FOOTNOTES:

At the Children's Asylum, all the weakly children were madeto take bitters, of different descriptions; and Dr.Sylvester'santiscorbutic drink, composed of cream of tartar and juniper berries, infused in water. As the disease declined in the house, under this administration of bitters, it is highly probable that they had a preventive agency. I much question, however, whether Dr.Sylvester'sdrink was productive of any advantage.

One question of some importance yet remains.Has mercury any agency in producing this affection?The salivary glands have never been observed to be affected in it. Dr.Parrishinforms me, that, after a strict examination, he has come to the conclusion that the previous use of mercury does not bring on, or aggravate this complaint, as he has noticed it. I have made the same observation; and, not being peculiarly sparing of the use of calomel in fevers, have had opportunities to verify it. I think I can add, that, in some cases, by shortening and moderating an attack of fever, calomel has been useful in preventing the ulceration. Given during the progress of one, and that a fatal case, it did not appear to aggravate it.

There is no evidence whatever tending to excite the suspicion ofcontagion.

Treatment.—A variety of remedies had been tried within my knowledge; most of them with but little success, and one or two with somewhat better. Feeling much disappointed with the results of my practice, in the small number of cases which fell under my care in the spring months at the Asylum, as well as elsewhere, I wished to exchange with another physician for a period when the disease was more prevalent; for the purpose of studying it, and making comparative trials of different remedies. Dr.Jos. G. Nancredewas so polite as to indulge me. Having then a large number of patients under my care, I was enabled to make more extensive observations, and with more precision; the results of which course gave me the first satisfaction I had ever felt relative to this disease. Trials were made of every thing that was suggested by friends, and generally upon 4 or 5 selected patients at a time. Thus, choosing them in the ulcerative stage, and having several at a time before our eyes, the result was seen in a very few days, much sooner than if patients had been successively subjected to the remedies; and no material time was lost in appealing to the article which appeared to answer best.

The remedy which beyond all comparison succeeded best, was sulphate of copper. The usefulness of this substance, though known at Salem, New Jersey, was discovered, at the Asylum, by the mistake of a nurse. It had been previously used, in lotions of the strength of gr. ij or iij to the ounce of water; and with little advantage. Observing that the empirical remedies said to have succeeded, were, as I considered them, immoderately strong, I furnished the nurse with a common solution of sulphate of copper, and with a vial containing 72 grains of the sulphate in an ounce of water, for the purpose of being progressively added to the other at different periods. This stronger solution was applied, by mistake, instead of the diluted one; and it was the first remedy which had produced a rapid tendency to a cure. I finally settled down, after various trials, in the employment of the following:

R. Sulph. Cupri,ℨijPulv. Cinchonæ,℥ssAquæ,℥ivm.

S. To be applied twice a day, very carefully, to the full extent of the ulcerations and excoriations.

The cinchona here is not absolutely necessary; but operates by retaining the sulphate longer in contact with the edges of the gums.

Simple ulcerations and small gangrenes, as well as the troublesome excoriation, when not in the last stage, yielded promptly to this remedy; the good effect being generally visible from the first application.

Dr.Fox, my friend and fellow-labourer in the Asylum, had already taught me that it was important early to extract the teeth. I was not, however, sensible of the full extent of this rule, till after examining the fangs of some of them which were drawn. The separation of a portion of the periosteum from the fang, within the socket, which was universally found whenever the tooth was loose, among two or three hundred specimens, proved the existence of the disease in a deep, narrow crevice, into which it was impossible, by any contrivance, to insinuate the lotion. This cavity was laid open by extracting the tooth; and when the remedy was applied, the sanatory effect was surprisingly prompt. From this period, forwards, the universal rule was to extract all teeth, the moment they were discovered to be in theslightest degree loose; and "the blue wash" above described, became the standing remedy.

It is at all times a dangerous boast for a physician to make, to say that, in the treatment of any complaint, he has always succeeded. He is frequently not credited; and he can never know at what moment disbelief may be borne out by his subsequent failures. A faithful adherence to fact, and justice to the medical art, oblige me to say that it was owing to the observation of these means, that I never had an opportunity of making a dissection, after the one mentioned in a preceding page. Upwards of 120 ulcerated gums came under my notice in the course of three months; of which 70 were affected at one time. Of these, by far the greater number would, unquestionably, have escaped gangrene. The experience of past winters, however, and that of the preceding autumn, justifies the belief that there would have been several gangrenous cases, and some deaths; unless interrupted by remedial means. Some 3 or 4 suffered small spots of mortification, and one, by the delay arising from the tardy report of a nurse, suffered necrosis in a portion of an alveolus; but they were speedily arrested, and the production of more such cases, I believe, prevented, by the employment of the above means.

I have been once, since then, called in consultation to a case in which this remedy failed; but this was only two days previous to death, and during the existence of swelled cheek, and of a thick gangrenous eschar, and it was in fact only once imperfectly applied.

The farthest advanced of all the cases which I have seen, since that time, relieved by this remedy, was in the practice of my friend, Dr.R. M. Huston. He aided it by the application of a poultice with lead-water to the external surface of the cheek. This was thought to be productive of much relief.

Great attention and care are requisite on the part of the physician, to see that every part of the ulceration and excoriation is made visible, and brought under the influence of the applications employed. Without this entire knowledge of the extent of the evil, the result will be failure. The disgusting sloughs and discharge, and the fear of an imaginarycontagion, make the nurses very unwilling to introduce their fingers into the reluctant little patient's mouth, and without this scrutiny all is in vain. The physician is compelled to set the example, to try the looseness ofthe teeth with his own fingers, and to ensure the nurse's entire knowledge of the extent of the disease.

Dr.Beesleywrites that the women in his neighbourhood, frequently used considerableroughnessin applying the lotions.Certaintyis absolutely necessary.

After the remedy had been thus accidentally discovered in the Asylum, and used for a few days, I received Dr.Beesley'sletter mentioned above; and I then learned that the sulphate of copper was the principal dependence of the physicians at Salem. As, however, I had never seen Dr.Vanmeter'sthesis, the use of it at the Asylum was new to me.

An excellent remedy, and one on which the sole dependence should be placed, were we not in possession of one which possesses a decided superiority, is one which was communicated to me by Dr.Parrish. It is as follows, including a slight correction made by the apothecary:

R. Sulph. Zinci,ℨiAquæ,ℨij Solve.Dein adde, Mellis Despum. et Tinct. Myrrhæ, aa℥ij

To be used in the manner described above. Some bad cases yielded to the following:

R. Sulph. Zinci,ℨijAquæ,℥im.

It is useful to record failures and unsuccessful trials; as they serve to deter others from unnecessary risk. We therefore record the following as not having succeeded in our hands:

R. Mellis etTinct. Myrrhæ, aa℥im.

The same, with the addition of powdered bark.

R. Aluminis,℈ijTinct. Myrrhæ, etMellis, aa℥ijm.R. Pulv. Cinchonæ,℥iMyrrhæ et Pulv. Carbonis. a℥ssm.et addeSucc. Limonum,q. s. ad massamfaciendam, quâ illineantur gingivæ.

Caustic potassa; and nitrate of silver.

Pyroligneous acid, both pure and variously diluted with water. This had but a very limited effect, even in destroying the fœtor; and I am by no means sure that it was of any use in arresting the disease.

Muriatic acid, though praised by such high authorities, did not seem productive of any distinct useful effects. Nitric acid, variously diluted, and sulphuric acid, which was tried in one case, diluted with an equal quantity of water, were entirely useless.

Ofconstitutionaltreatment, the disease seemed to admit very little. In the early stage, the means employed, were the same mentioned above as means of prevention. It was by no means evident that any of these were useful in retarding the progress of the complaint. Towards the decline of the worst cases, aromatic sirup of rhubarb, with magnesia, were employed, to remove the putrid matters swallowed; and to relieve the diarrhœa which generally took place, by the astringent operation of the first mentioned medicine. It is extremely doubtful whether these means were productive of any benefit.

While the above was in press, I have met with the article, "Gangrene de la bouche des enfans," in the Dictionnaire de Medicine; written byM. Marjolin. The author in the Dictionnaire des Sciences Medicales, has given nothing material but references to some of the writers mentioned above; with one or two which were not within my reach.M. Marjolinhas evidently identified the disease. He citesFabricius Hildanus, though we have not found a distinct account of it in that writer's works. He remarks that it is identical with thenecrosis infantilisofSauvages. He also refers toSaviard,Van Sweiten, whom he justly mentions with the highest praise,Underwood,Berthe,Capdeville,M. Baron, and the inaugural thesis ofM. Isnard. As we have no means of referring to the two last, we must judge of them byM. Marjolin'sstatements. He observes the dissimilarity ofBerthe'scase. From the thesis ofM. Isnard, he gives us an account of the disease which corresponds very nearly, indeed, with that ofVan Sweiten, and with the appearances observed at the Children's Asylum.

"Almost all the infants affected with this disease in the hospitals of Paris," saysM. Marjolin, "sink under it." He recommends,afterVan Sweiten, the use of muriatic acid, which he mixes with honey in equal proportions. Thick sloughs he cuts away with a bistouri or with scissors.MM. Jadelot,Guersent, andBaron, have employed the actual cautery with success in several instances.M. Marjolinhas cured three cases; one by the actual cautery, one by caustic potassa, and a third bymuriate of soda!which, he believes, will always destroy the fœtor. It would be interesting, undoubtedly, to make repeated trials of this simple remedy; and we shall endeavour to do so in cases which admit of delay.

FOOTNOTES:[1]Vol. I. p. 319, Anderson's edition.[2]Principles of Surgery; byJohn Pearson. Lond. 1788. p. 262, et seq.[3]Opera omnia. Vol. II. p. 271. In the Loganian Library.[4]Ibidem.[5]SeeCornelii Stalpaart Vander WielObservationes Medico-Anatomicæ. p. 167. Note by the editor,P. Stalpaart Vander Wiel. Amsterdam, 1687. In the Loganian Library.[6]In the Loganian Library.[7]Page 193.[8]Page 217.[9]Commentaria.—Edit. Lugd. Bat. 1742. Vol. I. pp. 766, 767.[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.Cancrumis 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.

[1]Vol. I. p. 319, Anderson's edition.

[2]Principles of Surgery; byJohn Pearson. Lond. 1788. p. 262, et seq.

[3]Opera omnia. Vol. II. p. 271. In the Loganian Library.

[4]Ibidem.

[5]SeeCornelii Stalpaart Vander WielObservationes Medico-Anatomicæ. p. 167. Note by the editor,P. Stalpaart Vander Wiel. Amsterdam, 1687. In the Loganian Library.

[6]In the Loganian Library.

[7]Page 193.

[8]Page 217.

[9]Commentaria.—Edit. Lugd. Bat. 1742. Vol. I. pp. 766, 767.

[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.Cancrumis 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.

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 desiredrelief. 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 thenursethought 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,resemblingthe menstrual flux. It resembled that flux incolour,consistence,want of coagulability, and in being, withal, accompanied by a considerable quantity ofslimy 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 expectationthat 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 ofpurpura, 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 thevaginawas most certain; but whether it was furnished by that canal, or bythe 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, whenviewed superficially, a few hours after death. No other examination was permitted.

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 seasonsand 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.

Winds—Days.1823.MeanTemp.Variat. Therm.Variat. Barom.Snow & Rain Water. Inches.N. W. to S. W.N. E. to S. E.January,31440.943.38228February,25421.171.93226March,37521.656.87219April,55471.081.771614May,61520.881.60198June,68460.650.872010July,72300.586.12236August,72350.604.68218September,63510.613.461512October,53420.602.02219November,38380.812.47219December,34311.077.372110————————For the year,50-3/4881.7042.542421091824.January,36481.253.67247February,31591.553.94217March,40390.712.631615April,50451.084.54228May,60440.881.59247June,73460.696.09255July,74300.388.80198August,70360.456.392011September,64410.656.60177October,54430.651.53235November,42380.892.49246December,37430.952.11247————————For the year,52-1/2851.5550.3825993The temperature of the wells and springs, in and near Philadelphia, is 52° Fahrenheit.

1823.Maximum ofTherm.91,June 19.Maximum ofBarom.30.45,Nov. 29.Minimum"3,Feb. 7.Minimum"28.75,March 30.———Variation,881.701824.Maximum ofTherm.90,June 8.Maximum ofBarom.30.45,Feb. 6.Minimum"5,Feb. 2.Minimum"28.90,Feb. 26.———Variation,851.55

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,35.2042.5450.3833.26

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 byFevers.Erysipelas.Measles.Small-pox.1822510400182375824156160182465428102324182537512386

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 byFevers.Erysipelas.Measles.Small-pox.1822393[14]6101823192[15]13117181824191[16]141003941825445205340

In Baltimore—Deaths byFevers.Erysipelas.Measles.Small-pox.18214000221182243014122182330421752182418331421825138093

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 byabsorption, 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 theconfluent, theroseate, thetuberculous, and theerysipelatous.

Theconfluentwas 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.

Theroseatevariety 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 eruptionis 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.

Thetuberculousvariety 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.

Theerysipelatousvariety 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 cuticlebegan 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 onpost mortemexamination 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.

Examinationin 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 œsophagus 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. Themucous 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.

ExaminationApril 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 œsophagus 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 samecolour. 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 stageof 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 œsophagus 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 œsophagus 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 œsophagus 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 œsophagus 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. Pulseslow 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.

Œsophagus 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.

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.

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