had taken a great deal of quinine. He had a deadly pale color; was very thin and weak; his conjunctivæ were so pale they looked pearly. He could see large objects in front of him, but could see nothing around about. His urine was highly colored and diminished in amount, sp. gr. 1.025, acid reaction, no albumen or sugar, no casts, a large amount of granular debris, and a few red blood cells. Blood examination: the red blood cells were pale and reduced to 2,500,000 to the c.mm.; the white cells were in the proportion of one to seven hundred or eight hundred reds; the hemaglobin was twenty per cent. He had before this examination taken quinine, so no examination for the plasmodium was made. He was put on quinine, iron, arsenic, and strychnia, and a liberal diet. After two days his chills were checked, but he improved slowly. Ten days later his blood examination showed 4,000,000 red blood corpuscles to c.mm., and the hemaglobin had increased to fifty per cent. He was dismissed October 20 200 22d much improved. At this date I examined his vision and eyes. The acuteness was in each eye, and the blood extravasations were much smaller, and the area from which absorption of the blood had taken place was of a peculiar whitish color. Kipp, Bull, Jones, and Bruns have reported cases of retinal hemorrhages as occurring in malarial poison, but none report so well marked a case as this. The two cases I have here reported were both young persons, and the eye changes were of value in the diagnosis and general treatment. Others have reported cases of retinal hemorrhages in the young where some disorder of menstruation or constipation, with slow pulse, headaches, and epistaxis, was the apparent exciting cause. The prognosis in retinal hemorrhages in the young is usually favorable, but when this condition is found after fifty years of age the outlook becomes more serious, even where organic kidney disease can be excluded. Hutchinson states that in such cases there is an arteriosclerosis of the retinal blood-vessels dependent on gout. Bull, Nettleship, and others take a similar view. Dr. Hasket Derby has recently reported a series of cases of retinal apoplexy where he has followed the cases for some time, and he states that the symptom is an ominous one; only five of thirty-one cases were still living, most of the cases. dying suddenly from apoplexy or heart disease. LOUISVILLE. SMALLPOX AND VACCINATION.* BY ALBERT BERNHEIM, M. D. During the last month the newspapers from time to time brought reports of smallpox epidemics in different States of this country. There were larger epidemics in Atlanta, Georgia, and in our State of Kentucky, especially in Middlesborough and Richmond. I therefore hope it may not be quite unsuitable to speak about "Smallpox and Vaccination." Smallpox has been known for centuries, although formerly often confounded with other diseases. The very name "smallpox," in French "petite vérole,” in German "blattern or pocken," is significant of its confusion with syphilis, which was called the "great pox," "grande vérole," "grosse blattern." The disease appeared in Europe, as far as we know, about 1,200 years ago, introduced by the Saracens, who found it in Africa. When brought over from Europe to America, it took out of Mexico alone nearly 4,000,000 people. It reaped a very great harvest among the Indians in North as well as in South America. ing to Europe, it depopulated the Northland. Return Smallpox is one of the most dreaded acute infectious diseases, and in earlier times it has destroyed thousands of thousands in its pestilential progress. Quite especially in times of war the epidemic of smallpox seems to revive and to become recrudescent, probably due to the meeting of a very large crowd on a relatively narrow space, especially when the rules of quarantine have to be neglected for the sake of other necessary measures. We need not go back very far in the history of the world, for we have only to allude to the Napoleonic wars, the Crimean war, the American Civil war, the war of 1866 between Prussia and Austria, the French-German war of 1870 and 1871, and the TurcoRussian war of 1878. I should think it would be of great importance to watch our Hispano-American war in regard to a prevention of smallpox as far as possible.§ It was the discovery of the possibility of prophylactic inoculation, and the ever increasing spread of this precautionary measure, which first robbed the disease of some portion of its terrors. What is the etiological agent of smallpox? *This paper was to have been read before the Kentucky State Medical Society, Maysville, May 12, 1898 After I had written this, I read a report of cases of smallpox among the Alabama troops. We must confess that we have not found it yet. Different observers have found different bacteria, micrococci, and protozoa. One found a protozoon, the Cytorycetes variola; another describes an intracellular plasmodion, like in malaria; another describes a sporozoon-motile, flagellate body in the blood in the early fever of variola and vaccinia. Another found a minute bacillus that may cause in calves vesicles from which children were vaccinated with good result. Another doctor found a new agent, the Dispora variola. To cut it short, at present we are sure there must be something that causes variola, but we don't know it yet. The discovery of the causing agent of smallpox must be reserved for the time when bacteriology and its technical means are farther developed. Predisposition to variola, except as diminished by vaccination, is universal. The disease may appear at any age, even in utero; in any climate, in any season, and with people of any race. Women are believed to be especially liable to it during pregnancy and childbed. It is said that persons ill from another acute infectious disease, such as scarlatina, measles or typhoid fever, are, for the time being, tolerably secure from smallpox; but there are exceptions. The same individual rarely takes the disease a second time. A case of variola is always the result of transmission of the poison to a healthy person from one who is already ill with it. The specific virus certainly is most abundant in the diseased portions of the body and in the pus of the suppurating pocks, as well as in the crusts and scales which are left when these have dried up; but the disease is also contagious in its earlier stages before the pustules develop, and even, according to a few observations, during the stage of incubation. Certainly the variolous poison is very volatile; that is, it is prone to disseminate itself through the air in the neighborhood of the patient. In order to catch the disease. it is not necessary to touch the patient, but merely to remain in hist vicinity. In many cases we can not, however, decide with exactness. the mode of transmission, since the contagion may either be direct or by means of objects and utensils with which the patient has come in contact-for example, glasses, cups, plates, soiled linen, etc. In regard to trade and industry, it is important to know that the contagion of smallpox may be transmitted over large distances, for instance by rags, hides, furs, for you may assume that even animals may transmit. the poison. The dead body is capable also of transmitting the disease. In general we have numerous instances pointing to a considerable tenacity in the virus. The precise manner of infection is not yet. known. It is not improbable that the poison is drawn into the lungs with the inhaled air. The disease can be transmitted to healthy. persons by direct inoculation of the contents of the variolous pustules. It is stated that monkeys and other animals may be successfully inoculated in the same way. Whether inoculation with the blood of the sick will reproduce the disease is not yet settled. The secretions, saliva, sweat, urine, and milk do not apparently contain the infectious matter. The stage of incubation lasts some ten to fourteen days, often a somewhat shorter time, seldom longer. You hardly can distinguish any prodromal symptoms. I shall not regard it as my task in this paper to speak about the different stages of variola, its varieties and their clinical course and symptoms. In respect to treatment I shall confine myself to the prophylaxis and vaccination. Regarding diagnosis, it might be sometimes difficult. The eruption alone never can give the absolute certainty. It might be confounded with typhoid fever, with a special form of measles, with syphilitic eruptions, with erythema exudation. It is important not to regard the dermatic appearances alone, but to note all other symptoms besides. The more The prognosis depends on the severity of the cases. abundant the eruption, the severer the case is usually to be regarded. Conditions peculiar to the individual are also important, namely, age, constitution, alcoholism, pregnancy, etc. The so-called confluent smallpox is of a greater danger, and an almost absolutely fatal prognosis may be told in the genuine hemorrhagic variety, the so-called "black smallpox." The mortality varies in different epidemics; on the average it may be assumed at about fifteen to thirty per cent. Beyond doubt, the introduction of vaccination has decidedly lessened the fatality of the disease by diminishing the frequency of the severe forms. The treatment ought to be principally prophylaxis. "An ounce of prevention is worth a pound of cure." While this saying ought to be applied to any disease whatever, it is especially true of smallpox, and that in spite of all adversaries of the vaccination and their arguments. Among the adversaries of vaccination we find our colleagues of homeopathy. Is it not ridiculous when a homeopathist makes in a case of a nervous, choretic child the diagnosis of a disturbance of the blood as a result of vaccination, applied several years ago, saying he must expel the vaccination by his homeopathic treatment? Does this doctor not disavow his only and chief maxim, "similia similibus "—upon which he bases his right to practice? Does he not saw the branch off on which he is sitting? I shall return later on to the different arguments of the vaccination adversaries. It seems that in the countries of the Orient the inoculation of smallpox as a preventive was performed many centuries ago. It was on the 1st of April, 1717, that Lady Mary Montague, the wife of the English Ambassador to the Porte, wrote a letter from Adrianople to a friend of hers, Miss Sarah Chiswell. This letter* may be regarded as the start of one of the greatest benefits which mankind ever partook of. In this letter she writes about the pestilence of smallpox, which had lost all its terrors. Maybe that not many have heard of the precise contents of this letter, and so I beg your pardon if I give it in full: "As I am just writing about diseases, I can send you an information that might give you the desire of being present in this country too. "The smallpox so much destructive among us and spread everywhere, is, in this region, entirely harmless, owing to the so-called inoculation. Many old women perform this operation in a businesslike manner every year in fall, in the month of September, when the hot weather is over. Then one asks the other if perhaps a member of the family wishes to be affected by smallpox, groups are formed, and when they are together, usually fifteen to sixteen in number, the old woman appears, a nutshell in her hand, filled with the best sort of smallpox. Asking 'which of your veins shall I open?' she opens the vein with a long needle, a procedure that causes not more pain than when you are scratching yourself, carries to the wound as much matter as sticks to the head of the needle, and dresses the small wound with. a piece of nutshell. Doing so, she opens four or five veins. The Greeks, superstitious as they are, have their veius opened, one on the forehead, one on the right and left arm, and one on the chest, in order to mark a cross; this, however, must be rejected, because these small wounds leave scars. A not superstitious one prefers the operation on the legs or the covered part of the arms. Children and young persons spend the remainder of the day together playing in a good health, till in the evening about eight o'clock they become afflicted with * Deutsche Med. Wochenschrift, 1896. |