The University Dakota 
 
 DEPARTMENT B$!]LGLflTINS 
 
 SMALLPOX 
 
 The Public Health Laboratories 
 
 Bulletin No. 23 
 
 Entered as second class matter at University, North Dakota. 
 Acceptance for mailing at a special rate of postage provided 
 for in Section 1103. Act of October 3, 1917, authorized 
 May 5. 1920. 
 
I, 
 
 
 
 
 
 
 
 
<oZa \\Z.*l B r o UJ vO 
 
 \ 
 
 NORTH DAKOTA STATE DEPARTMENT OF HEALTH 
 
 Hon. William E. Langer, Bismarck President 
 
 H. O. Cooperman, M. D., Minto Vice President 
 
 C. J. McGurren, M. D., Devils Lake Secretary 
 
 DIVISION OF VENEREAL DISEASE CONTROL 
 F. R. Smyth, M. D., Bismarck Director 
 
 DIVISION OF LABORATORIES 
 
 A. G. Long, M. D., University Director 
 
 A. G. Long, M. D Pathologist 
 
 Miss Caroline M. Steele, B. S. . . .Bacteriologist and Sereologist 
 
 Miss Maude S. Virden Stenographer 
 
 I. W. Mendelsohn, B. S Chemist 
 
 DIVISION OF SANITATION 
 
 I. W. Mendelsohn, B. S., University Sanitary Engineer 
 
 BRANCH LABORATORIES 
 
 Miss Delia Johnson, B. A., Fargo Bacteriologist in charge 
 
 E. M. Stanton, Bismarck Bacteriologist in charge 
 
 Chas. K. Allen, B. S., Minot Bacteriologist in charge 
 
SMALLPOX 
 
 There is no knowledge as to the first appearance of this 
 disease in Europe, it is believed that some of the great epi- 
 demics which devastated Athens in 430 B. C. and the plague 
 of Antoninus, which appeared in Italy in 165 A. D., were 
 epidemics of smallpox, but the descriptions are too indefinite. 
 The first medical description of the disease comes from two 
 Arabian physicians at t he end of the Ninth century. Up to 
 the beginning of the 12th century the disease was practically 
 constant in Europe. In the 13th century the disease became a 
 plague in England. Iceland and Greenland were visited a l 
 intervals and the greater portion of the population destroyel 
 several times. It was introduced to America in 1507 and has 
 never disappeared since being particularly active in the 
 destruction of the native population. Smallpox was perhaps 
 never more prevalent than in the 18th century when the 
 mortality was incredible. 
 
 Vaccination was introduced in the 19th century and since 
 then the frequency and mortality of the disease has begun -to 
 diminish. Compulsory vaccination was begun in Germany hi 
 1874. The disease flourishes equally as well in the tropics as 
 in the frozen north and the entire human race is susceptible. 
 
 Just how infection takes place is unknown, but it is thought 
 that the virus lodges in the mucous membrane of the respira- 
 tory tract of the susceptible individual and produces a lesion 
 
similar to that appearing on the skin. The development takes 
 12 days, then the parasites which have developed entetf the 
 circulating blood producing a fever. They then travel to all 
 parts of the body but only find suitable conditions for develop- 
 ment in the superficial layers of the skin. 
 
 In the past only five persons out of a hundred escaped it 
 and about a quarter of those who took it died from its effects. 
 Today, by the simple and safe process of vaccination, the 
 disease may be prevented in any community, and its occurrence 
 is always a mark of ignorance or neglect on the part of the 
 victim or of his associates and a sign that he desires to wear a 
 “waffle iron” face for the rest of his life. 
 
 The disease most likely to be mistaken for smallpox is 
 chicken-pox. The disease may begin with gradually rising 
 temperature and some severe symptoms lasting several days 
 before the eruption appears. In smallpox the temperature 
 arises abruptly and just as the eruption is coming out or before 
 it is out, it drops abruptly. 
 
 In chicken-pox the rise is gradual and is maintained after 
 the eruption appears lasting for a day or so. The paucity 
 of eruption is sometimes a pitfall. Smallpox very often pre- 
 sents a much more profuse eruption than chicken-pox, however 
 these are forms of rash which demand careful study. In 
 most cases the lesions are abortive ; some go no farther than 
 the papular stage ; some vesicles dry before reaching a typi- 
 cally pustular stage ,and sometimes the eruption goes through 
 all the classical stages with the pustules in a diminutive size. 
 Again the lesions of smallpox may be quite irregular in form 
 and large areas of the back or other surfaces may be covered 
 with an eruption which is superficial and not indurated. 
 
 There is no one thing upon which we may safely pin our 
 faith in the diagnosis of smallpox, while we may be reasonably 
 certain of our diagnosis we should take into consideration the 
 patient’s history as to previous childhood illness ; temperature 
 curve ; signs of successful vaccination ; characteristic course 
 and location of the eruption. 
 
The most important points in diagnosis between smallpox 
 and chicken-pox may be summarized as follows : 
 
 1. In smallpox the prodromal symptoms before the erup- 
 tion appears usually last about three days, but they may last 
 longer, four or five, or rarely six days, or may be no more than 
 one day. In eliicken-pox there is usually no distinct prodromal 
 period. - The eruption is often the first thing noticed. 
 
 2. In smallpox the onset of the prodromal symptoms is 
 abrupt. When there is a marked systemic disturbance in 
 chicken-pox the onset of the symptoms is much less abrupt 
 and they usually persist after the eruption appears. 
 
 3. In smallpox there is a marked fall in temperature with 
 the appearance of the eruption, or very soon after, or even 
 before the eruption shows itself, and in cases with a sparse 
 eruption there is no subsequent rise— there is no secondary 
 fever. In chicken-pox with distinct systemic symptoms the 
 temperature does not fall with the appearance of the vesicles: 
 it may remain at 101° or 102°F. or more for 24 or 48 hours or 
 so after the onset of the eruptive stage with a distinct rise with 
 each fresh crop of vesicles. 
 
 4. Aside from the macular stage, the eruption of smallpox 
 first appears as papules ; in chicken-pox as vesicles. 
 
 5. In smallpox, before encrustation occurs, the lesions pass 
 through the stages of papulation, vesiculation and pustulation. 
 In chicken-pox the lesions appear as vesicles and dry down as 
 vesicles with turbid contents — no true pustules. 
 
 G. In smallpox the lesions are not well rounded up as 
 vesicles, but as pustules they are semiglobular. In chicken-pox 
 the vesicles are well rounded out at first, but flatten down 
 before a true pustular starge is reached. 
 
 # 
 
 7. In smallpox abnormailities are frequent, and the erup- 
 tion sometimes goes through its transformation with remark- 
 able clerity, but the typical lesions before desiccation begins 
 are p pules about two d ys, vesicles two days, and pustules 
 
four days. In cliicken-pox the vesicles begin to dry down in 
 twenty-four or thirty-six hours. 
 
 8. Flatwise of the skin the smallpox lesions rarely depart 
 but little from the true circular in outline. In chicken-pox 
 many of the lesions are oval or irregular in outline. 
 
 9. The smallpox papule is indurated. It has the sliotty 
 feel, and the vesicle has a distinctly indurated base. In 
 chicken-pox there is no distinct induration. 
 
 10. In the distribution of the eruption of smallpox there 
 is likely to be the greatest profusion on the face, and it is 
 most scanty on the chest and abdomen. In chicken-pox it is as 
 abundant on the abdomen and chest as on the face, and often 
 more so. 
 
 11. In smallpox there is a more abundant eruption on the 
 back than on the abdomen. In chicken-pox a marked difference 
 is not the rule. 
 
 12. In smallpox there is a diminishing graduation from 
 the shoulders to the loins, and fro rathe chest to the lower part 
 of the abdomen. No such rule is followed in the distribution 
 of the eruption of chicken-pox. 
 
 13. In smallpox the eruption is usually more abundant on 
 the limbs than on the trunk. In chicken-pox it tends to avoid 
 the limbs. 
 
 14. In smallpox the eruption is more abundant on the dis- 
 talends of the limbs. In chicken-pox it is more abundant on 
 the proximal ends. 
 
 15. In smallpox the eruption is most profuse on the parts 
 which are most prominent and are the most exposed' to the air 
 or to irritating influences, and is most sparse in the depressions 
 and flextures. In chicken-pox no such law controls the dis- 
 tribution. 
 
 1<>. Chicken-pox is rarely seen in adults. 
 
Unmodified smallpox is usually one of the most fatal and 
 loathesome of diseases. Vaccination in childhood almost 
 always prevents a fatal result even if the disease is contracted 
 in old age. Vaccination, recently and properly done, will pre- 
 vent, almost without exception, the contraction of smallpox, 
 no matter how great the exposure. It is the usual thing to find! 
 tliata the community with a smallpox outbreak on its hands 
 is one in which there is no compulsory vaccination, and that 
 but a very small percentage of the community have availed 
 themselves of this protection. The more usual thing is a com- 
 munity apathetic as regards smallpox until the disease appears 
 and has spread to dangerous proportions. Statistics compiled 
 by observers in various parts of the world, all tell the same 
 story, namely, that 92.5 percent of smallpox occurs in the 
 un vaccina ted. 
 
 Every person should be vaccinated when an infant and then 
 re-vaccinated at regular intervals as it has been found that 
 successful vaccination on two occasions usually confers a life 
 long immunity which is as nearly absolute as anything can he 
 in this world. 
 
 Through the introduction of bovine virus it is absolutely 
 impossible to transmit any disease from person to person, and, 
 if due care of the wound is taken, it is not possible for tetanus 
 to develop as that germ has never been found in the vaccine 
 itself. 
 
 Vaccination should be performed by no one but an experi- 
 enced physician and one of the methods advised by the Surgeon- 
 General of the United States Public eHaltli Service is as 
 follows. It is known as the endermic or multiple puncture 
 method : 
 
 (1) The vaccination site, near the insertion of the deltoid, 
 may be washed with soap and water and then should be 
 washed with alcohol or ether. (2) After the skin has dried 
 a moment, a small drop of vaccine is deposited upon the skin 
 at three spots, forming a triangle whose points are not less 
 than two inches apart. (3) An ordinary sewing needle of 
 pretty good size, with a sharper point than those which usually 
 
come with the tubes of vaccine, is sterilized. Needles are 
 much more conveniently used if mounted in wooden handles, 
 or pushed into penholders as substitutes. (4) The vaccinator’s 
 hand, closed upon the arm from behind, draws the skin tense 
 in front. The needle, held slantingly, but nearly parallel with 
 the arm. is pressed against the skin through the drop of vac- 
 cine. About ten tiny punctures should be made through each 
 droplet of vaccine, each set of ten punctures, covering an area 
 of not more than one-sixth of an inch square. The punctures 
 should not draw 7 blood ; they should in fact, be hardly one one- 
 hundredtli inch deep. (5) The surface is wiped with a bit of 
 sterile gauze or cotton and the sleeve is drawn down. 
 
 There is no need of the application of bandages or any 
 kind of dressings : it is really better not to resort to anything 
 of the kind, unless, possibly, a square of sterile gauze is 
 attached by needle and thred or by safety pins to that part of 
 the sleeve covering the place of vaccination. 
 
 The advantages of this method are: (1) The vaccinations 
 may rapidly and easily be done. (2) It is bloodless, painless 
 and, therefore, not so objectionable to timid persons. (3) The 
 chances for sore arms and other undesirable results are reduced 
 to a minimum. (4) There is a saving of band ges and other 
 -dressings an dof time in applying them. (5) The percentage 
 of takes is as good or better than with other methods. 
 
 As smallpox is contagious from the time the eruption first 
 appears, until after it has entirely disappeared and until 
 scaling has ceased, the affected person should be isolated from 
 all but necessary attendants. He should be removed to a 
 hospital if possible. If treated at home strict isolation is 
 needed, all contacts and attendants should be freshly vac- 
 cinated. A placard with smallpox in large plain letters should 
 be posted in a conspicuous place. The advantages of vaccina- 
 tion of contacts are numerous, — it will prevent the develop- 
 ment of smallpox if performed soon enough : it will modify 
 the course of the disease if not performed soon enough ; and, 
 finally, it w T ill allow the contacts to go about their business, 
 but they should report for inspection daily for 20 days. 
 
\ 
 
 As the disease is very contagious and may be conveyed by 
 persons, clothing, letters, it is advisable to keep everything 
 away from the patient except what is absolutely necessary, to 
 receive all discharges into old rags which can be burned or 
 into vessels containing some good disinfectant such as 5 per 
 cent carbolic acid or 2 percent creolin. Eating utensils should 
 also be wet in 5 percent carbolic acid when removed from the 
 bed and allowed to stand two hours and then boiled. During 
 the scabbing and scaling stage the patient should have his 
 body annointed with oil or vaseline and the floors mopped daily 
 with carbolic acid solution. When the patient is ready to 
 dismiss he should be given a carbolic or 1-5000 bichloride bath 
 and his hair well washed also. He should go into another 
 room to dress and put on all clean clothes, his old ones being 
 carefully disinfected before being washed. 
 
 The quarters where the patient has been treated should 
 be carefully disinfected and cleaned according to the most 
 approved methods. The care with which the latter is done is 
 perhaps of greate rvalue than the former. Of the gaseous dis- 
 infestants formalin or sulphur may be used, the formalin being 
 perhaps the less injurious to fabrics and metals. In either 
 case the room should be tightly closed, the temperature of at 
 least ()0°F and the air very moist and the gas allowed to act 
 eight to twelve hours, when the room may be opened and the 
 floor, woodwork, walls and ceiling washed down. If the person 
 dies, there can be no public funeral. The patient must remain 
 in quarantine till all lesions have disappeared. 
 
 As home treatment of smallpox is difficult, it is advisable 
 to establish a hospital owned by the municipality and under the 
 control of the health department, such an institution could 
 serve several adjoining districts, who could unite in bearing 
 the cost of erection and maintenance. Such hospitals could 
 be rendered entirely non-infectious and could be used for any 
 communicable disease. It is not absolutely necessary to have 
 the building in an inaccessible situation as long as it is some 
 300 feet from any roadway or other building. The hospital 
 should be supplied with a vehicle which can be used as an 
 
ambulance, should have means for sterilizing and disinfecting 
 clothing, and some efficient means of disposing of excreta. 
 A resident matron is necessary, also provision should be made 
 for obtaining extra assistance as occasion demands. The 
 building should be attractively built and kept in good repair 
 so that patients will no*t object to being placed there. The 
 grounds should be sufficiently large in order that convalescent 
 patients may exercise in the fresh air, move around without 
 coming into too direct contact with the public. 
 
 If smallpox occurs in a school, don’t stop the school, stop 
 the student who has it and all the other children in the family. 
 Vaccinate all who have not been vaccinated at once, and carry 
 on just as if nothing had happened. If vaccination were com- 
 pulsory there would be no smallpox in North Dakota after the 
 present generation, except imported cases. 
 
 The regulations of the State Department of Health in 
 regard to smallpox are as follows : 
 
 Regulation 10. (A) House must be placarded. The State 
 
 Board of Health does not require an absolute quarantine for 
 smallpox, being convinced that vaccination is the only rational 
 method of preventing this disease. The requirements of the 
 State Board of Health are : When a case of smallpox is 
 reported to a health officer he shall place a sign bearing the 
 words “Smallpox Here” on each entrance to the house where 
 the disease exists. Any person suffering from smallpox is 
 prohibited from leaving the premises until desquamation is 
 completed. 
 
 (B) Cities and Counties May Quarantine. Cities have 
 authority to pass ordinances and county boards of health may 
 make regulations requiring more rigid quarantine for small- 
 pox, but until such ordinances have been enacted and until 
 such regulations have been adopted by the county board of 
 health and approved by the State Board of Health, no local or 
 county health officer has authority to enforce more rigid 
 quarantine for smallpox than is provided under Rergulation 
 10. Par. A. 
 
FREE BULLETINS FOR CITIZENS — ASK FOR THEM 
 
 1. State Public Health Laboratory. History, Instructions 
 and Fee Table. 
 
 *2. What You Should Know About Tuberculosis. 
 
 3. Pure Water and How to Obtain It. 
 
 *4. Sporotrichosis in North Dakota. 
 
 *5. Facts About Rabies. 
 
 6. The Production and Care of Milk for Infant Feeding. 
 *7. Facts About Cancer. 
 
 8. The Fly; a Disease Carrier. 
 
 9. Ninth Annual Report of State Public Health Labora- 
 
 tories. 
 
 10. The Sanitary Privy. 
 
 11. Your Baby, How to Keep it Well. 
 
 12. The Next Step Towards Efficiency in Public Health. 
 
 13. Fresh Air and Why. A talk on school-room ventilation. 
 
 14. Colds. Cause, Prevention and Home Treatment. 
 
 15. Cerebro Spinal Meningitis. 
 
 16. Keeping in Repair. How to care for the body — Physical 
 
 Examinations. 
 
 17. Scarlet Fever. How it may be detected. How it may 
 
 be avoided. Directions to mothers, nurses, physicians 
 and health officers for treating cases of this disease. 
 
 18. Disinfection and Disinfectants. 
 
 19. The Teacher and Communicable Disease. 
 
 How disease is caused and spreads, symptoms by which 
 the teacher may detect communicable disease. 
 
 20. Diphtheria. Cause, prevention and cure. 
 
 21. Typhoid Fever. Information for those who care for 
 
 patient, for physician and health officers in regard 
 to the spread and prevention of typhoid fever. 
 
22. Measles and Whooping Cough. Information for parents 
 
 and for those who care for the patient, for physicians 
 and health officers in regard to spread and prevention 
 of measles and whooping cough. 
 
 23. Smallpox. How to detect this loathsome disease. How 
 
 the disease spreads, an dhow it may be avoided. 
 Direction for care of patients. 
 
 24. The Wasserman Reaction as a diagnostic procedure. 
 
 Interpretation. Need for a history. Provocative 
 Wasserman. 
 
 25. Health Officer’s Loan Library. 
 
 *26. Stereopticon Loan Library. 
 
 *27. Rural Home Comforts. A series of four blue prints 
 together with specifications dealing with the subject 
 of septic tank and sewage disposal. 
 
 28. Influenza. 
 
 Not in print