HOW SO DIAGNOSE SMALLPOX wi%'*. W.ANKLYN LIC HEALTH LIB* . ■ 3F health DIVISION OF EPIDEMIOLOGY I •cH^ ' +A v* *> th m. .. VISION OF EPlDfc. HOW TO DIAGNOSE SMALLPOX HOW TO DIAGNOSE SMALLPOX A GUIDE FOR GENERAL PRACTITIONERS POST-GRADUATE STUDENTS AND OTHERS BY W. McC. WANKLYN B.A. Cantab., M.R.C.S., L.R.C.P., D.P.H. ASSISTANT MEDICAL OFFICER OF THE LONDON COUNTY COUNCIL, AND FORMERLY MEDICAL SUPERINTENDENT OF THE RIVER AMBULANCE SERVICE (SMALLPOX) OF THE METROPOLITAN ASYLUMS BOARD WITH ILLUSTRATIONS PAUL B. HOEBER 69 EAST 59 ST. NEW YORK 1914 PRINTED BY WILLIAM CLOWES AND SONS, LIMITED LONDON AND BECCLES M\w.L\e HEALTH / V LIBRARY PEEFACE Delay in the recognition of smallpox is an im- portant factor in its spread. To contribute to its earlier recognition is the object of this book. It treats of the diagnosis of smallpox as a matter vital to the control of the disease, and sets out the principal diagnostic points in handy form, so as to be readily available in practice. Drafted eight or nine years ago, in the form of notes for post-graduate demonstrations or lectures, it is intended primarily as a guide for those who are in general practice; others, however, who have to deal with smallpox, may also find it useful. Its subject matter is briefly as follows : the effect of unrecognised cases in spreading smallpox ; methods of clinical examination ; a description of typical cases of smallpox, with special reference to the arrangement of the rash upon the skin; an explanation of the principle underlying that arrangement ; other diagnostic a 2 845 vi PREFACE features of smallpox ; the initial rashes ; the differential diagnosis of chickenpox, measles, and other exanthems. The aim of the book is to warn the diagnos- tician of the difficulties and traps which he is likely to meet ; how to avoid them ; to assist him not merely to a rough proficiency, but to a high degree of accuracy in diagnosis. It is the author's belief that the data for a correct diagnosis are present and available in nearly every case of smallpox; and that accuracy in their interpreta- tion may be attained, with even a moderate amount of practice, if due attention be given to the methods here indicated. The book is based upon an acquaintance with smallpox extending over 20 years, and including the reception of the cases in the epidemic of 1901 and 1902, during which years it fell to the writer to receive from London about 10,000 cases certified as smallpox, and to revise their original diagnoses. I am glad of this opportunity of acknow- ledging my indebtedness to my former teacher and colleague, Dr. T. F. Bicketts ; especially as an earlier contribution escaped me, to my regret, PREFACE vii without such acknowledgment. That contribu- tion, and these pages, are little more than attempts to set out his teaching as it has been put into practice by myself. My thanks are also given to those who have helped me in the preparation of this book ; especially to my former colleague, Dr. A. F. Cameron. London, May, 1913. CONTENTS CHAPTER PAGE I. The Speead of Smallpox by Unrecognised Cases 1 II. Unrecognised Cases and their Remedy . . 10 III. Practical Points in the Method op Examination 19 IV. Individual Cases op Smallpox considered with a View to Diagnosis .... 26 V. Individual Cases. Other Features op the Kash 36 VI. The Explanation op the Distribution op the Kash 44 VII. Other Factors in Diagnosis .... 55 VIII. Differential Diagnosis 62 IX. The Initial Rashes 72 X. Differential Diagnosis of Chickenpox and of Measles 85 XI. Additional Points 97 Index 103 LIST OF ILLUSTRATIONS PLATES TO PACE PAGE I.-IV. Smallpox 54 V.-VI. Chickenpox 96 Chart. Prevalence of Smallpox in London between 1885 and 1912 18 DIAGRAMS I.-III. Petechial Initial Eash of Smallpox . . 84 IV. Dusky Erythema and Hemorrhagic Smallpox 84 HOW TO DIAGNOSE SMALLPOX CHAPTER I THE SPREAD OF SMALLPOX BY UNRECOGNISED CASES It is essential to realise the mischief which may be done by unrecognised cases of smallpox. There is hardly any disease of which the prompt recog- nition is more important to the general com- munity. Almost every outbreak in London in recent years has been started, or propagated and prolonged, by unrecognised cases. Epidemics teem with examples, which only cease to be recorded because they become trite. For instance, in 1888, Dr. Birdwood, then Medical Superintendent of the Smallpox Hospitals of the Metropolitan Asylums Board, reported : " The other lesson seems to be that greater care should be taken in distinguishing mild attacks of smallpox from 2 HOW TO DIAGNOSE SMALLPOX [ch. i chickenpox. It so frequently happens that the bedfellow of a confluent smallpox patient had previously a few spots that had been mistaken for chickenpox. There is only one way of putting this right — the medical profession should have opportunities for clinical observation placed at their disposal; your hospitals alone are available for that purpose, I see no difficulties in the way of admitting students to the practice of this hospital. They ought to be admitted in the interests of the public health." Of the year 1892, Dr. Ricketts, who succeeded Dr. Birdwood, wrote, "Early in March, smallpox broke out in a crowded locality in Shoreditch. The source of infection in this instance was a child who fell ill about 7th February, her complaint being diagnosed as chickenpox. It is not known how she contracted the disease, but it spread from her to other inmates of the same house, and thence rapidly to the sur- rounding population." Of the epidemic of 1893, Dr. Long, one of the medical officers engaged, reported that thirty-one persons attributed their attacks of smallpox to twenty-eight cases of " chickenpox." " Two of the local outbreaks," he proceeds, "are to be ascribed to 'chickenpox.' :h. i] UNRECOGNISED CASES Thirty-four persons ascribed their attacks to at least thirty-four cases of ' spots ' ; fourteen others to various complaints, such as measles com- plicated or not with spots, or chickenpox, influenza with or without spots, German measles, or some slight ailment. Some of these diagnoses were made by chemists and other irresponsible persons." In his report for the year 1894, Dr. Ricketts quoted this case — A young man had influenza • with spots.' He fell ill about January 16th. I E. B.'s brother living in same house fell ill with " chicken- pox " about 30th January. I He returned to work about 23rd January Fellow workman of above fell ill with " chickenpox about 6th February. E. B., smallpox rash ap- peared 20th Feb- ruary. A. C, smallpox rash ap- peared 20th Feb- ruary. H. W.'s brother died at home of smallpox. H. W., smallpox rash ap- peared February 19th. E. L., smallpox rash ap- peared February 19th. A., smallpox rash ap- peared February 20th. A.T., smallpox rash ap- peared February 22nd. Both of these patients lived in the same house as the above, and were removed to hospital. The last five of these cases were removed to hospital. With the exception of A. T., all came from the same house as the " fellow workman." A. T. had visited this house a fortnight before her rash appeared. Again : "Of the six patients mentioned (another group in the same year, 1894), two had been ill with smallpox for close on a fortnight before admission, and had been previously treated 4 HOW TO DIAGNOSE SMALLPOX [ch. i for measles. Another person in the house had been ill, and treated for three weeks for chicken- pox, while the fourth had an illness accompanied by an eruption which was supposed to be due to blood-poisoning. Supposing, as is probable, these persons really suffered from smallpox, the group of cases in this house may be tabulated as follows : — Mr. F., Fell ill in the middle of December with blood-poisoning, accompanied by an eruption of spots. He was not removed from home. Mrs. G., Fell ill with chickenpox at the end of December, and was in bed three weeks. She was not removed from home. A. M., smallpox rash ap- peared 1st February, admitted to hospital 13th February. Pre- viously treated for measles. W. M., smallpox rash ap- peared 1st February, admitted to hospital 13th February. Pre- viously treated for measles. -"1 C. G., smallpox rash ap- peared 9th February. W. M., smallpox rash ap- peared 22nd Feb- ruary. E. M., smallpox rash ap- peared 25th Feb- ruary. W. B., smallpox rash ap- peared 26th Feb- ruary. Such instances as the foregoing could be multiplied to fill a volume. I will give two further examples. That which relates to the year 1900 is a very remarkable series of cases, but ch. i] UNRECOGNISED CASES 5 led, however, to no great outbreak. There were sixty-four cases of smallpox altogether in this year. Dr. Ricketts reported: "A group of cases occurred in Hackney in January and February, 1900, which was traced to a gathering of friends in a small house in Homerton, on Christmas Day, 1899. It was found afterwards that a boy then present was suffering from a mild attack of smallpox. His illness had been mistaken for chickenpox. Eight persons present on that occasion afterwards fell ill of smallpox, and seventeen persons in all owed their illness to the same source. " On March 29th, the s.s. Caledonia arrived in the port of London. The steward and the ship's clerk returned to their homes in St. Pancras and St. Marylebone, and fell ill of smallpox within a few days of one another. Five persons with whom they came in contact afterwards developed the disease. On May 21st, a woman was admitted here with smallpox, who was the widow of a valet employed in Victoria Street, Westminster. Her husband had just died, it was supposed of measles ; but 6 HOW TO DIAGNOSE SMALLPOX [ch. i there can be little doubt that the nature of the disease was hemorrhagic smallpox. The origin of his illness was for long obscure, but it appeared probable that he caught smallpox at an eating- house in the north of London from one of the cases originating in the Caledonia. Thus, while the outbreak was stamped out in the north, its focus shifted to the south-west of London. Three persons with whom the valet's wife came into contact caught smallpox and were sent here ; while about the same time, a woman who lived in the same house in Victoria Street, and had come in contact with her or her husband, was admitted as a patient to a general hospital, and died there of a severe attack of confluent smallpox. The nature of this patient's illness was unrecognised, and five other persons who were patients or employed at that hospital, caught smallpox from her, and were sent here. When the valet died in Victoria Street, some linen from the house was sent to a laundry at Chiswick, and another centre for the spread of the contagion was thus furnished. Again the earlier cases were unrecognised, and nine patients were admitted in consequence. Nor was this ch. i] UNRECOGNISED CASES 7 quite all, for when the valet died, his brother came to London, and took the smallpox back with him to the provincial town where he dwelt. Four or five cases of smallpox resulted. "So far as is known, at least thirty cases in London and out of it could thus be traced back to the Caledonia, and over twenty cases to the man who died of 'measles' in Victoria Street. This is a somewhat unusual experience nowadays, and it is to be explained by the repeated mistakes in diagnosis which were made. Thus the nature of the original cases from the Caledonia was not at first recognised. The man in Victoria Street was supposed to have measles ; the patient taken to a general hospital died of a rare skin disease, the name of which has escaped me ; while the earlier cases in Kensington and those in the provincial town were classed as chickenpox. " Early in April, there was a small outbreak of smallpox in St. George's-in-the-East. Five patients were sent here from that infirmary, and two more from the same part of London, who all appeared to owe their illness to a common source. The first to fall ill was a boy, who was treated in the infirmary for chickenpox, the true nature of 8 HOW TO DIAGNOSE SMALLPOX [ch. i whose illness was not perceived until other secondary cases had occurred. " The cases so far touched on form the bulk of the admissions for the year, but it may be worth while to allude to the remaining cases. " In February, a young woman was admitted from Greenwich. She was shortly to have been married, but she died here of hemorrhagic small- pox. She caught smallpox from her mother, in whom the disease was of a similar nature, and had a similar result. How the mother got smallpox is unknown, nor was the nature of her illness recognised ; she was stated to have died of blood- poisoning. " Three persons, members of the same family, were admitted from Streatham, in August. The father of two of the patients had died shortly before their admission. His illness was supposed to have been due to measles. He seems to have caught smallpox from a son, who had come home on leave from a training ship at Devonport. The son was said to have chickenpox. " In November, two fellow servants were admitted from a house in Sloane Gardens. One of them has barely escaped with her life. It ch. i] UNRECOGNISED CASES 9 seems probable that they got smallpox from their master. They told me he had been suffering from blood-poisoning with an eruption of spots. " It has been mentioned that two patients were admitted from Orsett, in Essex (in July). The first patient was a youth in the Navy, who had returned to Orsett on leave from one of H.M. hospital ships. He said there was a boy there who had been suffering from German measles and chickenpox, a double-barrelled diagnosis, very suggestive of smallpox. The second patient admitted caught smallpox from the first, and died here. " I think it may be said justly that the most part of the cases of smallpox which occurred in London last year, might have been prevented very readily. Had the mistakes in diagnosis which 1 have recounted not been made, so much illness, much suffering, and some deaths would have been avoided. Smallpox is a disease which in practice seems to present more difficulties in its detection than do most others; it is the disease in which mistakes are of most moment; and yet it is, perhaps, of all diseases, that in which a certain diagnosis can be arrived at in almost every case." CHAPTER II UNRECOGNISED CASES AND THEIR REMEDY In the next year, 1901, to which the fol- lowing extract relates, though mis-diagnoses do not stand out so prominently, the results were more disastrous. They formed the begin- ning of an epidemic comprising nearly 10,000 cases. Dr. Ricketts reported : " The seeds of the present epidemic were sown in June (1901). The two first patients admitted in that month lived in Whitechapel and East Ham respectively. In neither case could the origin of the disease be traced, nor, so far as is known, did other cases develop from them. Two more important foci of infection appeared at the end of June: (1) A man who had visited Paris returned to his home in Streatham and developed ch. n] UNRECOGNISED CASES 11 smallpox there; he died, but the nature of his illness was not appreciated. A relative of his caught smallpox from him and was admitted here; his linen was sent to a laundry to be washed, and two persons working in that laundry also got smallpox. (2) A laundry carman working in Hackney caught smallpox, doubtless from the linen of one of the customers of the laundry ; a laundrymaid also caught the disease from the same source ; from this source nine others con- tracted the disease in July and August. " Two more centres were noted in the month of July. The first of these was a house in Norfolk Square, Paddington, the housekeeper and a domestic servant employed at the house falling victims, as well as a gentleman who was in the habit of visiting there ; the origin of the disease in this case could not be ascertained. The second centre was in Willesden, and the disease in this case appears to have been spread by means of infected bedding, which was sent to Willesden to be disinfected or cleaned. I do not know whence this bedding came, but three persons caught smallpox directly or indirectly from this source. 12 HOW TO DIAGNOSE SMALLPOX [ch. ii 'This carries us up to the end of July and the beginning of August, when a few cases occurred in the west of London— cases which were apparently unconnected, but which probably came from a common source and were the fore- runners of a serious outbreak. The first of these was a case of a woman of French nationality, who lived in the City of Westminster. At the same time occurred the cases of two sisters who lived in Marylebone; a sister of these patients was stated to have had chickenpox, but, assuming her illness to have been smallpox, its origin was unknown. A fourth case was that of a German waiter at the Langham Hotel. On August 9th, a patient was admitted who lived in Huntley Street, Tottenham Court Road ; a few days afterwards two patients were admitted from Holborn, another from St. Pancras. In none of these cases could the source of infection be traced, and, generally speaking, the cases seemed to be unconnected. But the common factor was that their places of residence, their avocations or amusements, took them into that part of London about the Tottenham Court Road, and it was in that neighbourhood, in ch. n] UNRECOGNISED CASES 13 some crowded streets lying on the west side of Tottenham Court Road, that smallpox broke out in the latter half of August, and shortly assumed an epidemic form. Between the 19th and 31st August, sixty-eight patients were admitted, of whom all but eight either resided in the district I have mentioned or appeared to have caught the disease there. In September the disease continued to spread to all parts of London. Its prevalence in its original seat continued up to the end of the year, so that of the total number of cases which occurred in London during the year, one-third were removed from St. Pancras, Holborn and Bloomsbury. But there was not a single union which escaped the visitation. "From what has been said it will be seen that, once it had obtained a foothold, the epidemic developed with great rapidity. Thus on August 19th, there were only fifteen patients under treatment in this hospital. In eight days this number increased to seventy-three. In a little over two months the hospital was full and patients were being transferred to Gore Farm, and in four months patients were being admitted at a rate of upwards of thirty a day. This course 14 HOW TO DIAGNOSE SMALLPOX [ch, ti of events illustrated once more the fact that outbreaks of smallpox are prone to occur without warning, and to reach unpleasant proportions with great rapidity ; and it emphasises the need for being always prepared to deal with an emergency." These and similar reports show how easy it is for smallpox to creep in, establish and propa- gate itself, undetected. Prompt recognition of the disease is seen to be vital to effective control. That, however, is by no means a simple matter. Smallpox diagnosis is a subject attended by circumstances which are altogether excep- tional. Not only is the opportunity of studying smallpox very limited, and the profession much handicapped thereby, but the disease itself presents greater difficulties of diagnosis than do most diseases. The early symptoms are common to many other disorders ; variations from type are numerous and wide ; the various stages of the disease present remarkable differences. The consequence is that smallpox has a power of deception which is as subtle as it is formidable. ch. ti] UNRECOGNISED CASES 15 In considering what can be done to meet this, it may be said that the diagnosis of smallpox is in the hands of a few ; that they cannot impart their knowledge, and that missed cases cannot be helped. I do not take that view. On p. 9, Dr. Ricketts has been quoted as writing of smallpox, " It is, perhaps, of all diseases, that in which a certain diagnosis can be arrived at in almost every case." Considering the difficulties which cases present, and the differences of opinion which they are apt to occasion among us, that is a remarkable state- ment and might well be challenged. But it agrees with my own experience, and I believe it to be true. I take the explanation to be this. Accurate diagnosis of disease results from the correct reading of accessible pathological data. In some diseases, as for instance in acute lobar pneumonia, these data are easily perceptible ; in others, such as in meningitis, they exist none the less, but are not readily accessible. The pathological data of smallpox, however, are mainly on the surface. It may be said of smallpox that, with very few exceptions, throughout its course it carries with it the naked- eye pathological evidence. The 16 HOW TO DIAGNOSE SMALLPOX [ch. n difficulty is to read this evidence aright. Rashes resemble hieroglyphics. Though the writing is all there, it is not always easy to read. Of course there is nothing like practical work for learning the subject ; experience shows, never- theless, that a great deal of useful information can be imparted in the study, and will be invaluable at the bedside, as opportunities of practice occur. Sound practical knowledge can be gathered from the written page even when actual smallpox cannot be seen. If anyone, who is anxious to improve his knowledge of the subject, studies what is given here, he can learn a great deal that will stand him in good stead when he meets with actual cases in practice. To illustrate this, reference may be made to the reports of the Metropolitan Asylums Board in reference to smallpox diagnosis. Formerly, the smallpox hospitals were in London itself, and patients were admitted to them direct. The hospitals were moved out of London on account of smallpox occurring in their neighbourhoods. Patients then were sent to be treated in hospital ships, first at Greenwich, and then near Dart- ford ; now the ships have been taken away, and ch. n] UNRECOGNISED CASES 17 the hospitals are on shore. At the present time patients are taken by a land ambulance from home to a riverside wharf, usually South Wharf at Rotherhithe, and sheltered there till the ambulance steamer takes them down the Thames to the shore hospital near Dartford. Formerly many of the patients directly admitted were found not to have smallpox, and some method of revising the original diagnosis was necessary before actual admission to hospital. In the year 1892, a temporary medical officer was stationed at South Wharf, Rotherhithe. In 1893 a medical officer was appointed to reside there, and, in the course of that year, shelters were erected in which, if necessary, patients could be detained and kept under observation. It was the duty of this officer to revise the original diagnoses, and to reduce to a minimum the admission to hospital of non- smallpox cases. In 1893, of 2433 patients sent on to hospital for admission, 73 turned out not to have smallpox, that is about 3 per cent, passed the diagnostic screen and were admitted. The next epidemic year was 1901. Of 1603 patients sent on to hospital for admission, 8 turned out not to have smallpox, that is 0*5 per cent. In the c 18 HOW TO DIAGNOSE SMALLPOX [ch. n following year, 1902, of 7208 patients sent on to hospital for admission, those who turned out not to have smallpox were 3 in number, that is 0*025 per cent. Various factors combined to produce this improvement in results, among them being the provision of certain administrative facilities; but the main factor was the method of diagnosis worked out by Dr. Bicketts, and taught by him to his colleagues. It is this method of diagnosis which I desire to set out. M' o & ! o o o c wrnn i,Uu.sj^ o o c o"o o ?» t * »vl)lH(MW «l F;s^rjr :;^t?n:i ; t! J t j — 'SSy /8*f I ^~- /■ "~ ==-? /8i.UiH.\M I. -Petechial iuitial rash of smallpox dotted in on diagram, with bedside notes. r&l* Out's k*trK\ \J \ initial rash of smallpox d< w Diagram II.— Petechial initial rash of smallpox dotted in on diagram, with bedside notes. */«{» 6/ C* A* ^ /t \ I / . '*,■?■¥. Diagram III.— Petechial initial rash of smallpox dotted in on diagram, with bedside notes. Hasuiorrhagio smallpox Bupervenod, ^X^JUvw-, 7K~ n- *— '-Y* &r • IV. — Dusky erythema i z '7X0. . f^LdV^ nu *~^ */**»"- (*-**>*« '"" Diagram IV.— Dusky erythema and hemorrhagic! smallp CHAPTER X DIFFERENTIAL DIAGNOSIS OF CHICKENPOX AND OF MEASLES Our attention is now claimed by the differential diagnosis of diseases which are apt to be confused with the rash of smallpox in its papular stage or later; and first comes chickenpox. From the list on pp. 62-3, it is seen that, of the total 607, no less than 203, that is one-third, were chicken- pox. This disease therefore requires special con- sideration. In the differential diagnosis of smallpox and chickenpox it is usual to take the history first and then to examine the elements of the rash ; and to leave the distribution to the last. The fallacies of histories have been pointed out on pp. 29 to 34 ; such an example of chickenpox diagnosed upon history, as is there given, is by no means uncommon. To get correct results, it 86 HOW TO DIAGNOSE SMALLPOX [ch. x is necessary to take the rash first, and carefully to consider its distribution. The distribution in chickenpox cases is striking, and significant. On the face the rash is well marked, and on the chest it is the same, and so it usually is on the back. But on the ex- tremities it fades away from above downwards, till on the hands and feet there is hardly any at all. This gradual decrease in the rash, as one passes from the shoulders to the hand, is a strong characteristic of chickenpox ; and, more- over, is in marked contrast to smallpox. When- ever a diagnosis is to be made between chickenpox and smallpox, it is a very practical step to have the patient stripped to the waist, and seated in a good light with the arms crossed in front, as in the man's photograph at the end of this chapter. Often this posture by itself will demonstrate the diagnosis without any further evidence. No opinion, however, should be given without a com- plete examination. The distribution should be carefully observed, stress being laid upon the relative density of the rash. In the photograph of the man alluded to, the density of the rash on the chest, compared ch. x] DIAGNOSIS OF CHICKENPOX 87 with that of the rash on the face, is more com- patible with chickenpox than smallpox ; that is to say it is too thick on the chest, relatively, for smallpox. And when the freedom from blemish of the arms and hands is considered with reference to the density on the chest and face, that relative distribution of the rash puts small- pox out of court. It is necessary to emphasize the word relative; it is the proportion of the spots in one area to those in another that is all important. The same comparison between the face, side, arm, and hand may be made in the case of the girl's photograph, resulting in the same diagnosis. That such a case is not smallpox may be perceived from the mere arrangement of the spots. This much should be added, however, about the distribution of the chickenpox rash. Occasionally it also shows a tendency to favour sore or irritated surfaces. I have seen chickenpox rash pick out scratches and burns ; and, in infants' skins, surfaces irritated by rubbing. Only the tendency for chickenpox to favour these sites is very much less than in the case of smallpox. 88 HOW TO DIAGNOSE SMALLPOX [ch. x Let us now take the individual lesions of the two diseases and compare them. Take the vesicular stage of smallpox. In the first place, many of the lesions are circular in outline; those that are not so, are but slightly out of the circular and some that at first sight looked elliptical, are seen on closer examination only to have that form from the fusion of two circular lesions. Nearly all the pocks are tense, and have a firm and definite outline ; and finally, they are all definitely set in the skin and not on it. In order to appreciate the depth at which the lesion is set, roll a loose fold of skin between finger and thumb ; a method which applies more especially when lesions are in the papular stage. It is, of course, an important point of differentia- tion, this degree of depth in the skin at which the lesions are situated. It is of no use to feel spots against a bony surface; when so felt, spots on the face are often shotty. Now look at the characteristics of the chicken- pox rash. Choose anywhere but the face if you can, for the purpose of examining the elements of the rash. The rash on the face, both of smallpox and chickenpox, is less easy to read ch. x] DIAGNOSIS OF CHICKENPOX 89 than on other parts of the body; so the face is best left till the last. Many cases occur in which the rash on the face is puzzling, but unmistakable in other regions. This is notably the case with chickenpox in adults. The rash of chickenpox on the face of an adult is apt to be coarse and obscured, and may resemble that of smallpox on the same region, much more closely than does a smallpox rash in the flank resemble chickenpox in this situation. Therefore, rather avoid the rash on the face, not in considering the distribution, of course, but in considering the elements of which the rash is composed. Look now at the individual lesions of chicken- pox on the trunk, in such a part as the small of the back, or the flank, or the neighbourhood of the umbilicus, or the anterior fold of the axilla, and see what the pock is like. Often it is not circular, but is elliptical, lozenge or spindle- shaped, the long axis lying in the same direction as do the natural folds of the skin on which the spot lies. That is a point worth bearing in mind. Next, the outline of the vesicle is not, as a rule, sharp and firm and well-defined, but is irregular and crenated. This goes with the general appearance 90 HOW TO DIAGNOSE SMALLPOX [ch. x of the vesicle, which commonly does not look tumid and tense and bursting with pressure from within ; often the pellicle is wrinkled and flaccid and even fallen in; so that a kind of spurious umbilication may be present. All these features of the chickenpox lesion are in association with, and are caused by, the superficial position of the spots in the skin. If a piece of the affected skin be lightly pinched up and rolled between the fingers, this superficial position will at once be evident. Though these various characters are often of material assistance in distinguishing chickenpox, they may be insufficient for that purpose; for the elements of the one disease may resemble the elements of the other with marvellous close- ness. Generally speaking, the resemblances between smallpox and chickenpox are very remarkable ; so much so as to suggest they are descended from ' a common ancestor. In adults at least, both are marked by sudden onset, by fever and the symptoms commonly associated therewith ; on the third day, a rash appears which runs a course from papule through vesicle, pustule, scab and scar. I recall three children of the same family ch. x] DIAGNOSIS OF CHICKENPOX 91 who were admitted together, and presented rashes which were very remarkable. All the attacks were mild and discreet. One of the patients might have been thought to have had both chicken- pox and smallpox at one and the same time — a phenomenon which I have never seen. Another frankly had smallpox. But the third had a rash which was a marvellous counterfeit of chickenpox, in almost every particular. The pocks seemed superficial and were free from any surrounding redness; they were unilocular, translucent, pearly little blisters, a "window" of which was almost impossible to distinguish from chickenpox. The lapse of twenty-four hours, however, displayed the rash in its true character, deeper, more robust, redder, and angrier. It is in such cases that we are driven to consider what else there may be which may differentiate the major from the minor disease. Unilocation will not help us. Nor is it of much practical assistance that chicken- pox may come out in crops. In any given window of the skin, chickenpox may show lesions in every variety of stage, namely as papule, vesicle, pustule, scab. This is in part due to the difference in size of individual lesions. The small ones run a shorter 92 HOW TO DIAGNOSE SMALLPOX [ch. x course than the larger ; and this partly accounts for the irregularity of the rash. A similar phe- nomenon is often seen in smallpox, though not to so marked a degree. No one should think of smallpox as a rash composed of elements of perfectly even size. That is seldom the case. Nor again are the spots evenly or regularly dotted about as if each were the centre of many regular squares or circles — that is never so. It is sometimes suggested that if lesions ap- pear upon the mucous membranes of the mouth, that fact excludes chickenpox. But the rash of chickenpox appears in those situations too. Nor is there any difference between the two diseases, so far as I am aware, in their relative incidence on the hard and soft palates, as has sometimes been alleged. A heavy incidence of rash on hands and feet is, by itself, an argument against chickenpox, but it requires to be supported by other evidence : I have seen not a few cases of chickenpox in which there was abundant rash on the extremities. The conclusion is that there is no single touchstone for the differentiation of smallpox and ch. x] DIAGNOSIS OF MEASLES 93 chickenpox. Stress has already been laid on the preference of the rash of smallpox for irritated and exposed surfaces, and no doubt that is the most useful single point of difference between it and many other diseases, chickenpox included. But it is imperative to take the whole of the evidence and weigh it together. Passing now to measles, which comes next on the list, we find that clinicians who have seen little smallpox are apt to think they are not likely to confuse smallpox with measles ; and I think they are right. It is those who are fairly conversant with smallpox who are more likely to be mistaken. That is one of the subtleties of smallpox. It by no means follows that an observer who has seen some hundreds of cases for diagnosis, and has got a good grasp of the subject, — it by no means follows that he will have no further difficulties or pitfalls to avoid. On the contrary, traps will be provided for him at every stage of proficiency; and measles is more apt to puzzle the skilled than the in- experienced. Let me give an illustration. I was with a practitioner who had recently left a smallpox 94, HOW TO DIAGNOSE SMALLPOX [ch. x hospital and entered general practice; he re- peatedly called my attention to the close re- semblance between some cases of measles we saw together and the smallpox cases with which he had previously been familiar. He repeatedly remarked how alike they looked at the first glance. It is in fact the case. Measles, when full out on the face, may bear an extraordinarily close resemblance to a smart attack of smallpox about the second day of the rash. I saw such a case recently. The patient was an adult ; when I went into the room and saw the face thickly covered with rash looking at me over the top of the sheets, smallpox involuntarily came into mind. At the first glance one could hardly doubt the rash was due to smallpox, and the apprehensions of my colleague with whom I was in consultation, seemed fully justified. Not only was the rash plainly raised to sight and touch, but in the circumoral region, especially at the right side of the lower lip, it felt tough and firm, and was slightly but plainly vesicular. Moreover the history was consistent. There was a two days' history of fever and its usual accompaniments; there had been pains, and there was prostration. ch. x] DIAGNOSIS OF MEASLES 95 The patient looked and was most seriously ill. But the temperature was 105° ; and that was a point against smallpox at the end of the papular stage. More important, however, was the distri- bution of the r&sh, I would repeat the warning, given on p. 89, to beware of paying too much attention to the elements of a rash on the face. I had the patient undressed to the waist. On an inspection of the trunk, the true nature of the rash became at once evident. If one had seen it first on the pectoral region or on the back, and had not seen the face, one could not have doubted, for a moment, that it was due to measles. Its density on the chest, the peculiar outline of its elements, the comparative regularity of its pattern, the absence of any definite papules — this with other points about its distribution generally, excluded smallpox, and settled the diagnosis of measles. I had an opportunity of seeing the case again at the end of twenty-four hours; by that time the rash had almost left the face. The skin was almost normal. Far otherwise would it have been in a case of small- pox ; a rash due to that disease, however soft and velvety it might have been even on the second 96 HOW TO DIAGNOSE SMALLPOX [ch. x day, would have become so aggressive and determined and enlarged, at the end of twenty- four or forty-eight hours, as to be impossible of mistake. Plate V Photo by Dr. J. Howell Griffiths.] CHICKENPOX. Plate VI Photo by Dr. J. Howell Griffith*.] CHICKENPOX. CHAPTER XI ADDITIONAL POINTS Generally speaking, when smallpox is suspected, the most useful plan is to ask the question of yourself, Can smallpox produce this ? Then ex- amine the various areas in turn from the point of view of distribution, and proceed to examine the elements of which the rash is composed. In this connection I may draw attention again to a point mentioned on page 28. It is that a well marked rash cannot be due to smallpox, if the skin of a whole limb or other extensive area be entirely free of rash. Take, for instance, the rashes mentioned in the above list as due to bites of insects. Several of these were due to bug bites. The favourite seat was the neck, with some extension on to the shoulder and back ; but the rest of the skin of the body was perfectly clear ; and that absolutely excluded smallpox. In this H 98 HOW TO DIAGNOSE SMALLPOX [ch. xi same class were several cases due to mosquito bites. Two of these patients were English persons who had been badly mosquito-bitten in Holland. The forearm, wrist, and hand of one of them bore a remarkable resemblance to those of a patient attacked by smallpox ; indeed, the rash was almost indistinguishable. Moreover, the face was similarly affected, the bites having been inflicted while the patients were asleep in bed. Now here were two patients whose rashes were conspicuous on the hands and face, and regarded cursorily, had the closest resemblance to smallpox, and were certified to have that disease ; but examination showed the rest of the skin to be absolutely free from any blemish whatever. That put the diagnosis of smallpox absolutely out of court. However much the local rash resembles smallpox, if it is at all copious and if it is strictly local, and the rest of the skin is clear, it cannot be smallpox. Smallpox is a generalised disease and exhibits something like a general symmetry in distribution. There are one or two additional points which may usefully be mentioned. It is well to know how to identify the latest ch. xi] ADDITIONAL POINTS 99 stage of smallpox, that is, after most of the scabs have disappeared. In inquiring into an outbreak it is not uncommon to receive a history of some one having fallen ill several weeks previously; and the suspicion of smallpox is raised. A complete and careful examination of the skin is required. Such an examination may establish an attack of smallpox, even where the rash has been light. A foot bath must be used if the feet are not perfectly clean ; for on their condition the diagnosis may turn. On the face, what may appear at first sight to be large papules, are on careful examination seen to be nodules of scar tissue. Similar but less prominent lesions may be seen on the hands. If, in addition to these, pigmented recent scars are seen scattered about the trunk and other areas (and the tenderer the skin, as a rule, the flatter and softer the scar), and if on a general review the distribution corresponds with that of smallpox, then it may with confidence be said that smallpox could have caused these lesions. A very careful inspection should be made of the palms of the hands and soles of the feet and toes, for in these situations the scabs 100 HOW TO DIAGNOSE SMALLPOX [ch. xi are apt to remain longest. If in such situations, deeply situated brown scabs can be seen through the horny epidermis and partly masked by it, the diagnosis can be clinched. Only it should be remembered that scabs under the thick skin do not, of themselves, denote smallpox : occasionally chickenpox produces them. The distribution of the scars and scabs must be consistent with that of the rash of smallpox. The assistance which may be gained, in obscure cases, from watching the progress and development of the rash should not be overlooked. There were sent for admission, for instance, a number of patients, several of whom had a chronic skin disorder ; from some of them smallpox could be excluded, but of one other the skin was already so thickly covered by a chronic syphilide that no opinion at first was possible. There was nothing to be done but watch the case; in the event, hemorrhagic smallpox supervened, but so thick was the chronic rash and so obscure the acute exanthem, that nothing but the lapse of time and the development of the rash could have rendered the diagnosis certain. The slow development, on the other hand, of such a rash ch. xi] ADDITIONAL POINTS 101 as is due to bromide or iodide of potassium may throw valuable light on its diagnosis. Vaccination is a factor which occasionally may assist diagnosis. But it should not be considered until the end of the examination proper. Of course recent and successful vaccination com- pletely excludes smallpox. But it may not be easy to say when vaccination is recent and successful. Mere scars may be of little value in this connec- tion ; and statements of patients that the operation was recent and successful are to be received with much caution. It is a sound administrative rule to regard no evidence of vaccination as satisfactory except the presence of a pigmented foveated scar. Even this may be misleading, if revaccina- tion has been unsuccessfully performed on an old scar. A matter which should always be in the mind of the diagnostician is the environment and con- dition of the patient's skin, as well as its texture ; it is the fineness and delicacy of the skin of children, for instance, that makes a smallpox rash occasionally appear in them to be so superficial. In like manner the rash which comes on the flaccid, inelastic, thin and partly atrophied skin of an 102 HOW TO DIAGNOSE SMALLPOX [ch. xi infirmary bedridden patient has a character all its own. In conclusion my advice is this. Have the possibility of smallpox always in mind. Have the greatest possible respect for it. Use every care in examining a case. Examine the whole skin, and see it in good light ; do not be satisfied until you have so seen it. Consider the distribution closely, and, if necessary, map it out on paper. Examine in what degree the rash is superficial or not. Consider the history last. Weigh all the evidence taken altogether, assigning the most importance to that afforded by the distribution of the rash. INDEX Acne, 39 Action brought for error in diag- nosis, 24 Anomalous smallpox rashes, 48, 49,50 Appendicitis, 64, 65 Backache, 31, 63 et seq., 84 Blood-poisoning, smallpox diag- nosed as, 4, 8, 9 Caledonia, the s.s. , 5 et seq. Chickenpox, differential diagnosis, 85 et seq. smallpox diagnosed as, 2, 3, 5, 8, 9, 24, 32, 62 Completeness of examination, 21, 24 Confluent smallpox, 42 Definition of smallpox, 44 Depth of lesions in skin, 88 Development of rash, 100 Diagnosis generally, on what it depends, 15 Diagrams, usefulness of, 27, 35 Differential diagnosis, 62 et seq. Direct evidence, importance of, 34 Distribution of rash, 27, 28, 44, 51 et seq., 86, 87 of smallpox rash, explana- tion of underlying principle, 51 et seq. Drug rashes, 80 Dual nature of smallpox, 55 Enteric fever, 69 Epidemics, origin of, 3, 4, 5, 10 et seq. Erythematous initial rash, 75 Flat type of rash, 41, 42 Hsemorrhagic smallpox, 6, 8, 77, 82 et seq. " History," the, 31 et seq. Influenza, smallpox diagnosed as, 3,68 Initial rashes, 72 et seq. petechial, 73 et seq. erythematous, 75 signs and symptoms, 31, 32 Irritated surfaces, 45 et seq. Late stage of smallpox, 99 Laundry, smallpox spread by, 6, 11 List of other diseases diagnosed as smallpox, 62 Loculation, 42, 43, 91 Measles, differential diagnosis of, 93 104 INDEX Measles, smallpox diagnosed as, 3, | Salvation Army captain, 56 4, 8, 62, 79 Methods of examination, 19 et seq. Metropolitan Asylums Board, 1, 16 et seq. Mosquito bites, 39, 98 Origin of smallpox epidemics, 3, 4, 5, 10 et seq. Pain in the back, 31, 63 et seq., 83 Petechial initial rash, 73 Prostration in smallpox, 32, 57 Purpura, 80, 81 Rash of smallpox, anomalies in, 48, 49, 50 on mucous membranes, 71 stages of, 60 Receiving station, 17 Relative density of distribution, 27, 28, 86, 87 Rheumatism, 64, 65 Rdtheln, 79 Scarlet fever, 78 Shottiness of smallpox rash, 39 et seq. Sites of early smallpox rash, 70 Skin texture, 101 Smallpox diagnosed as blood- poisoning, 4, 8, 9 as chickenpox, 2, 3, 5, 8, 9, 24, 32, 62 as influenza, 3, 68 as measles, 3, 4, 8, 62, 79 confluent, 42 hemorrhagic, 6, 8, 77, 82 et seq. Spread of smallpox by unrecog- nised cases, 1 et seq. Temperature in smallpox, 56, 84 Typhoid fever, 69 Varicella. See Chickenpox. Vomiting, 32 Umbilication, 37 et seq. THE END PRINTED BY WILLIAM CLOWES AND SONS, LIMITED, LONDON AND BECCLES. GENERAL LIBRARY UNIVERSITY OF CALIFORNIA— BERKELEY RETURN TO DESK FROM WHICH BORROWED This book is due on the last date stamped below, or on the date to which renewed. Renewed books are subject to immediate recall. rau $1 - D\V/ lull U JUN 7 1950 SENT GN ILL JU! 2 2002 U. C. BERKELEY LD 21-100m-l,'54(1887sl6 )476 HEALTH LIBRARY /3 72853 12-29 1M