woman was about the house
with well-marked smallpox, not sick at all. She had had fever
for a few days, but she said her husband had been sick the same
as she, except a great deal worse. I found the man at church,



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State Depaetmbnt op Health. 755

and he was cleaned up and washed up in good shape, and I
brought him home. It seems that a couple of weeks before, he
had not been feeling well, and being in the grocery store, where
they had patent medicines (which is good for smallpox, as well
as everything else) he began taking this medicine for his blood,
wihch was out of order, as he supposed, and it proved to be
wonderfully good medicine, because it drove out the eruption
thoroughly; and people came to the store and asked him what
the matter was, and he said he was taking this wonderful blood
medicine; and they all congratulated him upon the result, — how
this medicine had brought out a fearful eruption, and they
thought it was a good thing. Of course, when his wife com-
menced to have the symptoms, it was the same medicine, and it
brought it out on two of the children, although the children did
not take it, — ^but the medicine was so good that it brought out
the eruption all right.

So there are many funny things about some of these smallpox
cases. I could talk a great deal longer, but that is probably
enough; but I want to say right here that there has been a
great deal of literature published on this smallpox question, but
one of the best articles that I have read on smallpox and one
of the best lessons taught on it, is an article by Doctor Vander
Veer, published in the Albany Evening Journal a few years ago.
I hoi)e Dr Vander Veer will tell us about it.

Delegate — There i« one suggestion that I would make in refer-
ence to quarantine: Put a wire fence right around the premises,
and then it is quarantined, with the understanding that you can
go on the back stoop and talk, and all that sort of thing.

Delegate — Will an eruption of smallpox occur on the mucuous
membrane of the mouth?

Dr. Lewis — Dr. Hix, you can answer that question.

Dr. nix:

Mr. Chairman — I am not here to answer any questions. I
wish I was able to, but I do not feel able to discuss the sub-
ject, after it has been so ably discussed by men of such wide
experience, and I have only a limited experience ; but I have one
question to ask : We have been taught in regard to protozoa of



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756 TwBNTY-PiPTH Annual Rbpobt of the

smallpox, etc., and then we have been taught that there are many
cases of abortive smallpox, abortive in the vesicular and papular
state;; and I would like to ask Dr. Curtis and Dr. Johnson
and the other gentlemen, how much contagion there is in this
abortive period, — if they can tell us whether this protozoa has
been formed in those cases.

Dr. Curtis — ^W^hen Dr. Hix uses words of so many syllables^ I
have to say that I don't know; I think that is about it, though.

The type of smallpox we have now generally runs true; it
won't always do it, for I have seen hemorrhagic smallpox with-
out the slightest expression of the disease; but I think it can
generally be anticipated that like will produce like; and I am
sure that it is not very infectious. When you take your family,
who have never seen a doctor and have gone about the village,
and all of them have had smallpox, and very little comes of it,
it cannot be that it is so very infectious.

There is a good deal more fuss made over smallpox than there
ought to be. There are a great many worse things than that;
and as to the distance that it may go, I am very certain that
the tendency of feeling now is that the distance at which it
is infective is very much less than was formerly thought to be
true.

Someone has asked about the mucuous surface being affected.
Lesions in the majority of cases will occur in the roof of the
mouth in smallpox and in a marked case of chicken-pox as well,
and on the mucuous surface elsewhere than on the mouth you
will find them. I don't think that there is any reliance to be
placed upon the occurrence as characteristic of either one. There
is more reliance to be placed upon the occurrence of the lesion
upon the palm of the hand, but that will also sometimes be the
seat of lesions in chicken-pox, in my experience. All I can say
is that it does not occur centrally; that is as far as I have been
able to go, the center of the hand escapes in chicken-pox.

I would like to ask, Mr. Commissioner, — it is seldom that we
get a body of people together that know so much about small-
pox as is. gathered here ; and every one has experiences, — I would
like to ask if anyone has anything to contribute on the ques-
tion of the taking of the vaccination sequent to a recent case of
smallpox.



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State Department op Health. 757

Dr. Goler, have you ever tried the vaccinating of anyone after
his having had smallpox?

Dr. Goler — Yes.

Dr. Curtis— With what result?

Dr. Goler — Within a short time.

Dr. Curtis— Yes.

Dr. Goler — I have vaccinated cases with smallpox,

Dr. Curtis — 1 mean did they take the vaccine after having
had varioloid.

Dr. Goler — They might not; I think they did not*.

Dr. Curtis — Because it is used sometimes' as .a test. Dr. Hyde, of
Chicago, says that it is not a reliable test; but my exi)erience
is that they don't see cases through. I have asked health
officers to try it, and 1 know vaccination has taken after some
cases that we determined were chicken-pox. I have not
found it taking after those that really were smallpox; and there
is no authority for making the opposite statement.

Delegate — I would like to ask Dr. Curtis if the secondary fever
has any special significance with reference to the diagnosis. I
have heard nothing about the secondary fever which occurs about
the end of the first week. In the old cases, we used to read
about that considerably.

Dr. Curtis — ^Yes, I ought to have spoken of that thing in speak-
ing of the variolus fever; but that does not occur in abortive
smallpox. I mean by that smallpox that simply reaches the stage
of vesiculation, and then the lesion drys up. The secondary fever
is simply a pus fever. It won't occur unless postulation takes
place, and while it may be to some extent an essential fever,
still it is, -to a large degree at least, a suppurative fever, and is
not to be looked for in these mild cases that we see.

A Delegate — I would like to ask wliy smallpox appears in the
cases of those who were not vaccinated.

Dr. Curtis — Well, I don't know, except it is made that way.
We had, two or three years ago, in Albany, forty little children
in an orphanage, and all of them excepting one, who had for-



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758 Twenty-fifth Annual Report of the

tunately been vaccinated, had variola. Most of them had it very
lightly. There, was one little thing, just big enough .to creep
aronnd that never was sick enough to quit its play, never took
to bed. The initial fever was, iif other words, almost nothing,
and it had three or four little bright papules which did not even
vesiculate. It had never been vaccinated, it was a baby, and
it was a good case for true variola to occur if it was going to,
but it did not. It was simply because the type that it had been
exposed to was of that mild sort that it would not.

Dr. Clarke — Is it not possible that there is hereditary immu-
nity from smallpox ; that the generation back of us having been
vaccinated so many years that the progeny in that way carries
immunity with it?

A Delegate — I would like to ask Dr. Curtis in what stage of
the smallpox contagion begins.

Dr. Curtis — One of the most interesting lecturers that I ever
heard in the early days was Dr. Alonzo Clark. I don't know
whether he ever saw a case of smallpox ; but he is my authority
for saying (and I have sort of preached it ever since) that small-
pox is very little contagious until the fourth day of eruption,
or something like that. How is that, Mr. Commissioner?

Dr. I^ewis — I think that is perfectly true. I have heard Pro-
fessor Clark say so, I think.

Dr. Curtis — The text books claim its contagiousness, and I
see no reason why it should not be, from the beginning of the
first manifestation of the disease, but it does not seem to be
very much so until the eruption has arrived at the point where
it is diagnosable.

Dr. Miller — I have found one thing in my experience with
smallpox that the initial fever of smallpox has nothing to do
with the amount of eruption, its abortiveness, or anything of
that kind. In some case^ where the vesicles have aborted in
two or three days, the initial symptoms have been just as severe
as in the severest case of smallpox I ever saw.

Dr. Crum — ^How long should these mild cases be held in quar-
antine?



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iStatb Department of Health. 759

Dr. Curtis — ^Three weeks.

Dr. Crum — In a mild case of smallpox, how long shall we keep

these people isolated?

Dr. Curtis — ^Never less than three weeks.

Dr. Lewis — Doctor Curtis is whispering to me " never less than
three weeks." If I were going to answer it, I would say to
quarantine until there is no evidence of a skin lesion' that is
liable to communicate contagion. In other words, if I were
quarantining a case, and the eruptions were completely healed,
and the patient was well, I would let him go, even if it were
less than three weeks.

Dr. Crum — I know that is the rule, to keep them quarantined
until every vestige of the eruption is gone. But in these mild
cases, where you can not find any evidences of eruption in ten
days, as I saw one case, it seems to me hard to keep them under
quarantine.

Dr. Lewis — There is some possibility that the mucous surface
might communicate contagion in as short a time as that.

I think Dr. Lord wanted to defend the reputation of Haver-
straw.

Dr. Lord — There has been so much said about smallpox that
there is nothing left to be said from my standpoint. The health
officer sometimes has to satisfy the neighbors who insist upon
it that a person has smallpox when they have a buckwheat cake
rash.

I have seen about all the cases of smallpox in our community
within the last fourteen or fifteen years, and I have only seen
a very few that have been abortive. Two occurred three summers
ago. I was called in to see a patient by the physician, — ^the man
had chills and fever and his wife the measles. I told him I
thought it was smallpox, and a couple of days afterwards the
man died, — on the 15th day.

The abortive cases are interesting to assist the health officer
or physician in making diagnosis. I had one case last year in
which Dr. Curtis was interested. It was a negro and he had
a rash across his nose; I claimed he had smallpox. He was
working and his employer objected to having him quarantined,



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760 TWBNTY-PIFTH ANNUAL B&POBT OP THE

but I did it. Dr. Curtis came down and saw it, — ^he probably
remembers the case. About eight days afterwards the man was
taken down with confluent smallpox, and from him directly
came eight cases, in the same house, all relatlTes. This man
of whom I speak, with only a little rash across his nose^ was
able to work and was working in a brick yard.
I don't know of anything else to say.

Dr. Lewis — For what period do you quarantine smallpox?

Dr. Lord — ^I quarantine them until I am absolutely certain
that their skin is clean, absolutely. Forty-two days if necessary.
I have let them go as low as. twenty-seven.

Dr. Lewis — Did you ever raise the quarantine in two weeks?

Dr. Lord — ^Not if I quarantine them for smallpox.

Dr. Lewis — That is what I mean.

Dr. Lord — No.

Dr. Forster — I wish to say that, in 1862, I thought I knew
what smallpox was; and the longer I live the more I am satis-
fied that Dr. Johnson was correct when he said that it was
somewhat difficult sometimes, to know whether you had a case
of smallpox. Dr. Johnson will likely call to mind coming down
to my section of the country to tell me that we had smallpox.
On the occasion of his visit, I was assisting in helping to per-
form a marriage ceremony with one of the prime ( ?) cases, and
the gentleman had come in direct contact with sixty or seventy-
five people- Neither the wife that he married nor any other
person outside of his father contracted the disease from him.

They had some twenty cases in the two towns that I have the
misfortune to represent, and the only misfortune in connection
with the matter is that there didn't everybody have smallpox.
There was not anybody sick, — Dr. Johnson remembers it.

That is all I have got to say, — if I should live ten years
more, I would not know anything about it.

A Delegate — I have a question to ask ; and that is what is
meant by isolation, — twenty feet away from other people, half
a mile, or what distance. What must we do, — put them up at
the top of the house?

Dr. Lewis — You might do that.



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State Department op Health. 761

Delegate — If you are in a village, and have no pest house?

Dr. Lewis — Yes, sir.

Delegate — ^What distance will it carry?

Dr. Lewis — We used to advise, when asked that question, in
locating a pest house, one thousand feet from a habitation or a
frequented road. I went down to Kings Park a year or so
ago, when they had an epidemic, and found they had established
a pest house within two hundred feet of their largest pavilion.
I thought that was too near, but it was quite far enough. They
had severe cases, but it never extended from the pest house
which was two hundred feet from a building containing at least
two hundred and fifty people. So there can be no fixed rule
about it. I believe, now, from the experience I used to have in
New York city before we transported all of our patients to the
Island, that we had just as successful isolation on the top floor
of a private house in the city as if we had taken them four
miles out. It depends upon how carefully the person is iso-
lated or kept from contact with other people.

Delegate — I mean from a legal point of view. We had some
cases which we isolated about a quarter of a mile from every-
body. It was at least a quarter of a mile away, and the county
failed to pay the bill, on the ground that we should have burned
the clothing, or something of that sort.

Delegate — Is it possible to have smallpox without any erup-
tion?

Dr. Lewis — Is it possible to make a diagnosis without any
eruption? I won't say anything about it.

Tomorrow morning we sliall have an exceedingly important
paper on some legal aspects of sanitary work. We will adjourn
until 10 o'clock to-morrow morning.

MORNING SESSION.

Friday, December 16, 1904.

The conference was called to order by Dr. Johnson.

Dr. Johnson — Mr. Church will answer such questions as are
presented to him in reference to the matter that was brought
to your attention yesterday.



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762 Twenty-fifth Annual Bcport of the

Mr. Church — I had three inquiries submitted yesterday and
they are all practically on the same line, referring to the matter
of compulsory vaccination:

" If the board of education don't require vaccination, can vac-
cination be enforced by rule or ordinance of the Department of
Health?"

"Whose duty is it to see that the law excluding unvaccinated
children from the public schools is enforced?"

" How may the law excluding unvaccinated children from the
schools be enforced?"

I have since I was here yesterday examined at some length the
question of the interpretation of this statute, and that is what
it comes right down to, — ^what is the proper construction of this
health law?

I am going to read it again to you in order that you may under-
stand its provisions:

"No child or person not vaccinated shall be admitted or re-
ceived into any of the public schools of the State, and the
trustees or other officers having the charge, management or con-
trol of such schools shall cause this provision of law to be
enforced."

Now there is no question about the questions submitted here,
as to whose duty it is. That statute puts it right up to the
tnistees of the school.

Then it goes on to say : " They may adopt a resolution exclud-
ing such children and persons not vaccinated from such school
until vaccinated and when any such resolution has ben adopted
they shall give at least ten days' notice thereof by posting copies
of the same in Jit least two public and conspicuous places within
the limits of the school government and shall announce therein



Online LibraryNew York (State). Dept. of HealthAnnual report → online text (page 60 of 74)