opinion is expressed by modern writers. While some contend that even if vaccination fails to prevent the development of variola it is quite certain to modify its severity, others claim that it can be of no more advantage than locking the barn after a horse has been stolen.

The precise effect which vaccination during the stage of incubation may exert upon the subsequent course of the disease is very difficult to determine in one or even a small number of cases, since it is almost impossible to predict in any given case what the severity of the disease will be. In the opinion of Curschmann it is very doubtful whether vaccination can even render the course of smallpox milder. He states that in many instances where vaccination has been performed after exposure to smallpox infection the pustules of vaccinia and variola have been seen developing side by side, the former having apparently no effect upon the latter. In the opinion of Welsh, on the other hand, vaccination after infection often modifies the disease, and not infrequently prevents it altogether. He believes that when vaccinia has advanced to the stage of the formation of an areola around the vesicle, about the eighth day, it begins to exert its prophylactic power against smallpox; and as the period of incubation in variola is usually twelve days or more, an early vaccination may exert its protective influence in advance of the time when the variolous eruption should appear.

Welsh reports one hundred and ninety-four cases of vaccination performed during the stage of incubation, in which thirty-eight were perfectly protected against smallpox, sixteen almost perfectly protected, thirty-one protected to a well-marked degree, thirty partially protected, and seventy-nine were unprotected.

Of these one hundred and ninety-four cases the death-rate was 12.90 among those vaccinated early in the stage of incubation; it was 40.98 among those vaccinated from one to seven days before the eruption of smallpox appeared; while among the unvaccinated cases the death-rate amounted to fifty-eight per cent.

As it is well known that a secondary vaccination runs its course more rapidly than a primary one, it is evident that if an exposed patient has been already vaccinated a secondary vaccination is more apt to exert a protective influence. Since vaccination with humanized virus is more speedy in its effect than when bovine lymph is used, it is advisable to employ the former when readily obtainable and to make several insertions in order to increase the probability of success. Even a late vaccination in the stage of incubation may be of value, as it sometimes happens that this period lasts fourteen days or more. Early in the nineteenth century Waterhouse claimed that two days after infection vaccination would save the patient.

Good results from the subcutaneous injection of vaccine lymph have also been claimed by Farley and others, but the efficacy of this method of treatment appears to have been assumed rather than proven.

The speedy vaccination of all those who have been accidentally exposed to smallpox infection will do no harm, even if it fails to modify the disease when contracted. Indeed, it is always advisable, since the persons exposed, even if not already infected, are liable to contract the disease through possible subsequent exposure; and in the case of a threatening epidemic no precaution should be neglected which might tend to lessen the number of possible cases.

Since no drug nor specific remedy exists which administered during the period of incubation will abort or modify the subsequent eruption, the only thing to be done is to prepare the patient by means of a rigid regimen and all possible hygienic measures to withstand the impending attack. When the fact of exposure is certain, forewarned should be forearmed.

Period of Invasion (Initial Stage).—At the outbreak of the initial symptoms of smallpox a correct diagnosis is rarely made, owing to the fact that headache, lumbar pain, chills, fever, and nausea are not sufficiently pathognomonic to always suggest the true nature of the disease. In those cases, however, where it is known that the patient has been exposed to infection and an attack of variola is consequently anticipated, the diagnosis is comparatively easy. In such a case the patient should be put to bed, or at least confined in a large, airy room, from which all draperies and superfluous articles, capable of absorbing infectious germs, should be at once removed. The temperature of the room should be kept as low as possible in summer and should not exceed 60° to 65° F. in winter. An extra bed or couch should be provided, to which the patient can make a convenient and agreeable change later in the course of the disease, especially if it proves to be of a severe type.

At the outset the bowels should be freely opened by a dose of calomel and soda, followed in the morning by a saline purgative; and since constipation is apt to persist in most cases throughout the course of the disease, it is advisable to administer a little cold citrate of magnesia or some other agreeable laxative from day to day.

A warm bath should be taken and the skin from head to foot thoroughly cleansed by vigorous soap friction and the application of an antiseptic lotion. If the disease proves mild, a daily bath can be taken; or when this does not seem advisable, the daily sponging of the whole body with cool water will usually lessen the fever and add greatly to the comfort of the sufferer. If the patient happens to belong to the class of the unvaccinated, or has not been vaccinated for many years, and there exists consequently the prospect of a severe attack, the hair and beard should be closely clipped. In most cases, however, this procedure can be left until the eruption has appeared, and if this is moderate in amount, the cutting of the hair, especially in the case of young girls and women, may not be necessary.

The diet, which throughout the course of smallpox is a matter of the greatest importance, should be light and nutritious during this stage, consisting mainly of milk, broth, or gruel.

The medicinal treatment of smallpox in this stage and throughout the course of the disease must be mainly symptomatic. Upon careful nursing and the prompt treatment of the various symptoms as they present themselves we must depend in great measure for the fortunate termination in any case. The remedies and special methods which have been vaunted by some as tending to abort or modify the eruption and to lessen the severity of the disease, have been tested by others and found wanting. A specific for variola comparable in its action to that of mercury in syphilis or quinine in malaria is at the present time unknown, although, in view of the recent advances in antitoxic medication, the discovery of such is a hope that may possibly be realized in the near future.

A high degree of fever in the initial stage of smallpox with intense headache and backache are symptoms which call loudly for relief, although they may not betoken a corresponding severity of the disease in its subsequent stages. Aconite, quinine, phenacetine, and other antipyretics are remedies which may now be advantageously given, and the daily cool bath, although it may not have the notable effect so often observed in typhoid fever, will assist in lowering the temperature.

If the fever is combined with extreme nervousness, the old and reliable Dover’s powder will be found of service. In some cases delirium is present during the initial stage, and occasionally a suicidal tendency is manifested, which makes it necessary to have a watchful nurse in constant attendance upon the patient. Potassium bromide in full doses, chloral, or sulphonal may be advantageously employed as a sedative, but the most effective remedy is probably the hypodermic injection of the sulphate of morphine (gr.