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.