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Illustration V.-This case in its general history closely resembles No. III. A boy, aged seventeen, was admitted into the London Fever Hospital, August 21st, 1858. He had been vaccinated at the age of three months, and had a satisfactory mark. When one year old he had measles, and at the age of six he had small-pox, the marks of which remained. No history of exposure to any contagious disease could be made out, and no one else of the family was ill.

Aug. 19th.-Rigors, followed by hot skin, severe pain in back and limbs, great thirst, loss of appetite, and sore throat.

Aug. 20th.-Body covered with a scarlet rash.

Aug. 22nd.-Pulse 108; slept a little; sore throat; tongue moist and furred; scarlet rash well out.

Aug. 23rd.-Pulse 120; little sleep; much restlessness, but no delirium; throat sore; skin very hot, and covered with scarlet rash. Aug. 24th.-Nine A.M.- -Rash of a mulberry tint-at some places crescentic, and like that of measles; coryza.


Eight P.M.-Pulse 112; no delirium, and is quite conscious, but has passed much blood per rectum; arms, hands, and face covered with a papular rash, many of the papules containing lymph. Several large petechiae.

Aug. 25th.-Pulse very rapid and small; much weaker, and quite unconscious; face livid; many of papules vesicular, a few pustular and umbilicated; died at five P.M.

Illustration VI.—A man, aged twenty, a soldier in the Somerset Militia, was seized with all the symptoms of well-marked scarlatina, including the eruption, the characteristic tongue, sore throat, and delirium. Between the third and fourth day after the eruption had declared itself, and while this was still perceptible, but much faded, a number of vesicles, depressed in the centre, appeared; and in the evening of the same day the face was covered with well-marked smallpox pustules. On the following day this eruption was in its most confluent form; involuntary stools, profound coma, gradual sinking, and death.*

In the following cases the eruptions of the two affections appeared almost simultaneously:

Illustration VII.-A boy, aged thirteen, was admitted into the Hôpital des Enfans Malades, under M. Baudelocque, Feb. 10th, 1834. He was a music printer, was in good condition, and had always enjoyed good health. About the middle of January his body became covered with purpura spots; and on Feb. 8th he had severe rigors, followed by febrile symptoms and great lumbar pain. On admission, face and arms covered with a scarlet rash, and a papular eruption, which appeared in the evening of Feb. 10th on face, trunk, and limbs; also numerous petechiae and ecchymoses. Tongue thickly furred. Voice nasal. Tonsils could not be examined.

Feb. 12th.-Pulse 120; great prostration; intellect intact; several

Mr. Gallwey: Lancet, vol. ii. 1858, p. 229.

of the papules on arms have become vesicular, and are distinctly umbilicated; scarlatina eruption more violet in tint.

Feb. 13th.-Pulse 184; respiration 60; much restlessness and delirium in night, and now in profound coma; impossible any longer to distinguish the three eruptions; died at three P.M.

After death there were found variolous pustules upon the tongue and the surface of the tonsils; the pharynx and larynx were covered with gangrenous sloughs.

In the remarks upon the case it is stated, that in the same hospital where cases of small-pox and scarlet-fever were constantly being brought together, a combination of the two was a matter of not unfrequent observation.*

Illustration VIII.—A young Russian naval officer, while scarlatina and variola were both very prevalent, was seized, Nov. 25th, 1834, with vomiting. On the 26th he was better, but on the 27th he had alternate rigors and flushes, headache, vertigo, &c. On the 29th a scarlatina eruption appeared on the face, neck, breast, and upper extremities; as also several solitary papules on the face; much dysphagia and redness of fauces.

Nov. 30th.-Scarlet eruption paler, but the papules distinctly variolous, and extending over the body. The case ran its course with great mildness, and the patient recovered. In the account of the case it is stated, that a similar one had been observed by Hufeland, at Weimar, in 1798.t

Illustration IX.-A girl, aged nine, residing in London, was seized on Dec. 17th, 1844, with sickness, anorexia, and dysphagia. Had been vaccinated.

Dec. 18th.-Pulse 100; tongue furred, its tip red; fauces injected; chest and abdomen covered with a diffused scarlet rash, interspersed with thickly studded elevated red points.

Dec. 20th.-Pulse 90; the red points have increased into wellmarked papules, which are general over the body, and on lining membrane of mouth; scarlet rash gone.

Dec. 21st.-Papules enlarged, centres depressed, and at many places nearly confluent.

Jan. 4th.—The variolous eruption has run its usual course, and the scabs have partly fallen off.

Jan. 7th.-Anasarca and oedema of face; urine not examined.

Within twelve days after the accession of the attack, her three sisters, who had all likewise been vaccinated, and were living in the same room, became affected with modified variola; while another girl residing in the same house was seized on the twelfth day with scarlet fever. I

Lastly, we have cases in which the rash of scarlet-fever has supervened upon that of variola.

Gaz. Méd. de Paris, deuxième série, tome ii. p. 312. 1834.

† Dr. Glehn: British and Foreign Medical Review, 1837, vol. iv. p. 219.
Dr. Barnes: Lancet, vol. i. 1845, p. 640.

Illustration X.-Vieusseux, in 1799, recorded an instance of three children in one family who were seized with small-pox. This affection ran its ordinary course until the period of desiccation of the pustules, when all three became affected with well-marked symptoms of scarlet fever, including the eruption. Two died, not of the small-pox, but of the scarlet-fever; the third recovered.*

Illustration XI.-This case was recorded by M. Spadafora, an Italian physician, as an example of several similar instances which had occurred in his practice in 1830. A man, aged thirty-four, became covered with numerous purpura spots; on the fifth day a variolous eruption appeared on the face, chest, and hands; on the sixth day, the variolous pustules were well marked, and a second eruption had appeared, presenting all the characters of scarlet-fever; on the eighth day the purpura spots, the scarlet and the variolous eruptions, were all well marked; on the tenth day the patient died comatose.+

Illustration XII.-For this and for references to several of the other illustrations I am indebted to an excellent paper by Mr. Marson, Surgeon to the Small-Pox and Vaccination Hospital, which was published in the thirtieth volume of the Medico-Chirurgical Transactions.' I cannot do better than quote Mr. Marson's own words :—

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"In the course of the last eleven years I have seen at the Small-Pox Hospital seven persons who had variola and scarlatina simultaneously. No two of these patients were received from the same place. The only discoverable disease under which they were labouring on their arrival was small-pox; but in the progress of this disease, scarlatina also became evident between the fourth and fifth days of the variolous eruption. Judging by the length of time that each disease is known usually to remain latent in the system after its reception, before constitutional symptoms are manifested, we may conclude that the germs of scarlatina were received towards the end of the incubative stage of variola.

It is desirable that it should be clearly understood that these patients had all of them the leading symptoms of scarlatina well marked, and that the eruption was different from the roseola which frequently precedes the eruption of small-pox, and also different from the erythema arising from the miasm of hospitals; in fact, it was the florid red eruption peculiar to scarlet-fever, which can hardly be mistaken for anything else by a medical man whose eye has once been rendered familiar with it. Three of the patients had small-pox in the unprotected state, and four after vaccination. Six of them were adults; the seventh, a child four years of age. Three were males, and four females. In one the scarlet-fever was followed by anasarca; and in two by swelling of the parotid and submaxillary glands; and all had desquamation of the cuticle-a sequence which, it will be remembered, is not usual in small-pox, but, on the contrary, almost constant in scarlatina. All the patients recovered, but one."

Illustration XIII.-Mr. Marson, in the paper just referred to, also states, on the authority of Dr. Goodfellow, then Resident Physician in the London Fever Hospital, that three cases had been admitted into that institution with slight variola, and had there contracted scarletfever, the eruptions of the two diseases being concurrent.

• Recueil Périodique de la Soc. de Méd. de Paris, tome vi. p. 417
↑ Gaz. Méd. de Paris, 1837, deuxième série, tome v. p. 284.


I am not prepared to assert that all of the above cases were examples of the co-existence of small-pox and scarlet-fever. Some of the first class may have been instances of what has been described as roseola variolosa, which, according to Rayer, precedes the eruption of inoculated small-pox, about once in fifteen cases.

It seems difficult, however, on any other supposition than that here advocated, to account for those instances in which the scarlet eruption supervened upon the variolous, and was followed by desquamation, anasarca, and enlargement of the parotid and submaxillary glands. Illustration IX. also, in which the patient affected with the double disease would appear to have communicated scarlet-fever to one and variola to others residing in the same house, is of peculiar interest.

B. Variola and Rubeola.-The co-existence of these two exanthemata would appear, from the records of Medicine, to be by no means uncommon. Many such instances have been recorded by the older authors, such as Diemerbroeck, De Haen, and others; and Dr. Macbride, of Dublin, described a disease, under the designation Morbilli variolosi, or "measles resembling small-pox," in which, combined with a well-marked eruption of measles, there were many pustules which suppurated like those in the small-pox; and he tells us that, in 1769, a number of the children in the Foundling Hospital at Dublin having been inoculated for small-pox, were in the meantime seized with measles, both species of eruption being perfectly distinct.*

Pinelt and others, it is true, have recorded instances in which the supervention of measles after inoculation with small-pox would seem to have delayed until the termination of the measles the supervention of the variola with its concomitant fever; but there can be no doubt that, in very many instances, the eruptions of the two diseases have existed simultaneously. In a few instances the appearance of the eruption of measles has somewhat preceded that of small-pox, but in the great majority the order has been inverted. The following cases may be cited by way of illustration :

Illustration XIV.-Dr. Copland quotes, on the authority of Ettmuller, an instance in which the eruption of small-pox broke out on one side of the body, and that of measles on the other.‡


Illustration XV.—In 1765, small-pox and measles were both epidemic at Aleppo. Dr. Russell tells us that in many cases the one disease succeeded the other within two or three weeks, and that several were met with in which the pustules of the small-pox appeared on the face before the total disappearance of the measles on the limbs. cases are also recorded in which both eruptions were contemporaneous. In one, a female, aged two, there were the usual premonitory symptoms of measles, and on the fourth day the eruptions of both measles and small-pox appeared. On the eighth day the measles were fading, but

Practice of Physic, 1772, pp. 376-9.

† Nosographie Philosophique, tom. ii. p. 51.
Dict. of Pract. Med., vol. iii. p. 819.

the pustules continued very distinct, and ripened perfectly. The second case was a boy aged three. On the third day of febrile symptoms a measly rash and variolous pustules appeared. The pustules came to perfect maturity.*

Illustration XVI.-Two cases are recorded by Dr. Tracy, as having occurred to him in the spring of 1797. One of them, a young man, who a day or two previously had been exposed to the contagion of measles, which had excited some anxiety in his mind, was inoculated with small-pox. A mild attack of variola ensued; but on the tenth day the patient was seized with severe rigors, followed by febrile symptoms, and the day after by coryza and an eruption of measles, some of the variolous pustules not only remaining visible, but progressing towards maturation. The patient recovered. The other patient contracted small-pox after exposure to contagion; and on the third day after variolous eruption, a universal measly eruption, with the usual concomitants, supervened. Many new variolous pustules appeared after this, and the two diseases pursued their ordinary course "like two friendly sojourners in separate apartments of one tenement, without officious interference or molestation to each other." patient also recovered.t


Illustration XVII.-An infant, five months old, was inoculated in London with small-pox on April 19th, 1800. The inoculation was followed by a mild attack of variola. On the twelfth day, while the pustules were advancing to maturation, there was an increase of fever with stuffing at the nose. On the nineteenth day there was much coryza, redness and lachrymation of eyes, sneezing, and an eruption precisely resembling that of measles. On the fourteenth day the variolous pustules were still increasing, and "the morbillous eruption general and very distinctly marked." On the fifteenth day, "measles disappearing, small-pox advancing." On the seventeenth day, measles quite gone, and the variolous pustules dying away also. Convalescence.+

Illustration XVIII.-Ring records numerous cases in which the eruptions of variola and rubeola co-existed, without at all interfering with each other.§

Illustration XIX.-Dr. Winterbottom tells us that, in the winter of 1804-5, small-pox and measles were both epidemic in South Shields, and frequently co-existed in the same patient.||

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Illustration XX.-In the Quarterly Report of the Edinburgh New Town Dispensary,' for April, 1819, two cases of small-pox and measles co-existing are described. In the one the eruption of measles came out on the fifth day of the eruption of small-pox, and both ran their usual course; in the other the eruption of small-pox came out

* Trans. of Soc. for Med. and Chir. Knowledge, vol. ii. p. 90. 1800.
Ibid., vol. iv. p. 29.

† Medical and Physical Journal, vol. iii. p. 572.

§ Treatise on Cow-pox, pp. 262, 267, 1029.
Medical and Physical Journal, vol. xiv. p. 25.

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