the actual number of people of colour brought to the hospital being
greater than the whites, and the proportionate mortality much more
considerable; being as four deaths to six cases of disease in the
former, and two deaths to four cases of disease in the latter. As
regards sex, the proportion of deaths among the males was three-fifths,
among the females two-fifths, of the entire number under treatment in
the hospital. In both, the violence of the disease, and the number of
anomalous symptoms and complications, depended greatly on their prior
dissolute life. Drunkards among the men, and prostitutes among the
women, rarely escaped death. The former had the roseate eruption, and
the latter the confluent, on which dark spots as if gangrenous were a
frequent appearance. Menorrhagia, at any time in the course of the
disease, was a bad augury.
The better to elucidate the nature of this dire malady, we shall now
give from our records some cases of fatal termination, and add an
account of the appearances on _post mortem_ examination of these same
subjects.
CASES.--I. Wilhelmina Smith, white, aged nineteen years, of irregular
habits, has a well defined circular scar, with smaller pits in it, on
the left arm; but has no recollection of having been vaccinated, nor
does she remember ever having heard her parents, who are now dead, speak
of it.
She was taken sick on Thursday night, the 11th of March, 1824, and in
the morning had vomiting and pains in the back. On the 13th in the
afternoon, the eruption first appeared.
15th. Admitted and visited. Eruption on face slightly prominent, is red,
tuberculous and rough--small and scattered on the arms, like flea bites.
Legs nearly clear: they have many cicatrices, especially on the shin and
outer part. There is at present an ulcer above the inner ancle. Tongue
yellow, and furred in centre, white at borders. Pulse small and
threaded.
16th. Eruption rising vesicular from face and limbs; no fever; tongue
greenish and loaded; coughs much.
17th. Eruption fine, dry, flat, and partly indented in centre on the
face, which burns much; skin red and inflamed; on limbs same appearance,
but eruption less copious; pulse small, threaded, and frequent; tongue
furred and yellow in centre; complains of pain in deglutition; cough.
18th. Eruption on face dry, flat, white and small in size, and copious;
rather more elevated on limbs and neck; tongue dry and furred; pulse
frequent and threaded; throat sore.
19th. Eruption same as yesterday; pulse scarcely to be felt; skin cool;
coughs with an appearance of choking.
Dead at midnight. She retained her muscular strength and ability to sit
up to the last.
_Examination_ in the afternoon of March 21.--On removing the sternum and
anterior portion of the ribs, the anterior mediastinum was found filled
with a frothy adipo-mucous collection of a yellowish colour. The lungs
on both sides adherent to the thorax, and the left lobes to each other.
A sanguineo-serous effusion on both sides, probably a quart on the
right, the lungs of which were changed in texture, and shrunk. The
pericardium contained a large quantity of the same kind of fluid, which
was found in the cavity of the thorax. The heart was highly injected. On
removing the lungs and the trachea, and larynx, the lining membrane of
the two last showed a brownish-red, coated with mucus, and deeply
injected. Same appearances in a more marked degree in the bifurcations
of the trachea.
The oesophagus next examined, was found of a natural appearance,
except near the stomach, where it was injected and assumed a red hue,
contrasting with the whiteness of its upper part. The mucous membrane
of the stomach near the cardiac orifice was in some parts of a roseate
hue, in others a brownish-red; while in others it was ash-coloured, and
dotted with red and yellow points. Towards the pyloric orifice, less
disease. The stomach contained nothing but dark green bile and mucus.
The duodenum was also highly injected. Lower down, the small intestines
were in places lined with a dark red and brown, and the mesentery highly
injected in the portions corresponding to these spots. Intestines much
inflated, and omentum dark and injected. The uterus was not examined.
The ovaria were large, white and soft; in the left was a small sac of
dark blood, which readily burst on pressure.
The liver was very large, of a soft texture and white colour;
gall-bladder full of dark green bile, which had in part transuded
through its coats.
On looking at the trachea after it was washed, it exhibited in places
whitish elevated spots, having all the appearance of an eruption.
II. Ann Collins, white, aged 18 years, unprotected, became sick on
Tuesday evening, March 23, 1824, and was taken to the Alms House, as one
having the measles, on Wednesday. On Thursday evening, some eruption was
visible; on Saturday evening, March 27, admitted.
28th. Visited. Face covered with a red, flat, dry eruption, particularly
on the cheeks; small and vesicular on the chin and around the mouth. On
the arms, it has the appearance of measles; on the hands, it is of a
deep scarlet, with central vesicular elevations; on the legs is slight;
tongue loaded and yellow, except at the borders, which are clean; pulse
natural; complains much of pain in the back and sickness of stomach.
30th. Eruption covering the face, vesicular on a deep red ground with
some tumefaction; rising vesicular on the limbs with scarlet bases.
Tongue smooth and shining anteriorly, and with vesicles on it. Throat
sore. Salivation. Pulse small and feeble. Has had menorrhagia since her
admission into the hospital.
31st. The menorrhagia continues. Had last night epistaxis. Pulse small
and slow. Tongue furred and red. Eruption confluent with indented and
dark centres. Surface white and dry. Skin between, red and inflamed.
Very slight eruption on legs, and none on feet.
April 1. Menorrhagia continues. Pulse small and labouring. Respiration
laborious and hurried. Face swelled. Surface smooth, with white spots to
represent the pustules. On breast and arms the eruption is in confluent
patches which are nearly continuous--some pustules flat and indented,
others smooth, with appearance of radii, and some more elevated forming
blebs. Skin of the feet cold, and blue in spots; no elevated eruption on
lower extremities. Tongue furred and yellowish. Throat sore. Eruption
very copious on body, generally with blebs.
_Vespere_; pulse hardly perceptible. Anxiety and distress great. Dead at
10, P. M.
_Examination_ April 2nd, in the afternoon.--On opening the thorax, the
lungs and heart were found of the natural appearance and size. The
larynx and trachea being divided, exhibited all the way down to the
lungs an injected surface with whitish irregular spots, having nearly
the same appearance as the flat smooth eruption on the face: in parts it
was more evidently pointed, and showed, by the aid of the microscope, a
pustular appearance. In the lungs, the inner surface was still darker.
The root of the tongue was covered with large and rather hard papillae,
with open summits. The oesophagus was smooth and white. The stomach
near the cardia injected, and of a brownish-red in spots: the remaining
portion white, presenting no diseased appearance. The spleen was very
large and covered with copious miliary points. The omentum, to
appearance gangrened, was dark, and altered in texture. The peritoneum,
especially in the pelvis, was injected and inflamed, being of a
semi-opaque dark colour. The uterus, small and firm, contained some
bloody mucus in its cavity.
III. Joseph Foster, white, aged 22 years, unprotected, became sick on
Monday evening 8th of March. The eruption began to show itself on
Wednesday morning, 10th.
12th. Admitted and visited. Face covered with a red, dry, tubercular
eruption, with some few yellow pustules. Same on arms, but no pustular
appearance; partly tuberculous, partly vesicular. More sparse and
scattered on breast and legs: none on feet. Slight cough. Tongue white,
clammy, and loaded in middle--red at borders. Pulse rather frequent.
14th. Face covered with a pustulo-vesicular eruption, with whitish
summits, red and inflamed bases. Skin between, of same colour. Eruption
dry and hard; very red, copious on limbs; less so on trunk. Tongue moist
and less loaded. Pulse regular.
15th. No fever. Face of a deep red colour; eruption rising from it
rather flat, irregular in figure and white at summits. Eyes inflamed. On
limbs the eruption is red at base, vesicular in body and summit: on
trunk in clusters. Tongue yellowish and rather furred. No complaint
made; rests easy; sleeps well.
16th. No fever: tongue moist and a little loaded. Pustules nearly white.
Some yellow, and beginning to dry on summits. Skin between still of a
deep red. Eruption filling on limbs and trunk.
17th. Pulse strong and frequent; skin hot; tongue moist and loaded.
Pustules scabbing on face. Not yet entirely filled on limbs, where they
are in clusters with inflamed bases.
18th. Pustules full and matured on limbs. Running into each other in
places. Tongue dry, brown, and furred in centre, yellow and loaded at
sides. Pulse quick and frequent. Lies easy.
19th. Blebs formed on arms; pustules running into each other, beginning
to shrink; matter oozing out. Tongue covered with a dark crust. Pulse
quick and frequent. Erysipelas of eyelids and ophthalmia. Throat sore.
20th. Blebs larger and more numerous on hands and arms; purulent matter
oozing out from some of the pustules. Face nearly scabbed over. Some
small white pustules formed on the eyelids. Pulse frequent and
vibrating. Tongue as yesterday. Gums tender.
21st. Pulse weaker. Desquamation going on; pustules shrunk and drying on
limbs. Tongue as yesterday.
22nd. Matter much absorbed on limbs, leaving a shrunk cuticle. Face
covered with a brown and yellow scab and scurf. Tongue black and furred;
clear at apex.
23d. Some erysipelatous inflammation of the skin; pustules all nearly
disappeared from arms, trunk and thighs; some few, white and soft remain
scattered over breast. Pulse frequent. Tongue black and incrusted.
24th. Was brought into town from Bush Hill.
30th. Desquamation nearly complete. Low frequent pulse. Respiration slow
and laboured. Tongue incrusted.
April 2nd. Dead at 10, A. M.
Calomel had been freely given to this man in the earlier stage of his
disease: and during the last week, spts. terebinth. and nutritive
farinaceous food.
_Examination._--The pericardium, of a greenish colour and its
capillaries finely injected, was full of yellow serum. The lining
membrane of the larynx and trachea was of a greenish-yellow colour
throughout, and in the spaces between the cartilages ulcerated and
disorganized in several spots. Beneath the membrane was a venous
injection. About the bifurcation it was injected; and in the
ramifications of the trachea were seen several inflamed, and in places
abraded and disorganized spots. A chocolate coloured liquor with a
sediment filled the bronchiae and the larger tracheal subdivisions.
The oesophagus was sound. The stomach showed clusters of bright red
and brownish-red spots, in stellated and other regular figures extending
along the smaller curvature. The duodenum, at its commencement and in
its course, presented similar clusters. The rest of the intestine was
healthy. The brain was to appearance in a natural state.
IV. Peter Johnson, black man, aged 38 years, unprotected, was taken sick
on Monday, 29th March, in Sandy Hook. Eruption of small-pox appeared
April 3d, Saturday morning. Admitted same day.
4th. Eruption copious on face; papular and of irregular figure. Eyes
suffused and red. On arms, same appearance as on face, but less
tuberculous. On breast and body, eruption small and pointed; beginning
to show on legs. Throat sore. Tongue yellow and loaded at sides; red in
centre. Pulse full, equal, and rather frequent. Cough.
5th. Much anxiety and moaning. Eruption rough and tuberculous on face.
On arms, it is in parts papillary and pointed, and in parts flat with
indented centres. Pulse slow and equal.
6th. Eruption hard and tuberculous on face and arms; small and pointed
on breast. Pulse slow; throat less sore; mind wandering. Is sitting up
in bed, dressed. Tongue moist and yellow.
7th. Delirious through the preceding night; is now dozing. Eruption same
as yesterday. Not so thick on legs, but hard and tuberculous.
8th. Tongue black and incrusted. Throat very sore. Eruption hard and
flat. Pulse active.
9th. In a comatose state. Pulse slow. Skin cool.
10th. In the same condition. Drawn down in the bed, the thighs flexed on
the abdomen, and lies on his side.
11th. Dead at six A. M.
_Examination._--The upper surface of the tongue of a brownish yellow,
full of holes and rough. At the posterior part, in place of the larger
papillae, were ulcers and cavities. The posterior nares and pharynx were
covered with holes, formed by ulceration, and of a brownish hue,
adjoining injected and apparent pustular parts. Tonsils ulcerated, and
their investing membrane mostly destroyed. The oesophagus immediately
below the glottis, smooth and sound. Yellowish matter flowing from the
glottis. On opening the larynx, it was found half filled with a viscid
light olive-coloured fluid; on removing which, the whole lining
membrane, down to the bifurcation of the trachea, was found covered with
clusters of ulcerated pustules of a yellow colour, with the intervening
spaces of a brownish-red, highly injected, and destitute of its natural
smooth, shining appearance. The internal surface of the glottis and
epiglottis was in a similar but less marked state as the larynx and
trachea. The pustular surface extends to the minute ramifications of the
bronchiae, and their cells beyond were highly injected.
On opening the abdomen, the omentum was found dark and shrunk. Stomach
contracted. Intestines distended, shining, and very vascular, with
capillary injection when viewed externally. The peritoneal covering of
the stomach showed a similarly injected appearance.
The stomach being opened, displayed at its upper curvature, spaces
studded with spots of a deep red or purple; apparently effusions
surrounded by a vascular net-work. Same appearance towards the pyloric
orifice, and in places on the duodenum, which, together with the
jejunum, particularly the latter, is of a dark leaden colour, and
injected.
The diaphragm on its upper surface, highly injected, as was also the
pleura lining the thorax. The pericardium healthy.
The brain was not, unfortunately, examined.
V. Jacob Fry, black man, aged 30 years, unprotected, was taken sick on
Sunday, 11th April, 1824. Eruption appeared on Thursday, April 15th.
16th. Admitted and visited. Eruption copious and papular on face; smooth
and flat, with dark centres, on trunk and arms. Tongue loaded. Cough.
Tenderness of epigastrium on pressure. Throat sore. Pulse small and
threaded. Eyes muddy.
18th. Eruption flat and rough; diffused over face. On breast red and
flat; on limbs in clusters, shrunk, and hollow in centre. Pulse small.
19th. Tongue moist. Pulse small and frequent. Throat much swelled.
Restless, and somewhat delirious.
20th. In a comatose state; but is roused to attention by calling him.
21st. Dead at five P. M.
_Examination._ April 22nd.--On opening the thorax, the lungs were seen
to appearance healthy. Both adhered to the pleura costalis. The pleura
lining the diaphragm, and also the pericardium, were finely injected.
Fauces inflamed, injected, and ulcerated. From the tonsils oozed out
pus.
The larynx contains a light olive coloured fluid, muco-serous, which
likewise covered the trachea and bronchiae. The lining membrane
throughout was rough, and exhibited a net-work of a brownish-red colour,
finely injected.
The oesophagus about half way down, has its lining membrane removed
for one-third its length, showing miliary points on its muscular coat.
The stomach on its outer surface, and near its upper end, showed a black
spot, like effusion of black blood, under the peritoneal coat. On
examining the oesophagus near the cardia, it was found of a dark
colour in lines. From the cardia, half over the inner surface of the
stomach, radiates inflamed membrane of a deep red colour, and corroded
at the place corresponding to the dark spot above mentioned. Red spots
near the pyloric orifice. Intestines not diseased. Liver adherent by its
right lobe to the ribs; this lobe was of a greenish leaden colour. No
alteration of its structure. Brain injected in its arachnoid coat.
Ventricles contained some serum. Tela choroides dark and gorged.
VI. William Lawrence, aged 18 years, unprotected, became sick on
Saturday, April 17th. On Sunday taken to the Alms House, and on
Wednesday, 21st was transferred to the Hospital.
21st. Eruption fine and papillary on face; red and scarcely raised on
arms. None on legs. Has cough since yesterday. Pulse slow and regular.
Tongue brown, and incrusted in centre. Moist on sides.
22nd. Eruption confluent and red. Papulo-vesicular on face and arms.
Flat, dry, and copious all over the trunk. Scattered and small on legs
and feet. Pulse small and regular. Tongue loaded and brown in middle.
Eyes sparkling. Is delirious and very restless.
23rd. Eruption very copious all over the body, rising vesicular from red
margin. Pulse small and slow. Tongue loaded, furred, and yellow. Head
and back easier. Has slept well. Face deeply suffused with red.
24th. Cough. Eruption flat, indented centres, dark in places. It is now
coming out on legs. Pulse small and firm. Skin cool. Much uneasiness and
hurried breathing.
25th. Dead at seven A. M.
This man had been bled twice before his admission, and once again on the
22nd. Cold affusions had been freely used.
_Examination_, on the 26th April.--Pericardium sound, but contained much
sanguinolent serum. Pleura sound. Lining membrane of pharynx partly
destroyed. No ulceration. Tonsils give out pus on pressure.
Oesophagus of a dark red, and partly lost its inner membrane. Larynx
and trachea injected; but the membrane lining them is entire, without
pustules or ulceration. Some frothy effusion in bronchiae.
Liver healthy. Spleen large. Omentum sound, and of a natural white
colour, traversed by some large veins. Stomach externally of a brown-red
colour; and when opened, presents, spread out from the cardiac orifice,
dark brown-red streaks; and towards the pyloric orifice and upper side,
an extensive surface shaded over with vermillion and darker spots. Near
the duodenum, the surface is white. Intestines slightly injected.
Bladder dotted all over with bright red spots on its inner surface,
which is covered with a fine capillary reticulated structure.
VII. An infant, white, unprotected, aged three weeks, child of Clarissa
Clarke, who had been inoculated twenty-one years ago. Taken sick on
Sunday, 2nd May. Eruption appeared Thursday, 6th. Admitted 9th.
10th. Eruption copious, and in confluent patches, with red bases, and
flat vesicular summits. Has also aphthae.
13th. Eruption confluent, in large white patches on face. Throat very
sore.
15th. Dead at eight A. M.
_Examination._--The stomach of a light colour, perfectly healthy. Folds
and plaits of mucous membrane strongly marked. Mucous surface of trachea
nearly healthy.
VIII. Infant, female, of a woman who died in the Alms House of varioloid
disease, shortly after giving birth to this child. It is three weeks
old; was admitted Sunday, 25th April, second day of the eruption. Dead
on Thursday, 29th. The skin became livid after death..
_Examination._--Pharynx inflamed, and the eruption on it extending all
the way down the oesophagus, to near the cardiac orifice; the lining
membrane being also in part destroyed. Stomach of a fine clear red, and
beautifully injected to the minutest capillaries all over the mucous
surface. Intestines, both large and small, red and injected.
The larynx has some eruption on its lining membrane. The trachea and
bronchiae nearly healthy; there being no eruption or secretion on their
surface.
Doctor DARRACH was present at the majority of the above detailed
examinations, and kindly officiated at some of them. This gentleman,
well known for his zeal in the study of comparative and morbid anatomy,
made many interesting microscopical examinations of the various kinds of
variolous pustules, and the corresponding changes in the cutaneous
tissue, the results of which, we hope, he will make public.
Having thus freely described what we saw, we wish it were in our power
to lay down next, for the benefit of those who come after us, a
satisfactory method of treating small-pox. The hospital returns are not
of such an encouraging nature as to make our self-love predominate over
observation and experience, and lead us to inferences which might seem
to sanction the utility of this or that medicine, or curative plan. We
had to deal, it is true, with the worst portion of the community;
persons of constitutions exhausted or perverted by excess of sensual
indulgences, or by poverty, or both conjoined. In private and even
dispensary practice, where the subjects were of a better physical and
moral nature, we often saw the disease subside, and health return, after
less attention to administer medical aid, or to supply other wants, than
was exhibited at the hospital. We are, notwithstanding, sanguine enough
to anticipate useful results from our attentive study of the symptoms of
the disease, in connexion with that of the post mortem examinations, and
to consider ourselves as in possession of lights to guide us with more
certainty than before. Let us see how far a cautious analysis will tend
to dispel old errors, and establish useful truths.
The gastric distress, and the associated uneasiness and pain in the
head, back, and limbs, with evening exacerbations of fever, for the
three days preceding the eruption, evince conclusively a disease to
which the skin is a stranger, except by its usual sympathies of heat and
coldness, moisture and dryness. The appearance of the tongue, the loss
of appetite, thirst, nausea, and occasionally vomiting, are testimonies
to the impeded function of the stomach in this first period, or that of
precursory fever: and if to this we add the soreness of the fauces and
pharynx, producing impeded deglutition, we cannot refuse our assent to
the belief that the mucous surface, on which the _preparatory process_
of digestion takes place, is mainly affected. The next leading symptom
is the appearance of the eruption on the skin. The character of the
disease is now fixed, and the physician feels himself compelled to
respect the cutaneous inflammation, throughout its entire course,
naturally enough regarding it as the disease itself, rather than the
last link in the chain of morbid actions. To support the circulatory
system at such a degree as shall enable the skin to secrete this new
matter of small-pox, is nearly as much as he proposes to himself. But
here arises a question of great practical moment. To what extent, if
any, is the eruption a natural or necessary sequence of the previous
symptoms or condition of the system. Perhaps in the existing state of
medical science, we hardly dare reply positively to this question. This
much we know, that there is no correspondence in general between the
intensity of the precursory fever, and the copiousness of the after
eruption. We are, moreover, well apprized of the fact of very many, who
had been protected in earlier life by inoculation or vaccination, being
seized with all the symptoms of the precursory fever of the small-pox,
and remaining seriously indisposed for a few days, yet with very little
eruption in some cases, and without any in others.
Next we may inquire, what control, salutary or otherwise, we can
exercise over the skin in reference to its eruption, by adopting certain
methods in medicine and hygeine, during the period of invasion or of
precursory fever. To foster the germ of the poison, as yet only
affecting the inner surfaces, into efflorescence on the outer or
cutaneous one, by hot air, warm and heavy clothes, and cordial drinks,
is a practice, which, though at one time advocated on what was thought
very sufficient theory, is now abandoned as at war with experience. Of
these means, clothing acts primarily on the skin, and we will suppose
heat to do the same: the cordial drinks must however affect this organ
by stimulating and irritating the gastric and intestinal surface.
Against all stimulation of this surface we are then bound, from
knowledge and theory, to object.