on the third day of the eruption of measles, which last continued visible for two days more. Both children recovered.*

Illustration XXI.-A shoemaker, residing in Exeter, had three children, whose respective ages were six years, four years, and seven months, of whom the eldest alone had been vaccinated. The eldest child was attacked with measles, which, on March 29th, 1824, disappeared. On the same day the second child began to sicken with febrile and severe catarrhal symptoms. On April 1st a measly eruption appeared, interspersed on the right cheek with a few minute pimples. On the 2nd the pimples were more numerous, and some of them vesicular. On April 4th there were distinct umbilicated pustules, and on the breast and arms were "the brown marbled spots frequent after measles." On April 8th the pustules began to dry up; and on the 11th the crusts were separating. A child was inoculated with some of the matter from one of the pustules, and small-pox ensued. On April 8th the infant of the first family became covered with the rubeolar eruption. By the 15th it had completely recovered; but on this day she became feverish, and between this day and the 20th had several convulsions, and on the latter day small-pox appeared. Measles at the time was very prevalent in Exeter; and it was discovered that the two eldest children had been attending the same school as a child who had recently died of what had been described as combined smallpox and measles.†

Illustration XXII.-Two cases in which the eruptions of measles and small-pox co-existed occurred under M. Guersent, in the Children's Hospital at Paris. The eruption of measles appeared in one case on the fourth, and in the other on the third day of the variolous eruption. One case recovered; the other proved fatal from double pneumonia.‡

Illustration XXIII.-Two cases of small-pox concurring with measles and purpura have been described by Dr. F. J. Brown as having been observed at Rochester in 1845. One man had the concurring affections mildly, and recovered; the other, aged twenty-six, a sailor, died on the eighth day. The rash of measles came out on the third day of the variolous pocks, and increased for four days, during which the pocks remained comparatively stationary; after this the pocks progressed rapidly, and on the sixth day purpura showed itself, and there was hæmorrhage from the lungs and bladder.§

Illustration XXIV. This was the case of a young soldier in the Military Hospital at Devonport in 1854, which has been recorded by Mr. Broke Gallwey, Surgeon, Royal Artillery. The patient was declining rapidly of phthisis, when he became the subject of measles, so well developed that it might have been selected as a model case from which to study that exanthem. The eruption had arrived at its climax, and gained its turning point, when the patient sustained an attack of rigors, and on the following day the entire face presented, as

Edinburgh Medical and Surgical Journal, vol. xv. p. 314.

† Mr. Delagarde: Medico-Chirurgical Transactions, vol. xiii. p. 163. Lancet, vol. ii. 1858, p. 290.

Gaz. des Hôpitaux, 183 4, vol. viii. p. 34.

it were, a substratum of shot beneath the skin. "Twenty-four hours later," writes Mr. Gallwey, "and I found I had a case of confluent small-pox, engrafted on a ground of rubeola, to deal with; and I may truly say that never had I met with more finished representations of either disease than were now delineated together in the same individual." The patient died about the period of maturation of the pustules. Mr. Gallwey considers this case as unique in the chapter of medical curiosities;" but a reference to the literature of medicine shows that such cases are far from uncommon.*

C. Variola and Roseola, or Erysipelas.-Allusion has already been. made to a roseolous eruption which sometimes ushers in that of variola, and which has been designated roseola variolosa; but this is rather to be considered as a part of the disease than as a distinct affection.

Erysipelas, again, is a not unfrequent and a very fatal complication of small-pox, as well as of the other exanthemata, and owes its origin apparently, in some cases, to vitiated hospital air, and in other cases to contagion.

D. Variola and Pertussis.-Although no cutaneous eruption accompanies hooping-cough, it resembles the exanthemata in attacking an individual but once in the course of life, in being infectious, and consequently in depending upon a specific poison. According to the observations of Dessessarz, quoted by Dr. Copland,† the presence of hooping-cough delays the eruption of variola; while, on the other hand, it has been thought that an eruption of variola will arrest, or, in some cases, effect a cure of pre-existing hooping cough. Dr. Willan mentions cases of hooping-cough, in which "this disorder was instantly superseded by the appearance of small-pox, after the decline of which the cough returned with the same violence as at first." Mr. Okes relates the case of a child, whom he inoculated with small-pox while labouring under severe hooping-cough. As soon as the eruption appeared, the cough ceased and never returned.§

But we have the most abundant and conclusive evidence that the two diseases may co-exist in the system, without at all interfering with each other. Take, for instance, the following account, given by Dr. Willan, of the prevalence of small-pox and hooping-cough in London in 1796:

"These two complaints have been intimately connected for several months past. In many instances the paroxysms of the cough continued without abatement through the whole course of the supervening small-pox. The hoopingcough, in other cases, first commenced during the eruption of the small-pox, and remained a long time after it without any material alteration. These observations tend to set aside an established opinion among physiologists, that two specific diseases, at least two specific contagions, cannot actuate the human constitution at the same time. That the operation of one contagion is occa

Lancet, vol. ii. 1858, p. 229.

+ Dictionary of Practical Medicine, vol. iii. p. 819.
Reports on the Diseases of London, p. 3

§ Medical and Physical Journal, 1802, vol. viii. p. 426.

sionally suspended while the body is under the influence of another, may be granted; but I am convinced, from a variety of cases, that this is not a universal law.”*

E. Variola and Varicella.-An example of this combination is recorded by Ring:

Illustration XXV.-Two children in one family were inoculated with small-pox matter. One had small-pox, followed by chicken-pox. The other child, who had previously been vaccinated, had modified small-pox contemporaneous with chicken-pox. A schoolfellow had chicken-pox at the same time.t

F. Variola and Vaccinia.—These differ in their mutual relations from the diseases whose combinations we have been already considering, inasmuch as they are both probably only modifications of one and the same poison; yet they are modifications presenting a very striking contrast. As a general rule, after vaccination has run its usual course, the constitution may be regarded as protected against the action of the variolous poison; and, in like manner, after an attack of small-pox, the constitution is proof against the vaccine virus. But, as was shown by Willan, when a person is inoculated with vaccine and variolous matter at the same time, or within a week of each other, both inoculations take effect, and each pursues its course as in two different subjects. Willan, indeed, figures a variolous pustule, which rose and maturated within the margin of the vaccine vesicle; and there are instances on record of both diseases resulting in individuals who have been exposed to the infection of variola at the time of vaccination, or a few days previously.§

Illustration XXVI.-Numerous cases of the co-existence of variola and vaccinia are recorded by Ring. One of the most remarkable is the following. A variolous eruption appeared in a girl five days after vaccination. "One of the variolous pustules appeared distinctly within the margin of the vaccine tumour." A child was inoculated with matter from the vaccine vesicle; cow-pox resulted. Three children were inoculated with matter from the variolous pustule which encroached upon the vaccine vesicle, and all took the small-pox.||

Illustration XXVII.—A girl, aged fourteen, was vaccinated, and eight days after inoculated with small-pox matter; having in the mean time been also exposed to the contagion of variola. She contracted the two diseases, and "both went on together without interfering with each other."¶

Illustration XXVII. (bis).—A child was seized with confluent small-pox on the fourth day after vaccination. The vaccine pock ran its usual course, and on the ninth day matter was taken from it, with

Op. cit. p. 38.

Treatise on the Cow-pox, p. 944.

On Vaccine Inoculation, 1806, 4to, p. 3.

§ Williams on Morbid Poisons, 1841, vol. ii. p. 40.

Treatise on Cow-pox, p. 481, &c.

Mr. Pole: Medical and Physical Journal, 1801, vol. v. p. 340,

which three other children were inoculated. All three had the cowpox only.*

Illustration XXVIII.—Mr. Marson, of the Small-Pox Hospital, writes: "I have several times seen small-pox and the vaccine disease advancing pari passu, without the usual progress of each disease respectively having been interrupted."+

În most cases, such as those just described, the variola is modified, the pustules being hard, and not advancing to maturation; but there are exceptions: Bousquet has given no fewer than sixteen cases in which vaccinia and variola co-existed, and yet all the patients perished.‡

Some curious experiments have been made by inoculating a mixture of the vaccine and variolous secretion. Adams maintained that under such circumstances only one of them will produce its effect;§ but of three children inoculated in this manner by Bousquet, two had the cow-pox only; while in the third, the cow-pox proceeded as usual till about the eighth day of that disease, when a slight variolous eruption appeared. ||

G. Vaccinia and Scarlet Fever.-Illustration XXIX.-Jenner has recorded the case of a child in whom scarlatina with sore throat appeared on the ninth day after vaccination. During the persistence of the scarlatina there was a total suppression of the areola around the vesicle. A sister of this patient, in whom the areola had already formed, was also seized. The scarlet rash was slight, and suddenly disappeared; but four days later, on the decline of the cow-pox, the usual symptoms of scarlatina anginosa appeared, and ran their course. T In these cases the two poisons would appear, to a certain extent, to have mutually neutralized each other.

Illustration XXX.-Three children were vaccinated by Ring. Before the cow-pox had attained its height they were attacked with scarlet fever, the violence of which appeared to be neither increased nor diminished by the cow-pox. All recovered.**

H. Vaccinia and Rubeola.-Illustration XXXI.-Ring has recorded five cases in which measles supervened at various periods from the second to the eighth day after vaccination. The measles ran its usual course, and the vaccine pustule was not at all interfered with, the areola remaining perfect.++

Illustration XXXII.-In the winter of 1804-5 many children, who had been vaccinated at South Shields, took measles. In all "the cow-pox vesicle proceeded regularly, except in appearing to be larger than usual, and having no areola.' Three children were vaccinated with matter taken from a child on the eighth day after vaccination, * Medical and Physical Journal, vol. xiv. p. 25.

+ Medico Chirurgical Transactions, vol. xxx. p. 125.

Traité de la Vaccine, p. 117.
Op. cit., p. 328.

** Treatise on the Cow-pox, p. 656.
tt Ibid., pp. 108, 249, 744. 1801-3.

and on the fourth of the eruption of measles. All three took the cow-pox, but none of them measles.*

Illustration XXXIII.-On December 27th, 1821, an infant was vaccinated in each arm. On the following day its brother had a distinct eruption of measles. On Dec. 30th, the vaccinated infant was also seized with measles, the eruption of which, two days later, was very characteristic. A third and a fourth child in the same family became successively affected with measles. In the vaccinated child, the measles and cow-pox both ran their usual course together. With matter from one of the vesicles another healthy child was vaccinated with perfect success.†

I. Vaccinia and Pertussis.-Adams, in his work on 'Morbid Poisons,' expressed a belief that a permanent cure of hooping-cough was often effected by vaccination; and he adds, that in his day, this was so generally understood, that mothers were in the habit of bringing their children to the hospital for vaccination, under the expectation of curing them of hooping-cough, and that he had seldom known them disappointed. On the other hand, Mr. Marson, Surgeon to the SmallPox Hospital, writes:-"Hooping-cough and the vaccine disease may often be seen co-existing, each pursuing its course without interfering, or being interfered with, by the other." There is no reason why vaccination should not be practised in the course of hooping-cough. The matter takes as well as under ordinary circumstances, and is equally effective; while in occasional instances the hooping-cough may be suspended by the supervention of vaccinia; but still the two diseases not unfrequently co-exist.

K. Vaccinia and Varicella.-In some instances the action of the cow-pox virus would appear to be suspended by the supervention of chicken-pox; but, at the same time, there are many cases on record which show that the two diseases are capable of co-existing. The following are illustrations of both these phenomena :

Illustration XXXIV.-An infant, aged thirteen months, was inoculated with vaccine matter, which did not take; but on the eleventh day an eruption of chicken-pox appeared. The latter disease was thought to be prevalent in the neighbourhood. The infant was afterwards vaccinated with effect.§

Illustration XXXV.-Two children in one family were vaccinated on the same day; in one the cow-pox went through its usual course; the other had, on the eighth day, an attack of chicken-pox, of which there were several other cases in the same house; and in the meantime there was a complete suspension of the cow-pox until the

* Winterbottom: Medical and Physical Journal, vol. xiv. p. 25.

† Mr. Gilder: Medico-Chirurgical Transactions, vol. xii. p. 186. 1823. Medico-Chir. Trans., vol. xxx. p. 126. See also Williams on Morbid Poisons, vol. i.

p. 171.

§ Dr. Patterson: Medical and Physical Journal, vol. vi. p. 43. 1801.