Smallpox

“ There is an old and oft-repeated statement that a uniform rash is a characteristic of smallpox and that a mixed rash indicates chicken-pox. This deserves to be promptly refuted. It is most unusual to find a case of smallpox with its eruption all in one stage. While it is a well known fact that chicken-pox runs a hasty course,—so that in from one to two days we may have macules, papules, vesicles, and even crusts,—in smallpox this is not likely to occur, as the disease never runs such a rapid course. ”

“ Period of Incubation.—During this period, which extends from the date of infection to the appearance of the earliest symptoms of the disease, treatment is rarely demanded, since in the great majority of cases the outbreak of the disease is a surprise, and in no case can it be positively known that a patient has smallpox until the initial symptoms appear, and often not until the characteristic eruption has developed. In many instances, however, it is quite certain that an individual has been exposed to the contagion of variola ”

“ One is absolutely safe from [Pg 207] acquiring smallpox if recently and successfully vaccinated, and thus has one of the most frightful and fatal scourges to which mankind has ever been subject been robbed of its dangers. The contagium is probably derived entirely from the scales and particles of skin escaping from smallpox patients, and in the year 1905–6 the true germ of the disease was discovered by Councilman, of Boston. ”

“ It is an excess in the number of pustules which we chiefly dread in the smallpox; but in the cow-pox no pustules appear, nor does it seem possible for the contagious matter to produce the disease from effluvia, or by any other means than contact, and that probably not simply between the virus and the cuticle; so that a single individual in a family might at any time receive it without the risk of infecting the rest or of spreading a distemper that fills a country with terror. ”

“ It is absolutely certain that smallpox has been communicated to susceptible persons by those coming from patients ill with that disease merely passing the susceptible man on the street. The number of persons that will not take smallpox when exposed to it is very large. In Washington in 1895, during an epidemic of smallpox, 187 persons, to my personal knowledge, were exposed to one group of 39 smallpox patients without taking the disease. ”

“ Whatever things contributed to the growing evil repute of smallpox among epidemic maladies, there is so much concurrent testimony to the fact itself that we can hardly take it to have been wholly illusion. In some parts the mildness of smallpox was still asserted as if due to local advantages. ”

“ Leprosy, influenza, smallpox, cholera, typhus fever and bubonic plague constituted the dreadful group. In most countries, including England, smallpox was practically endemic; an attack of it was accepted as a thing inevitable, in children even more inevitable than whooping-cough, measles, mumps or chickenpox is regarded at the present time. There was a common saying—"Few escape love or smallpox." In the eighteenth century so many faces were pitted from severe smallpox that it is said any woman who had no smallpox marks was straightway accounted beautiful. ”

“ Measles and scarlatina have not shown the same tendency to change or limit their incidence. Smallpox may have surprises in store for us; but, as it is an exotic infection, its peculiar behaviour may not unreasonably be taken to mean that it is dying out,—dying, as in the death of some individuals, gradually from the extremities to the heart.
With all those changes, the fatality of smallpox, or the proportion of deaths to attacks, came out in the great epidemic of 1871-72 curiously near that of the 18th century epidemics, namely, one death in about six cases. ”

“ There would be hardly any fever, certainly a very slight eruption and perhaps none at all (p. 68) , It had, indeed, been questioned whether a patient who had but very few pustules, or only one, has had the smallpox as truly as [Pg 497] one who has been very full, and whether he is equally safe from catching it. He answers in the affirmative, according to the doctrine of variolosity: “No reason can be alleged, why we should have the smallpox but once, that will not equally hold good for one as for ten thousand pustules” (p. 69) . ”

“ The atmosphere around a smallpox patient is charged with the products of the disease, which likewise cling to clothing, furniture &c. The disease is probably communicable from its earliest manifestations onwards to its close, but it is generally held that the most infectious period extends from the appearance of the eruption till the drying up of the pustules. Smallpox may also readily be communicated by the bodies of those who have died from its effects. No age is exempt from susceptibility to smallpox. ”

“ Within three or four days the experienced observer will be able to determine whether the vaccination is successful or not; a negative result will of course have but a moderate value, but a positive result will serve to definitely exclude the diagnosis of smallpox. In all cases of doubt, whether before or after the eruption has appeared, the physician owes it to himself not less than to the patient and the community to frankly explain to the patient or his family the difficulty in arriving at a diagnosis, and to express his suspicions that the case may be one of smallpox. ”

“ Smallpox is unquestionably a highly infectious or communicable disease, and in the language of a past day, there is a virus or poison which can pass from the sick to the unaffected; when this transference occurs on a large scale we speak of an epidemic of smallpox. As Sir William Osler truly says, "It is not a little remarkable that in a disease, which is rightly regarded as the type of all infectious maladies, the specific virus still remains unknown." The same, however, is true of the common diseases of scarlatina, measles and chickenpox. ”

“ As a result, smallpox has become one of the rarest, instead of the commonest, of our infectious diseases. Only a few dozen people die of it each year in Europe, instead of several hundred thousands; scarcely one one-hundredth of the people now in our blind asylums have been sent there by smallpox, and I dare say that many of you have never even seen a pock-marked person.
Another disease that used to be very dangerous to little children is diphtheria. ”

“ The marks appeared chiefly on the nose, and did not exactly resemble those of the smallpox with us, inasmuch as the deep scars and grooves left the original surface and skin in isolated specks on these people, whereas the effects of smallpox with us appear in little isolated hollows, no parts of the higher surface being detached like islands, as they appeared on the noses of these natives. This was what is termed, according to Souter, the confluent smallpox. ”

“ The saving of life by the extinction of plague was in great part balanced by the loss from smallpox, which fell, however, more and more upon the earliest years of life until at length it was almost confined to them. The first great decline of smallpox itself corresponded to a great decline of typhus fever during the second half of the French war; but while there was no great infectious disease in those years to thin the ranks of the adults, measles took the place of the more loathsome smallpox in cutting off a certain number of young lives. ”

“ Single cases of certain infectious diseases may appear in a community year after year, and at intervals the cases become so numerous that the disease is said to be epidemic. Such a disease is smallpox. This is a highly infectious disease, towards which all mankind is susceptible. Complete protection against the disease can be conferred by Jenner's discovery of vaccination. The disease becomes modified when transferred to cattle, producing what is known as cowpox, in which vesicles similar to those of smallpox appear on the skin. ”

“ May it not then be reasonably conjectured that the source of the smallpox is morbid matter of a peculiar kind, generated by a disease in the horse, and that accidental circumstances may have again and again arisen, still working new changes upon it until it has acquired the contagious and malignant form under which we now commonly see it making its devastations amongst us? ”

“ In some of the countries of the Orient smallpox kills more people than cholera, plague and dysentery together. Many reports have shown that as many as 80 to 90% of a native population may be attacked in an outbreak and of these practically one-half die. In such communities the disease is more one of young children, the adults possessing a certain degree of immunity from attacks in childhood during previous epidemics. ”

“ Smallpox in the Arabic Annals.
For our purpose the evidence on the antiquity of smallpox in China and India may be accepted, and for the rest left out of account. The Arabian influence is nearer to us, and is the only one that practically concerns us. Coming, then, to the history of smallpox in its prevalence nearest to Europe, we find a definite statement of the disease appearing first among the Abyssinian army of Abraha at the siege of Mecca in what was known as the Elephant War of A.D. 569 or 571. ”

“ A still more serious form is that termed malignant, toxic or purpuric smallpox, in which there is intense streptococcus septicaemia, and the patient is from the onset overwhelmed with the poison and quickly succumbs—the rash scarcely, if at all, appearing or showing the haemorrhagic or purpuric character. Such cases are, however, comparatively rare. The term modified smallpox is applied to cases occurring in persons constitutionally but little susceptible to the disease, or in whom the protective influence of vaccination or a previous attack of smallpox still to some extent exists. ”

“ The only known factor in the origin of smallpox is contagion—this malady being probably the most contagious of all diseases. Its outbreak in epidemic form in a locality may frequently be traced to the introduction of a single case from a distance. The most direct means of communicating smallpox is inoculation. By far the most common cause of conveyance of the disease, however, is contact with the persons or the immediate surroundings of those already affected. ”

“ Quarantining smallpox is a most expensive luxury, which may possibly retard the progress of this disease, but was never known to check an epidemic of it. Every epidemic of smallpox during the last one hundred years has been checked by vaccination.
Why some diseases do not return
There are certain diseases which you are not likely to have more than once; one attack protects against another. ”

“ If a person does not catch smallpox, then he is not bewitched by anyone, and he himself has no witchcraft.
During an epidemic of smallpox at Monsembe in 1893 it was absolutely impossible to isolate patients, for, according to their belief regarding infectious diseases—that no one would have it unless he were bewitched to have it—there was no need for isolation. I have seen the hut of a patient literally crowded 289with women, lads, and girls, giving advice and showing sympathy with the sick. Many died from the loathsome disease. ”

“ Before the eighteenth century closed practical medicine had made great advance. Smallpox, though not one of the great scourges like plague or cholera, was a prevalent and much dreaded disease, and in civilized countries few reached adult life without an attack. Edward Jenner, a practitioner in Gloucestershire, and the pupil to whom John Hunter gave the famous advice: "Don't think, try!" had noticed that milkmaids who had been infected with cowpox from the udder of the cow were insusceptible to smallpox. ”

“ In Fyvie, Aberdeenshire, “there has been no prevalent distemper for some time except the putrid sore-throat” (IX. 461) . But, in Dron, Perthshire, smallpox owing to the prejudice against inoculation, continues to carry off a great number of children; the hot regimen, and the keeping of the patients too long in their foul linen and clothes, are bad for the disease (IX. 468) . In Fordyce, the ravages of the smallpox are very much abated by the practice of inoculation; the most prevalent distemper is fever (III. 48) . ”

“ The deaths by smallpox in the last week of August, 1681, reached the very high figure of 168, the next highest cause of death that week, and the highest the week after, being “griping in the guts,” or infantile diarrhoea. The smallpox of 1685 was more uniformly distributed over the months of the year, which was one of malignant typhus, the worst week for fever having 114 deaths (ending 29 Sept.) , and the worst week for smallpox 99 deaths (ending 18 Aug.) .
The deaths by smallpox in the London bills are the only 17th century figures of the disease. ”

“ Hence in a large population there is always likely to be an increasing number of individuals who have become susceptible to smallpox. This probably explains its occasional and even apparently periodic epidemic outbreaks in large centres, and the well-known fact that the most severe cases occur at the beginning—those least protected being necessarily more liable to be first and most seriously attacked. ”

“ There are certainly more forms than one, without considering the common variation between the confluent and distinct, in which the smallpox appears in what is called the natural way. About seven years ago a species of smallpox spread through many of the towns and villages of this part of Gloucestershire: it was of so mild a nature that a fatal instance was scarcely ever heard of, and consequently so little dreaded by the lower orders of the community that they scrupled not to hold the same intercourse with each other as if no infectious disease had been present among them. ”