Chapter 5

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 papulæ 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 papulæ, 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 papulæ, 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.

The African race would seem to be peculiarly obnoxious to the small-pox: 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 papillæ, 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 bronchiæ 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 papillæ, 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 bronchiæ, 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 bronchiæ. 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 bronchiæ.