night of the second day, of a discharge from the vagina, _resembling_
the menstrual flux. It resembled that flux in _colour_, _consistence_,
_want of coagulability_, and in being, withal, accompanied by a
considerable quantity of _slimy or mucous matter_. Every diaper which
was used during that night, and the greater part of the next day, was
stained more or less with this discharge. It was also observed, that,
during the flow of this fluid, the spasms ceased; and that, whenever the
discharge was suppressed, even for a very short time, they uniformly
returned. In this manner they alternated at intervals of a few hours,
until the occurrence of the death of the child, which happened on the
eighth day after birth.
As this case is related more for its singularity than from an
expectation that any practical suggestions will be furnished by its
perusal, but few remarks will be necessary, either upon its pathology or
treatment. Although it will be perceived by the scientific reader, that
the disease observed, differed materially from any of the forms of
_purpura_, described by systematic writers on diseases of the skin;
still I apprehend it may be justly considered as more nearly allied to
that genus, than to any other.
The spots were evidently caused by an effusion of blood beneath the
cutis, and the presumption is strong, that it issued from the little
point discoverable in the centre of each spot. Those points were, in all
probability, _arterial_. That they were arterial terminations, I think
is evident, from the great extent to which the cellular membrane was
injected, especially over the parietal bones. The force exerted must
have been very considerable to elevate so large a portion of scalp, and
yet no pulsation could be discovered in any one of the points.
But whence came the vaginal discharge? That it issued from the _vagina_
was most certain; but whether it was furnished by that canal, or by _the
uterus_, was not ascertained. To assert that it was menstrual, would be
hazarding more than a prudent regard for truth would justify. But, if
not, why the pain and spasms which preceded it, and the alternation of
these symptoms with each other? and, especially, why the slimy
appearance, mixed with red matter, without a trace of any thing like
coagula? Certainly we do not find these appearances in ordinary cases of
haemorrhage. So that there is no other way of accounting for the
discharge in this case, except by considering it as having been secreted
by the vessels of the parts from which it came.
From the difficulty which the child experienced in swallowing, but
little food could be taken; and the same difficulty precluded the
administration of medicines. What caused this impediment could not be
ascertained, but it was supposed to result from a spasmodic action of
the muscles of the part.
The only medicine attempted to be given was a weak infusion of bark, and
this was soon abandoned.
The spots, particularly the large ecchymosed surface on the head,
exhibited no change in appearance, when _viewed superficially_, a few
hours after death. No other examination was permitted.
FOOTNOTES:
ARTICLE III.--_History of the Natural and Modified Small-Pox, or of the
Variolous and Varioloid Diseases, as they prevailed in Philadelphia in
the years 1823 and 1824._ By JOHN K. MITCHELL, M. D., and JOHN BELL, M.
D. attending physicians at the then Small-Pox Hospital. With a Plate.
In a question of less moment, some apology might seem due for once more
directing public attention to that which has been so oft discussed and
described by many eminent physicians and experienced observers. But, if
descriptions of any disease be valuable; if to record faithfully an evil
be among the first steps for its removal and prevention; and, still
more, if additional confidence, derived from enlarged experience, can be
imparted to the means hitherto adopted to guaranty the human frame
against a mortal and loathsome malady, our efforts at this time may
claim the favourable notice of our professional brethren, and of the
community at large.
Sedulously abstaining from the parade of erudite research or indulgence
in speculations, however ingenious, it is our intention to describe with
accuracy all that we saw; and if, in so doing, we shall be found
repeating what others have said before us, and proposing inferences
previously drawn, the observations and deductions are to be considered
as not the less our own, since we only speak from conviction, founded on
the evidence presented to our senses. Our opportunities for accurate
judgment were most ample, being derived as well from an attendance of
nine months on the hospital for the reception of the poor, labouring
under the disease, as from one of us prescribing, during a part of the
time, for the Philadelphia Dispensary, added to the cases furnished us
by private practice, and very many others, the records of which have
been kindly placed at our disposal by professional friends.
The ravages committed by the small-pox in Baltimore, and the fact of
many who had been previously vaccinated having been attacked by the
disease during the years 1821 and 1822 were notorious to us all, but
were productive of little alarm in Philadelphia. The non-appearance of
the scourge in the greater part of the period, when the former city was
suffering under it, justified, to a certain extent, this feeling of
security, and seemed to call more on our sympathies for our neighbours
than on our fears for ourselves.
In the month of September, 1823, some cases of fever, with pustular
eruption, first arrested the attention of the medical faculty, some of
whom were, of course, called on to render professional assistance. The
residence of some of the persons, thus attacked, in Water street, and
their emigration from Europe, naturally induced a suspicion of this
disease being no other than the small-pox, imported by, or brought in
with them. Very nearly about the same time, however, some scattered
cases of a similar eruptive disease, were noticed in the upper or
western portion of the city, without our being able to trace any
intercourse or connexion between these and the others in the lower or
eastern part, viz. Water street.
The first return of death from small-pox, furnished by the Board of
Health, was in the week between the 13th and 20th of September. The next
was between the 4th and 11th of October. From this time to the end of
the year there was a progressive increase of mortality, and the annual
return for 1823, presented no fewer than one hundred and sixty deaths by
small-pox. The greatest mortality in any one week was thirty-three, from
December 20 to 27. During the months of January, February and March,
1824, the disease prevailed extensively, and was fatal to many. In the
following months its violence subsided, and in the month of June our
attendance on the temporary hospital[11] was discontinued, in
consequence of a resolution of the Managers of the Alms House to close
it. Though a few patients were afterwards received into it, yet the
malady soon disappearing, justified its final closure. The annual return
for 1824 exhibited three hundred and twenty-four deaths by small-pox.
The entire mortality from this cause was four hundred and seventy-three,
in a period of twelve months, from November 1, 1823, to November 1,
1824. The deaths before the first, and after the second date, were but
eleven.[12] Contagious as this disease unquestionably was, we cannot, at
the same time, withhold our belief of its having been in a measure
subjected to epidemical influences, viz. in a particular character of
the seasons and atmospherical changes. It is then within our province,
as historians of events, rather than as expounders of causes, to present
our readers with a summary account of the weather during the years 1823
and 1824. We do this both from a sense of duty, considering it as
pertinent to our present labour, and from a wish to encourage others by
our example to preserve and transmit the meteorological registers, in
their respective districts, of those years, marked by new or aggravated
diseases.
METEOROLOGICAL REGISTER.[13]
------------------------------------------------------------------------
| | | | | |Winds--Days.| |
| | | | |Snow & |------|-----| |
| | | | |Rain |N. W. |N. E.| |
| |Mean |Variat.|Variat.|Water. | to | to | |
| 1823. |Temp. |Therm. |Barom. |Inches.|S. W. |S. E.| |
|-------------|------|-------|-------|-------|------|-----| The |
|January, | 31 | 44 | 0.94 | 3.38 | 22 | 8 | |
|February, | 25 | 42 | 1.17 | 1.93 | 22 | 6 |temperature |
|March, | 37 | 52 | 1.65 | 6.87 | 21 | 9 | |
|April, | 55 | 47 | 1.08 | 1.77 | 16 | 14 | of |
|May, | 61 | 52 | 0.88 | 1.60 | 19 | 8 | |
|June, | 68 | 46 | 0.65 | 0.87 | 20 | 10 | the |
|July, | 72 | 30 | 0.58 | 6.12 | 23 | 6 | |
|August, | 72 | 35 | 0.60 | 4.68 | 21 | 8 | wells |
|September, | 63 | 51 | 0.61 | 3.46 | 15 | 12 | |
|October, | 53 | 42 | 0.60 | 2.02 | 21 | 9 | and |
|November, | 38 | 38 | 0.81 | 2.47 | 21 | 9 | |
|December, | 34 | 31 | 1.07 | 7.37 | 21 | 10 | springs, |
| | | | |-------|------|-----| |
|For the year,|50-3/4| 88 | 1.70 |42.54 | 242 | 109 | in |
|-------------|------|-------|-------|-------|------|-----| |
| 1824. | | | | | | | and |
|January, | 36 | 48 | 1.25 | 3.67 | 24 | 7 | |
|February, | 31 | 59 | 1.55 | 3.94 | 21 | 7 | near |
|March, | 40 | 39 | 0.71 | 2.63 | 16 | 15 | |
|April, | 50 | 45 | 1.08 | 4.54 | 22 | 8 |Philadelphia,|
|May, | 60 | 44 | 0.88 | 1.59 | 24 | 7 | |
|June, | 73 | 46 | 0.69 | 6.09 | 25 | 5 | |
|July, | 74 | 30 | 0.38 | 8.80 | 19 | 8 | is |
|August, | 70 | 36 | 0.45 | 6.39 | 20 | 11 | |
|September, | 64 | 41 | 0.65 | 6.60 | 17 | 7 | 52 deg. |
|October, | 54 | 43 | 0.65 | 1.53 | 23 | 5 | |
|November, | 42 | 38 | 0.89 | 2.49 | 24 | 6 |Fahrenheit. |
|December, | 37 | 43 | 0.95 | 2.11 | 24 | 7 | |
| | | | |-------|------|-----| |
|For the year,|52-1/2| 85 | 1.55 |50.38 | 259 | 93 | |
------------------------------------------------------------------------
1823.
Maximum of Therm. 91, June 19. Maximum of Barom. 30.45, Nov. 29.
Minimum " 3, Feb. 7. Minimum " 28.75, March 30.
-- -----
Variation, 88 1.70
1824.
Maximum of Therm. 90, June 8. Maximum of Barom. 30.45, Feb. 6.
Minimum " 5, Feb. 2. Minimum " 28.90, Feb. 26.
-- -----
Variation, 85 1.55
The amount of water which fell in rain and snow during the four years,
from 1822 to 1825, inclusive, was,
1822. 1823. 1824. 1825.
Inches, 35.20 | 42.54 | 50.38 | 33.26 |
We next subjoin a summary of deaths by fever, erysipelas and measles, in
the above period; being more desirous of narrating all the circumstances
associated with the appearance and continuance of the small-pox, than of
insisting on them as supporting causes or necessary connexions. It will
appear from the accompanying statement, that the diseases febrile and
eruptive were in number, violence and mortality unusually great, in the
above mentioned years, as we discover by comparison with the returns for
1822 and 1825.
Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1822 510 4 0 0
1823 758 24 156 160
1824 654 28 102 324
1825 375 12 38 6
In New York and Baltimore, the coincidence between increase of fevers,
measles and erysipelas, and the mortality from small-pox, is not so well
marked.
In New York--Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1822 393[14] 6 1 0
1823 192[15] 13 117 18
1824 191[16] 14 100 394
1825 445 20 53 40
In Baltimore--Deaths by
Fevers. Erysipelas. Measles. Small-pox.
1821 400 0 2 21
1822 430 1 4 122
1823 304 2 175 2
1824 183 3 14 2
1825 138 0 9 3
We now proceed to give a brief sketch of the disease called the natural
small-pox, (occurring in persons unprotected by previous vaccination or
inoculation,) and the deaths from which are given in the above
statements. We must, in advance, insist on the great diversity in the
appearance of the eruption in different individuals; so great, that an
attempt to make an accurate picture of one case pass for a faithful
representation of the many, must be deceptive and injurious.
In the premonitory symptoms, constituting the characters of the fever
precursory to the eruption, there was considerable uniformity: the
complaint of nearly all those attacked being at first chills and rigors;
pains in the loins, head and limbs, with thirst and want of appetite;
with which were soon associated gastric uneasiness, and in many,
soreness of throat, rendering deglutition painful, hoarseness and
weeping eyes. The duration of these symptoms, aggravated by febrile
exacerbations, varied from one to three days, more usually the latter,
after which the eruption begins to appear. It is first seen round the
forehead and temples, near the hairy scalp; then on the cheeks and
breast and back; on the arms near the shoulders; the abdomen and thighs;
and subsequently on the fore-arms and hands, and finally on the legs and
feet. The appearance of the eruption is that of red or scarlet papulae,
presenting to the touch a sensible resistance, but not much raised, and
without roughness or hardness. These papulae, becoming more and more
defined and elevated, are after a day or two converted into vesicles,
with small elevated centres or bodies of a yellowish-white, and more
diffused red and somewhat hard bases or margins. The redness extending
as the eruption becomes copious, converts the skin, especially of the
face, neck, and hands, into a red ground, from which project, in relief,
the whitish vesicles. Similar appearances, but of a less marked nature,
owing to the eruption being more scattered, are found on the trunk. The
vesicles, containing at first a thin, semi-transparent fluid, become
gradually larger, fuller and yellower, and filled with a thick,
tenacious matter. This change is completed, and the pustules are
entirely formed, after a lapse of time from the first eruptive effort,
which varies from the fifth to the ninth day, and is occasionally
longer. The mean for the beginning of maturation, or the finishing of
the secretion of matter in the pustule, may be received as five days for
the face, and eight or nine days for the body generally. The stages of
the eruption, as regards its appearance, may be very properly called
papular, vesicular, and pustular. This last having attained its height,
completes what is termed the period of maturation, during which the
pustules retain their fulness and spheroid figure; and exhibit the
greatest proportion of whitish-yellow shining surface of their body, and
diminished extent of redness at their base. A yellow dry point on the
summit of the pustule, which loses thereby somewhat of its former
spheroidal shape, by becoming flatter, or slightly indented, indicates
beginning desiccation, at which time the body exhales that peculiar
odour, so unpleasant, and so readily recognizable, after it has once
been perceived. There is no uniformity in the size of the pustules on
the body generally, nor any equality among them on a particular part:
more usually one larger and fuller is surrounded by others less so. Nor
is it to be supposed that the changes above mentioned are gone through
in regular succession on all parts of the surface, uniformly. It was no
uncommon thing to see the eruption papular on the legs, vesicular on the
trunk and arms, and pustular on the face, at the same epoch. One part
even, as the arm for instance, has exhibited to us the three forms at
the same time.
Maturation complete and desiccation going on, the pustules break, and
have their thin coverings converted into a yellow hard coat or crust, to
which adheres the pus that was not removed by absorption, and the
residue, by evaporation of its watery part, is now converted into a scab
of varying thickness, firm and prominent in its centre, and made up
outwardly of concentric circles. The margins of the pustules, before of
a distinct red, now assume a bluish-red or purplish colour, and the skin
begins to desquamate.
The constitutional sympathies, or the symptoms in the milder and regular
variety of the disease, are not of any great violence or intensity. The
premonitory pains, diminishing or disappearing, after the coming out of
the eruption, leave in their place a regular fever. The action of the
heart and capillaries is hurried during the papular and vesicular
stages; but becomes more equable while maturation is going on. During
the former period, the loaded and not unfrequently furred tongue
evidences disordered stomach, the cravings of which are for cold drinks.
The somewhat laborious respiration may, in some cases, depend on the
swelling and soreness of the fauces and pharynx; in others, on the
eruption extending along the lining membrane of the larynx; whilst in
others, it may be caused by bronchial engorgement.
The febrile symptoms, which abate during the process of maturation, are
apt to return during desiccation; and when the skin begins to
desquamate, they then constitute what is called secondary fever. The
skin which had suffered so much, occasionally exhibits at this time an
erysipelatous blush, accompanied by an inflammation of the subjacent
cellular tissue, and the formation of troublesome boils, or infiltration
of serum, especially where there is much laxity of structure, as in the
eyelids, cheeks, lips, &c. The cutaneous system, during and immediately
after the removal of its cuticle, and much of its rete mucosum, is of
course very sensible, as well to the impression of clothes as to
atmospherical extremes, and particularly cold. This is with many a
critical time. It not unfrequently happened that persons, who had passed
through the different stages of the disease, and were advancing rapidly
to convalescence, were suddenly seized with an affection of the chest,
pleurisy, bronchitis or pneumonia, and speedily carried off by the
violence of the inflammation. The skin, exquisitely sensible in its
denuded state to atmospherical vicissitudes, transmits with great
promptness the morbid impression to the lungs, already prone to take on
disease, in consequence of the active part they are compelled to play
during the eruptive fever.
The anomalous varieties, if we can admit any standard form of the
disease, were numerous. Those which most fixed our attention were the
_confluent_, the _roseate_, the _tuberculous_, and the _erysipelatous_.
The _confluent_ was ushered in by symptoms of greater febrile disorder
than the regular distinct variety: the throat was sorer; eyes more
suffused and watery, and more intolerant of light; gastric and pulmonic
uneasiness, and oppression more aggravated. In place of the papulae being
separate, or merely in clusters, they are so crowded, that on the
progress of the eruption the vesicles first and then the pustules are
contiguous at their bases, and often run into each other, forming at
times, a large irregular bag filled with pus, and technically called
blebs, or else exhibiting over a considerable space of skin the
appearance of imperfect vesication. The vesicles and pustules are, in
such cases, flattened, and with indented centres, which latter display
at times a dark point or spot, while the edges are of a livid red. This
is the appearance of the limbs and trunk. The cheeks and forehead during
the process of maturation present a continuous puffy elevation of a
pearly white colour. The eyes are nearly closed by the swelling of the
lids, and the thick copious secretion from the borders and the
conjunctiva; the lips are tumid and the angles of the mouth ulcerated.
In fact the human face divine, deprived of all lineaments and
expression, is now a foul, misshapen mass. Associated with this state
are swelled throat, rendering deglutition very painful--salivation,
cough--occasional vomiting, delirium, sometimes phrenitical, sometimes
evidencing itself in low mutterings and jactation.
The _roseate_ variety of small-pox might, without creating much
confusion, be ranked with the confluent, which it closely resembles in
its second stage. The first is characterized by the rose or pink colour
of the face, which is covered with a copious eruption of papulae, some
with dry points, while from others, the bases of which are small and
hard, arise minute vesicles of a pearly colour, which soon dry away. The
inflammation, however, still continues, but spreads under the cuticle,
which is raised in large patches of a white colour, but not vesicular,
or distinctly pustular, or containing fluid: they approximate and
produce the continuous puffy elevation already described. On the trunk
and extremities, the eruption is either of confluent patches or of
pustules dry and flat, with indented centres, the intermediate skin
being of a deep red or crimson colour.
The constitutional disorder runs high in these cases,--delirium and
great gastric distress being very common symptoms. The tongue,
especially at its border, is frequently the seat of eruption, which may
be compared to the vesicular stage on the skin, with the summits cut
off. The lining membrane of the mouth and fauces and pharynx, are, we
presume, similarly affected, judging from the soreness of these parts,
and the thick muco-purulent matter sometimes mixed with blood, which is
spit out or brought up by screatus. The subjects most liable to the
roseate eruption, were the intemperate and debauched of the sanguine
temperament.
The _tuberculous_ variety of small-pox was most frequent among the
negroes. The eruption at first consisted of broad papulae, which were
converted into hard, rough, and knotted prominences, tuberculous at base
and flattened in the centre. This was not unaptly called by some the
seal skin eruption. Sore throat, causing the greatest difficulty in
deglutition, and delirium were the almost invariable concomitants of
this variety. Occasionally the patient was in a state of stupor and
disinclination to motion--at other times wakeful and restless, and
requiring coercive means to confine him to his bed. In many instances,
the muscular strength was retained to within a few hours of death. The
fatal termination in these three varieties, confluent, roseate, and
tuberculous, was in the second period of the disease, that is, in the
one corresponding with the completion of maturation, and the absorption
and drying away of the pus in the simple distinct form of small pox.
After some experience, we were enabled, from the appearance of the
eruption at the outset, to presage the event, which in the above
described kinds, was almost universally fatal.
The _erysipelatous_ variety was more an adventitious conversion of the
primary form of the disease, by hospital air and delicacy of the
cutaneous tissue induced by prior irregularities of life, than a
distinct kind to be met with in general practice. It was most commonly
presented to us in persons who had a very copious eruption, interesting
to a great degree the whole cutaneous surface, and in whom the process
of maturation was complete, and the cuticle began to lose its adhesion
to the subjacent tissue. In some cases, even after desquamation was
almost completed, and the skin nearly dry and smooth, erysipelatous
inflammation would supervene, and seem to be repeated on the pulmonary
and gastric surfaces, producing great trouble in respiration and
derangement in the digestive functions, accelerated pulse, and other
symptoms of fever.
We could readily pourtray other nicer shades of the natural small-pox,
but the originals might not perhaps be so readily recognized by
succeeding observers, or their nature well understood by our
readers.[17] Our object being to convey practical knowledge, we pass on
to a notice of the subjects, most liable to suffer from exposure to the
variolous poison.