Chapter 4

[10] This name may be either from the ancient English or the low Dutch; if the one, by tradition, if the other, from the use of it by medical men. _Cancrum_ is an odd grammatical blunder; being, in reality, nothing but the accusative of Cancer, put instead of the nominative. The latter name was, as is well known, frequently applied by the older surgeons, in a vague manner, to any terrific and unmanageable ulcer; and, in particular, it was often applied to gangrene. The error appears to have been first made by Pearson, and copied by Mr. Cooper. Compare Muys and Vander Wiel, with Pearson, at the above references.

ARTICLE II.--_Case of Purpura in an Infant, attended with Extraordinary Symptoms._ By R. M. HUSTON, M. D., &c.

On the 28th of August last, A---- V----, after a moderate labour of four hours' continuance, was delivered of a female child. About a month previously, she had laboured under an attack of intermittent fever, which yielded, in a few days, to the ordinary treatment. She was 23 years of age, an English-woman by birth, had generally enjoyed good health, and was as well as usual at the time of her confinement. Her labour was strictly natural, and her delivery accomplished without any extraordinary assistance.

At birth there was nothing remarkable about the child. Its breathing was natural, its skin of the usual colour and appearance; in short, all the common indications of a continuance of life and health were present. A few hours, however, after birth, it became uneasy, cried much, and showed signs of colic. The nurse, supposing these symptoms to arise from flatulence, administered some warm tea; but without any apparent advantage. On the following day, I saw it again, and learned, that it had evacuated a considerable quantity of urine, and some intestinal matter, of the ordinary appearance after birth. The spasms continuing at intervals, a teaspoonful of castor oil was ordered, to evacuate any remaining meconium, that might lie in the bowels, producing irritation; upon the presence of which, it was presumed the spasms depended. It operated well, but without producing the desired relief. On the next day, viz. forty-eight hours after birth, a number of bluish or purple spots were observed on different parts of the child's body, but most numerous on the extremities. They were of various sizes, from that of a mustard seed, up to that of a grain of Indian corn. Some were slightly elevated, but most of them were not in the least so. In the majority, there was a minute central spot, or little point, more red or pink coloured than the blue areola, by which it was surrounded. In many instances, these little points projected, so as to become manifest to the touch. In the course of twenty-four hours, the spots, which had first appeared, began to decline, leaving a greenish mark, very like the remains of a bruise; but much more rapidly than these declined, others of larger size appeared on different parts of the child's body.

On the third day after birth, large blotches appeared, one behind each ear. These rapidly increased, until they covered the whole extent of the parietal bones, and considerably elevated the skin, giving it a puffy or tumid appearance, like that caused by a blow from a large or blunt instrument. The parts soon became hot and tender to the touch; and this tenderness extended over the greater part of the scalp. A blotch, similar to those upon the exterior surface, was likewise observed within the mouth, covering the whole extent of the palate bones. The child experienced great difficulty in swallowing after the third day; and the _nurse_ thought the spasms were often excited by attempts of this kind.

But the most singular feature of the case was the appearance, on the 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 hæmorrhage. 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° | |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 papulæ, presenting to the touch a sensible resistance, but not much raised, and without roughness or hardness. These papulæ, 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_.