symptoms until the eruption appears, which is about the third or fourth day of the fever. The eruption first appears as small macules, then forming papules, vesicles and pustules. Sore throat is also present in the majority of cases. I have noticed that those who have been recently successfully vaccinated rarely contract the disease, and when they do, it is in a very mild form. I also noticed that those who have undoubtedly had the small pox never contract it.

The treatment is simple and entirely. symptomatic. I have never lost a case up to the present time.

I send you a photo taken by myself of one of my patients, taken on the twelfth day of eruptiv stage.

Pickering, La. J. S. TILLERY, M.D

"Cuban Itch" or Small Pox? Editor MEDICAL WORLD:-In your January issue you ask for reports on what is popularly known as "Cuban itch." "Cuban itch." As we have had an epidemic of that affection for the past few weeks, I have studied it with a view to finding out its relation to small рох. The period of incubation is the same. The symptoms of headache and backache are similar. Temperature corre

sponds to that of a light case of variola. Eruptions appear in point of time same as in small pox.

Now for the points in which the two diseases (if two there are) differ. First, the pustules are of all sizes, from a millet seed to a large pea or even larger, and there is no tendency to uniformity of size as in variola. Then the important differentiating point of all is the absence of umbilication in any of the pustules. With the exception of umbilication the eruption goes thru all the stages similar to the eruption of variola. All the symptoms are rather mild, except in the aged, when they are sometimes rather severe.

In point of infection the two diseases are similar, as well as in immunity resulting from vaccination.

We have had the two diseases here simultaneously, so the opportunity for comparison has been excellent. I have a theory which I will present for what it is worth: As heat is very destructiv to vaccine virus, and probably also to the small pox germ, as variola spreads very little in hot weather, why is it not reasonable to suppose that in a tropical country the virulent properties of the variola germ is gradually weakened until finally it is so modified that it can only produce variola in a modified form? As vaccination is as effectiv as a preventiv as it is in variola, it certainly must be variola in a modified form. A. M. NEWMAN.

Canadian, Texas.

Cuban Itch."

Editor MEDICAL WORLD:-In January WORLD, page 24, I notice an inquiry in regard to this new disease called "Cuban Itch" and a response by the Editor, inviting comments and reports. You may include Nebraska among the states in which this disease is prevalent. Bladen reports at this time eight cases up to the date of writing, January 9, 1901. In town, two cases, and in country near by, six cases, five men and three women, all grown to maturity and all presenting the same symptoms, from beginning to finish. The period of latency we cannot get positivly. Up to the time of and including the eruption it very closely resembles smallpox, except the shot-like feeling at first signs of rash and the umbilicated appearance of the developt vesicle. From the time of eruption to the completion of the disease and recovery the symptoms

diverge from those of smallpox. Let me describe these cases and you may make your own comparison.

All of our cases complain of one or two days' langor, followed by chill and fever, 103° F.; pain in back, hips and some headache; tongue coated with white and grey coating. A fine rash appears on forehead resembling measles, which in two to four days develops into well formed vesicles, with rounded tops and raised above the skin, accompanied with redness. These vesicles suppurate and scab over in seven to ten days without any irritation or uneasiness of the patient, except some itching. The face, body and limbs of patient is a mass of pustules, ranging in size from a pea to two or three times as large; they are discrete, seldom two running together and drying with dark brown scabs, which come off in about a week more, leaving some redness but no pitting.

Notice the absence of shot-like feeling of vesicle at first, no umbilication of vesicle, no deep-seated inflammation of true skin. Another striking feature of all these cases is, no secondary fever or constitutional disturbance of any kind after the eruption comes out. The patient seems fully restored to his ordinary health and feels strong and well, with splendid appetite (not missing a meal), and secretions and excretions all normal.

Mr. Editor, you state in the article I have referred to that any observant physician may be certain of his diagnosis in an epidemic of small-pox. I think so, too. Now, I have given you the exact symptoms of these eight cases. What do you say? Dr. Towne, Secretary of our State Medical Board, has made several visits over the state and pronounces everything that has a rash and is contagious small pox. But that does not help us out, as many of our best and most careful men say it is not small pox. It surely was introduced into the West by returning soldiers. May it not belong to the family of lichen? Prof. Jones treated something similar in 1845-7. A similar affection was observed as early as 1812. After the War of the Rebellion a disease also prevailed in some sections quite similar. One of my books classifies it as "Lichen Americana." How would the name "Lichen Agrius" (Scudder) do? Now, Mr. Editor, I agree with you that the disease is new in this country. Our profession in the West is not made up of

Editor MEDICAL WORLD :-There seems to be quite a discussion at present in the medical journals over the new variety of small pox that has recently made its appearance in many parts of our country, and while it is of a mild form, yet it partakes of every symptom of genuin small pox. Yet many eminent practitioners discredit the small pox theory. Some call it small pox, some "Cuban itch," and still others chicken pox. Nor can we wonder at such a diversity of opinion when in a great many instances it is very difficult to diagnose.

I notice in the last number of THE MEDICAL WORLD a query from a Missouri doctor, inquiring if there exists such a disease as Cuban itch." Having past thru quite an epidemic of this disease during last winter, and having personally attended more than fifty cases during that time, I feel that my opinion should be entitled to some consideration. In answer to my Missouri friend's question and many others I have noticed from time to time, I shall endeavor to give them my views on the subject, and produce some actual facts to substantiate them.

In the fall of 1899 the disease appeared in Oklahoma. The matter was brought to the attention of the Territorial Board of Health, and they promptly pronounced it small pox, and instituted rigid quarantine measures. Notwithstanding this, it proceeded on its rapid march, and the Board of Health reports show something like 1200 or 1500 cases in the Territory to date. It is a very virulent and contagious disease. In my experience with the disease, I found the discrete form to be the predominant, having seen but five cases of the confluent variety. The rash generally

appeared on the third day of the fever, and in no case did the fever persist after the appearance of the eruption. In most every case I observed the umbilicated vesicle. A symptom that proved of inestimable value to me in the early diagnosis of the disease was the soreness of the scalp. It, with the aid of the intense pain in the back and the intense pyrexia, enabled me to make an early diagnosis.

So, in summing up, we see in this disease the every symptom of small pox. Coming on down to the question of Cuban itch, and to the various decisions that have been handed down by the various boards of health, I can do no better than quote from them.

The Ohio Board of Health came out emphatically in favor of the small pox theory, and the Illinois Board pronounced it small pox, and not "Cuban itch," as termed by some. In no instance do we find that any sanitary authority has recognized the existence of the so called "Cuban itch "

The Surgeon General of the U. S. Marine Hospital Service, in a report to the Illinois Board of Health on December 7, 1899, says: "I am aware of no disease called "Cuban itch" which could be mistaken for small pox. There are several erythematous eruptions in Cuba called 'Cuban itch,' but they are prickly heat or ring worm."

With a little experience in diagnosing this disease, there is no necessity for mistaking it for some other, for the symptoms stand forth most prominently. Stella, Okla.

DR. J. E. JORDAN.

Is it Variola? Editor MEDICAL WORLD:-There is an eruptiv disease all over this country, somewhat resembling small pox. We would be glad to know what it is. More or less fever, with headache, pains in the back and limbs, and lasting two or three days, ushers in the attack. About the third day the eruption appears, sometimes very abundant, and sometimes there are but few vesicles. No chill nor rigors. When the eruption appears (first on the face) the patient declares himself well; gets up, eats heartily, and visits among his neighbors or goes to work. You meet them on the highways and in towns covered with the eruption in all of its stages.

It

is almost entirely confined to the negroes. Some of the patients tell me that the eruption spreads over the entire body and limbs

in fifteen or eighteen hours after its appearance. It seems to be vesicular thruout. I have seen no pustules. Some of the vesicules are umbilicated. They vary from

No

to inch in diameter, and are elevated about inch above the surface. odor, no secondary fever. Those whose eruptions will average 8 or 10 vesicles to the square inch suffer no more, constitutionally, than those who have but few vesicles. All seem to be well when the eruption comes out. When the scabs fall off there are no scars left, but some white spots which disappear sooner or later. When scabbing begins the vesicles become deprest in the center, a dark scab forms which extends to the edges. There is much itching in this stage. The negroes neither fear nor try to avoid the disease which they call "Cuban itch," or "the bumps." Now, what is it?

D. C. MCCAMPBELL, M.D.

Editor MEDICAL WORLD:-Relativ to your remarks in the January WORLD, page 24, concerning the so called "Cuban itch," I would say that about a year ago an eruptiv skin disease made its appearance in this community that was somewhat of a puzzle to me, as well as to neighboring physicians. During my experience of twelve years, nothing of the kind had come under my observation. Some physicians called it itch, others called it chicken pox, and the laity soon got in the habit of calling it "Cuban itch." The cases coming under my observation were mild, and characterized by a vesiculo pustular eruption, with an itching and burning sensation, and distinctly contagious in character. In but few cases was there any febrile disturbance, and none were detained from their usual duties. It seemed to attack by preference children, yet some adults were affected by it. Parts affected most were hands, feet and face. My diagnosis is impetigo contagiosa. For a complete and graphic description of the disease as I saw it, I refer the reader to the article on impe

tigo contagiosa, by Dr. Whitehouse, in "Twentieth Century Practice of Medicin," Volume V, page 418.

My treatment consisted of the use of carbolic acid, icthyol and citrine ointment in varying strengths, according to the necessity of the case. The best treatment, according to my judgment, seemed to be the touching of each individual vesicle as soon as it was detected with a very little pure carbolic acid. This seemed to have the effect of aborting the disease. Moorefield, O. E. D. MOORE, M.D.

Small Pox.

Dr. A. R. Sisk, of Somerfield, I. T., reports that small pox of a comparativly mild form has been in that part of the country for the last ten months. All have it except those who have been vaccinated at the high school. The mortality has been only about one or two per cent. The course is as follows: Chilly sensations, headache, severe backache, frequently sick stomach and vomiting; high fever, eruptions appear on the third day, and then the patient is better, and the eruption runs the course. The period of incubation is from fourteen to sixteen days. The fatalities have been caused by complications. All the treatment that has been necessary has been: good hygienic surroundings, light diet, and laxativs; aconite when the fever is high.

Small Pox.

Editor MEDICAL WORLD:-As this is the season in which zymotic diseases are most prevalent, I have selected the above subject. It is a subject with which none of us are any too familiar. Many physicians will go thru a practise of twenty-five or thirty years and never treat a case.

The history of small pox is as old as, and coincident with, the history of man. It is an Asiatic disease, and is first mentioned in the most ancient writings of the early Chinese and India medical writings, and from there followed the trend of empire westward, leaving desolation and death in its wake, and often almost depopulating entire cities or communities, until the immortal Jenner, David like, slew this giant disease, small pox, with vaccination, and thereby placed in the hands of the medical profession one of the greatest discoveries in the history of medicin.

Small pox is a germ disease, and is both contagious and infectious. The more im

portant divisions of this disease are confluent, discrete or distinct, purpura variolosa, hemorrhagic or black small pox, and varioloid. It is divided into five stages: First, incubation; second, invasion; third, eruption; fourth, suppuration, and fifth, dessication. The stage of incubation lasts from one to three weeks from time of exposure. The stage of invasion occupies two to four days, and is ushered in by a chill, headache and backache, followed by fever and perspiration, which will continue more or less until the maturity of the eruptive stage, and is a feature distinctive of this as compared with other eruptive fevers. The fever ranges from 102° to 105°, owing to the severity of the disease. Nausea and vomiting, with pain in the epigastrium are often present, and pain in the loins is usually a markt symptom, and is considered of diagnostic importance; the bowels are usually costiv; partial paraphlegia, also paralysis of bladder may exist, but usually disappears with the complete development of the eruption. Delirium and convulsions, mostly in children, occasionally occur in the eruptiv stage of the disease. In the stage of invasion often occurs a cutaneous efflorescence or red rash, which erythemetic redness closely resembles the appearance in scarlet fever or measles. Petechiæ or ecchymoses may appear more or less abundantly in this stage, in some cases extending over the entire body, and in other cases foreshadowing subsequent hemorrhages.

The eruptiv stage occupies from two to three days in its diffusion over the entire cutaneous surface, appearing first on face, neck and hands, then on body, and last on arms and legs. It first appears as a maculated eruption of small red spots or specks, sometimes of a purplish or livid color. The maculæ become hard, elevated, and pointed. A change has now taken place from a maculated to papular eruption, which may be mistaken for measles. We should remember that the papulæ are smaller, rounder, harder and lacking in the crescentic arrangement which characterizes the eruption of measles. The papulæ feel like small shot under the skin next the cuticle; they become elevated at the apices by a drop of liquid. The papulæ now are vesiculæ. This occurs in from twenty-four to thirty-six hours. About the fourth or fifth day the vesiculæ become nmbilicated, or deprest in the center.

This is a highly characteristic symptom of small pox, and is considered pathognomonic. After their full development the vesiculæ become pustules. The depression in the apices disappears as the vesiculæ become full, distended and pointed, and with this change begins the stage of suppuration. With the full development of the eruptiv stage the fever subsides until the temperature and pulse are about normal. This is a highly diagnostic feature of small pox, except in the confluent form, when this feature is much less markt. With the development of the suppurativ stage the fever and pulse again come up, the skin of face becomes swollen, eyes closed, and features distorted and repulsiv, and in the confluent form the hands and feet are swollen; delirium, coma and subsultus with diarrhea in this stage are unfavorable omens. The stage of suppuration lasts about five days. The stage of dessication commences on about the twelfth day. The tumefaction and redness subside, the pustules break, and the pus concretes into thick scabs, in severe cases forming a complete mask and presenting a hideous appearance. The entire body may present a similar aspect. During this stage the skin and breath exhale a sickening and characteristic odor. The scabs fall off, leaving the skin unbroken except in severe cases, when circular or linear cicatrices called pock marks are left. The stage of dessication lasts from six to ten days, making the duration of the disease from eighteen to twenty-four days.

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Various complications may occur, such pharyngitis, laryngitis, bronchitis, pleuritis, pericarditis, ophthalmitis, gangrene and hemorrhage, all of which result from the eruption appearing in those parts. Small pox is both contagious and infectious; that is, it is communicated by inoculation and by a miasm emanating from the body or exhaled with the breath; it is communicated usually in the stages of suppuration and dessication. The susceptibility is greater in children. One attack usually immunes, but the disease has been known to re-occur a second and even a third time. The disease may be communicated to the child in utero, which usually causes death; but children have been born showing all stages of the disease, and some showing that they had passed thru it and made a complete recovery previous to birth. The ratio of fatal cases in unmodified small pox is 1 to 3 or

4, and previous to the discovery of vaccination it was much greater, going in some epidemics as high as 75 per cent. In the modified and milder forms, death is one in ten or fifteen, and often less; the largest percentage of deaths occur in the second week of the disease.

I will now call your attention to six cases of small pox which came under my care for treatment. These cases presented for observation typical types of all the different forms and stages of small pox. The first case was Harry Pitts, age 20, and occurred in Dec. 1883. He was an extremely nervous and impulsive young man who sacrificed his life on the altar of friendship. A young man, a friend of his, while visiting in St. Louis became sick; he came home and sent for a homeopathic physician who gravely informed him that he had contracted measles. Later Dr. Wm. A. Haskell was called in and pronounced it small pox, and the young man was removed to the pest house. His isolated and apparently neglected condition made a strong appeal to the impulsiv friendship of Harry Pitts, and he deemed it his duty to pay frequent visits to his friend at the pest house, which resulted in his contracting the disease. About two weeks after his exposure, which time covered the stage of incubation, I was called in to attend him, and found him suffering with the first symptoms of small pox in the stage of invasion; headache, backache, and an increast temperature and pulse, skin normal. This was about 11 o'clock in the morning. Owing to the gravity of the disease the parents requested that I call Dr. Wm. A. Haskell in consultation, so together we saw the patient about 8 or 9 p. m. of the same day. He was about the same as in the morning except the temperature had increast to 102° and a cutaneous efflorescence or red rash had appeared on almost the entire body. Dr. Haskell passed his finger with some pressure over his reddened skin and it left a white streak or mark, and he remarkt that we might possibly have a case of scarlet fever to deal with; but as this symptom often occurs in small pox, especially when of the purpuric or hemorrhagic type, we would await developments. The following morning at 9 o'clock his condition was much the same, except petechie or ecchymoses had appeared on the efflorescent skin, and by 3 or 4 o'clock p. m. of the same day these ecchymoses had developt