outbreak is sometimes only confirmed by the appearance of a genuine case of the confluent or of the hæmorrhagic form."

DISCUSSION.

Dr. A. N. BROUGHTON, of Jamaica Plain

There is one

thing which has been emphasized as characteristic of smallpox about which I am in doubt. It has been stated that in any given area all the lesions are of the same type. For example, if on the forehead there is a papular eruption, they are all papules, and no pustules. In a case which I saw a few weeks ago, the patient had a temperature of 103, and a universal eruption which would make a perfect picture of syphilis. This eruption in the mouth as well as in the body was entirely papular, with the exception of two distinct vesicles on the forehead and these appeared to me to be umbilicated. On the following morning 1 saw the case with an officer of the Board of Health, who thought it was probably not variola, especially as there were several vesicles on the abdomen, back and forehead, and yet, everywhere else were still papules. That afternoon Dr. Shea sent him to the hospital as a case of variola. I would like to ask Dr. McCollom if that statement is correct,—that the lesions in a given area are all uniform?

Dr. J. H. McCOLLOM: In reply to Dr. Broughton's question, I will say that sometimes we do see on the abdomen, or in the inguinal region, or in the axilla, a pustular eruption, when the rest of the eruption is vesicular. There is a great difference between modified small-pox and the unmodified variety.

Dr. T. B. SHEA, of Roxbury: I think something might be said in regard to varicella. Dr. Bullard said that this is a disease occurring essentially in children. During the past week I have seen several cases of varicella in adults. The text-books pass this disease over very lightly by saying that it is a disease of childhood. Varicella is not a light thing in adults. The history looks a good deal like small-pox.

The eruption does not appear for twelve or fourteen hours, and sometimes it commences on the forehead as does smallpox. Now, as to the question of the eruption of small-pox in the beginning always being found on the face. That statement is not borne out by the experience we have had this past winter. I have seen about 1300 cases since last August. In the early cases, I usually look for the eruption on the abdomen. Also, another place where the eruption may be seen very early,—on the arch of the foot. will often find a few papules occurring there before they occur on the face. No matter how the disease has been modified by vaccination, I think something will always be found there.

You

ARTICLE IX.

LEGISLATION WITH REFERENCE TO SMALL-POX AND VACCINATION.

BY SAMUEL W. ABBOTT, M.D.

OF NEWTON CENTRE.

FOR more than thirty centuries the necessity of requiring mankind, by means of legal enactments, to observe certain rules of health, has been recognized by every civilized gov

ernment.

"This necessity has found expression in those statutes which have had for their object the prevention of disease, and the result has been that those people who have most carefully protected themselves by strict legislation, and who have most rigidly enforced the observance of health laws, have enjoyed the greatest immunity from the ravages of plagues and pestilence; while a neglect of proper precautionary measures has usually resulted in periodical decimation of the population by the scourge of communicable dis

ease.

The foregoing extract forms a fitting introductory to the observations which I shall present, relating to the subject of legislation in its relation to small-pox and vaccination. Froude says of legislation in general: "Our human laws are but the copies, more or less imperfect, of the eternal laws, so far as we can read them, and either succeed or

*Parker and Worthington. The Law of Public Health and Safety.

promote our welfare, or fail, and bring confusion and disorder, according as the legislator's insight has detected the true principle, or has been distorted by ignorance and selfishness."

In the early history of the Province of Massachusetts, small-pox was the one disease which caused, among the people, the greatest degree of anxiety and alarm. Notwithstanding the sparsely settled condition of the population, its appearance was frequent, spasmodic and alarming. It had a way of swooping down upon the population like a destroying angel at frequent intervals, attacking nearly every man, woman and child who did not already bear upon their own bodies the scars of a previous epidemic.

In 1721, 6006 persons in Boston were ill with smallpox, or more than half the entire population, and 850 of these died. In 1792, 8346 had the disease. In this latter epidemic, it is stated that, out of a population of 19,484, 10,655 had already had small-pox, and that only 221 persons escaped having the disease, the remainder having moved out of town."

So virulent did it at times become as to compel the Legislature to hold its sessions in some other town.†

There can be little wonder, then, that legislatures should have sought relief from this unfortunate condition by enacting such legislation as seemed necessary for the protection of the people. Many of the statutes of Massachusetts, now in existence, bearing upon this subject, date from 1701, 1776, 1792 and 1797, and are the outcome of serious epidemics. Then came the fortunate discovery of vaccination, with further legislation of 1809, and later enactments upon this same subject.

Let us now briefly review the existing legislation of Massachusetts and see what has been accomplished for the

Report of State Sanitary Commission of 1850, p. 70.

+Report of State Sanitary Commission of 1850, p. 64. See also Stone's Life of Sir William Johnson, Vol. 1.

protection of the community. How does this legislation affect the management of epidemics of small-pox?

I shall treat the subject under two general heads: Laws relating to Small-pox, and Laws relating to Vaccination.

SMALL-POX.

-a

1. NOTIFICATION.-First, and most important, is the law requiring the attending physician to give notice of a case occurring in his practice ("a person whom he is called to visit") immediately, to the local Board of Health. (Revised Laws, Chap. 75, §50.) This notice must be "in writing, over his own signature "—a mere verbal statement, delivered upon the sidewalk, or over his carriage-wheel, is not sufficient in the eye of the law. It may be urged that the young and inexperienced physician, sometimes also older and more experienced men, may not be able at the first, or even at a later visit, to distinguish between smallpox and some other disease; for example, chicken-pox or measles. In such cases, where there is even a suspicion of small-pox, it is best to give the community the benefit of the doubt, and to call in an expert who has had a large experience in the diagnosis of small-pox. During epidemic prevalence of small-pox, as at the present time, the presumption in each doubtful case (of its being small-pox) is greater than at other times. The English Notification Law differs from most American statutes upon the subject, in allowing the general practitioner a fee of 2s. 6d. for each legal notice of a case of infectious disease.

2. The same duty of notification is also incumbent upon the householder (Revised Laws, Chap. 75, §49), but, except in flagrant cases, it has not been the custom to enforce this law to the same extent as the former, chiefly from the fact that laymen cannot be expected to be as familiar with diagnosis as the trained physician. In all cases, however, of wilful concealment, when there can be no doubt as to