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 petechia and ecchymoses. Tongue thickly furred. Voice nasal. Tonsils could not be examined. Feb. 12th.-Pulse 120; great prostration; intellect intact; several 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 at 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 the 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.t 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. 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 well-marked 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.§ Lastly, we have cases in which the rash of scarlet-fever has supervened upon that of variola. Illustration X.-Vieusseux, in 1799, recorded an instance of three children in one *Mr. Gallwey: Lancet, vol. ii. 1858, p. 229. + Gaz. Méd. de Paris, deuxième série, tome ii. p. 812. 1884. Dr. Glehn: British and Foreign Medical Review, 1887, vol. iv. p. 219. 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 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 variolous eruptions, were all well marked; on the tenth day the patient died comatose.t 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 :— "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 scarlet-fever, the eruptions of the two diseases being concurrent. I am not prepared to assert that all of the above cases were examples of the coexistence 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 * Recueil Périodique de la Soc. de Méd. de Paris, tome vi. p. 417. 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.* Pinel 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 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. Two 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 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." This patient also recovered. 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 * Practice of Physic, 1772, pp. 876-9 Dict. of Pract. Med., vol. iii. p. 819. Trans. of Soc. for Med. and Chir. Knowledge, vol. ii. p. 90. 1800. **Treatise on Cow-pox, pp. 262, 267, 1029. Nosographie Philosophique, tom. ii. p. 51. ¶ Ibid., vol. iv. p. 29. pox and measles were both epidemic in South Shields, and frequently co-existed in the same patient.* 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 the small-pox, and both ran their usual course; in the other the eruption of small-pox came out on the third day of the eruption of measles, which last continued visible for two days more. Both children recovered.t Illustration XXI.-A shoemaker, residing in Exeter, had three children, whose respecages were six years, four years, and seven months, of whom the eldest alone had tive 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 2d the pimples were more numerous, and some of them vesicular. On April 4th there were distinct unbilicated 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 smallpox 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 small-pox and measles. Illustration XXII.—Two cases in which the eruptions of measles and small-pox coexisted 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 miidly, and recovered; the other, aged twentysix, 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 Davenport 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 it were, a substratum of shot beneath the skin. "Twentyfour 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 * Medical and Physical Journal, vol. xiv. p. 25. + Edinburgh Medical and Surgical Journal, vol. xv., p. 314. Mr. Delagarde: Medico-Chirurgical Transactions, vol. xiii. p. 163. Lancet, vol. ii. 1858, p. 290. 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 hoopingcough, 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 observation of Dessessarz, quoted by Dr. Copland,t the presence of hoopingcough 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 hoopingcough 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 hopping-cough, 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 occasionally 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 + Dictionary of Practical Medicine, vol. iii. p. 819. Medical and Physical Journal, 1802, vol. viii. p 426. **On Vaccine Inoculation, 1806, 4to. p. 8. *Lancet, vol. ii., 1858. p. 229. |