& ^%. IMAGE EVALUATION TEST TARGET (MT-3) % A 4rj L<'/ 1.0 1.1 |50 '""^^ ■^ IIIM 2.2 12.0 1.8 1.25 1.4 16 ^ 6" ^ Scieices Corooration 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^^y CIHM/ICMH CIHM/ICMH ^ Microfiche Collection de ^ Series. microfiches. C&nadian Institute for Historical Microreproductions / Institut canadien de microreproductions historiques Technical and Bibliographic Notes/Notes techniquas at bibliographiquas The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographicaily unique, which may altar any of the images iri the reproduction, or which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de couleur r~~| Covers damaged/ Couverture endommagte Covers restored and/or laminated/ Couverture restaur^ et/ou pelliculAe Cover title missing/ Le titre r'9 couverture manque Coloured maps/ Cartes giographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relii avec d'autras documents D D D Tight binding may cause shadows or distortion along interior margin/ La re liure serrie peut causer de I'ombre ou de la distorsion ie long de la m^rge int^rieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajoutiea lors d'une restauration apparaissent dans le texte. mais, lorsque cela Atait possible, ces pages n'ont pas 6xi film^es. Additional comments:/ Commentaires suppl^mentaires; L'Institut a microfilm^ le meilleur exemplaire qu'il lui a iti possible de se procurer. Les details de cet exemplaire qui sont peut-itre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite. ou qui peuvent exiger une modification dans la mithode normale de filmage sont indiqute ci-dessous. D D n »/ v/ □ n Coloured pages/ Pages de couleur Pages damaged/ Pages endommagies Pages restored and/or laminated/ Pages restauries et/ou pellicuides Pages discoloured, stained or foxed/ Pages dicolor^es, tacheties ou piqudes Pages detached/ Pages ditach^es Showthrough/ Transparence Quality of print varies/ Quality inigale de {'impression Includes supplementary material/ Comprend du materiel supplementaire Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partieilement obscurcies par un feuillet d'errata, une pelure, etc.. ont iti filmdes d nouveau de facon ^ obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ca document eat film* au taux de reduction indiqui ci-dessous. 10X 14X 18X 22X 12X 16X 20X 26X 30X 24X 28X 32X The copy filmed here has been reproduced thanks ro the generosity of: Medical Library McGill University Montreal The images appearing here are the best quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed cr illustrated impression. The last recorded frame on each microfiche shall contain the symbol — ^^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Maps, plates, charts, etc., may ba filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: L'exemplaire film* fut reproduit grflce A la g^n^rositi de: Medical Library McGill University Montreal Les images suivantM ont 4lt< reproduites avec le plus grand soin, compte tenu de la condition at de la nettet« de l'exemplaire film«. et en conformity avec lea conditions du contrat de fllmage. Les exemplalres originaux dont la couverture en papier est imprimte sont filmte en commenpant par le premier plat et en terminant soit par la dernlAre page qui comporte une empreinte d'impression ou d'iiiustratlon, soit par le second plat, salon le cas. Tous lee autres exemplalres originaux sont filmte en commenpant par la premiere page qui comporte une empreinte d impression ou d'illustration et en terminant par la derni^re page qui comporte une telle empreinte. Un des symboies suivants apparaitra sur la dernlAre image de cheque microfiche, selon le caa: la symbols —»> signifie "A SUIVRE", le symbols y signifie "FIN". Les cartes, planches, tableaux, etc., peuvent dtre fiimte A des taux de reduction diff«rents. Lorsque le document est trop grand pour dtre reproduit en un seul clichA, 11 est film« A partir de Tangle supArieur gauche, de gauche d droite, et de haut en baa, en prenant le nombre d'images nAcessaire. Les diagrammes suivants illustrent la mAthode. 1 2 3 4 5 6 (i\ O^er \d] \o^y\, CLINICAL NOTES SMAL I. THE INITIAL EASHE II. H^MOEKHAGIC SMALL, III. A FOEM OF H.EMOER BY WILLIAM OSLER, M.D., Latk Physician to the Small-Pox Department of thk General Hospital, AND Professor op the Institutes op Medicine, McGill University, Montreal. ^ ?Rontitcah PRINTED AT THE "GAZETTE" PRINTING HOUSE. THE OSLER LIBRARY McGILL UNIVERSITY MONTREAL '^t;'' Ace. -Si ;•' I. THE INITIAL RASHES In the abundant literature of small-pox, contained in the standard text-books, and scattered through the various periodi- cals, mention is occasionally made of rashes occurring in the initial stage of the disease. The reference to them in the ordinary English works on the Practice of Medicine is usually limited to two or three lines, stating that the eruption is sometimes pre- ceded by an erythematous or erysipelatous rash. (See text books of Aitken, Wood, Watson, Niemeyer, Barlow.) Many make no mention wliatover of tiiom. (Bennett, Tanner). Even in the special works on the subject the notice is scarcely more extended. Thompson* refers to a roseolous rash as a common precursor of varioloid. Munrof speaks of a " rosy efflorescence as in measles prc- •oeding the eruption in malignant small-pox." Gregory^ makes no mention of them, but refers to a scarla- tina-like rash in the progress of the secondary fever. • On Varioloid Diseases, pp. 35-151. t On Small-pox, p. 97. t On Eruptive Fevers, p. 49. 2 THE INITIAL RASHES OF SMALL-POX. Marsoii* states, tliat in varioloid the eruption " is very often preceded by roseola, which lasts two or three days — the r. exanthematica." Foreign Phvsicians appear to have paid more attention to them, and very good accounts are to be found in some of the recently translated works | Many of the older authors believed them to be independent affections, and, according as the eruption was diffuse or mottled, spoke of scarlatina or measles occurring simultaneously with small-pox- Sydenham was evidently acquainted with them, and refers to the difficulty they may cause in the diagnosis. " The afore- said small-pox," speaking of the discrete form, " breaks out some- times after the fashion of erysipelas, sometimes like measles. From these they are difficult to be distinguished even by the practised physician, provided that he goes by the external appearance only.":]: In some of the cases collected by Murchis(in§ of the sup- posed coincidence of two fevers at the same time, the mistake has been made of confounding the initial rashes with indepen- dent diseases. — (Illustrations, 3, 4, 5, 6, 7, 8, D, 10.) Our definite information on the subject dates from the publica- tion by Dr. Theodor Simon of Hamburg (whose premature death last year was a severe loss to the profession in Germany), of a series of articles in the Archives f. Dermatologie und Syi'hilis, Bds II, III, & IV, on the "Prodromal Exanthems of Small-pox." Other papers on the subject appeared in the same journal from the pens of Drs. Knecht and Scheby-Buch, and less important observations have been published in several of the German period- icals within the past four years. The probable reason why such scanty reference to them is found in the records of the older epidemics is that they appear • Reynolds' System.— Article Small-pox. t Trousseau.— Clinical Medicine (Sydenham Society) Vol. 2. Hebra. Skin Diseases, (Sydenham Society) vol. 1. Ziemssen's Encyclopedia, Curschmann. Art Small pox. X Works of Sydenham (Sydenham Society) Vol. 1, page 127. § Med. Chirurgical Review, 1859, THE INITIAL RASHES OF SMALL-POX. 3 1 I with i__h- borhood of the knees and elbov-.s, the backs of the hands and feet, on the genitals, and lastly, as a streak extending from the ankle along the skin over the extensor hallucls longus." My experience has been that they are chiefly purpuric ; in the limited number of cases which I have observed, only two, were unaccompanied by peteehiie. In very many of the cases reported by Simon and Knecht no mention is made of the pre- sence or absence of cutaneous extravasations. Scheby-Buch, on the other hand, believes them to be, in most instances, of an- hacmorrhagic nature, i. c, numerous petechiaj occur upon an. erythematous base. The following cases will give a good idea, of the nature and extent of these initial rashes. TUB INITIAL r.ASIIKS OK SMALI.-POX. Cask I.— IX R., ait. 14. Admitted November 28th. Vac- cinated, one ^ood murk, lleviiccinatod 8 days before admission, three points, v>hich had taken, were just y assing into the pustu- lar stage. A diffuse erytieniatons rash of a daik-rcd hue existed over the abdominal region, extending upwards in the hiteral thoracic areas, and (h)\vn\\ards upon the thighs. Face nnich sullused, extremities unaH'ectcd. On jtressing with the finger upon the skin of the abdomen, numerous petechiai) were evident, most abundant in the groins, and inner surfaces of the thighs. Tenij). 101^. Slight delirium. A papular eruption over face and arms. 2dth. — Erythema lias disappeared, leaving the ecchymoses visible as small, dark, punetilbrm spots, closely set together in the groin, and more scattered towards the navel. The largest existed in the lateral thoracic regions, over the serrati muscles. A few were also noticed on the legs about the inner surfaces of the tibia?. Coursi' of the Biaease. — Eruption became confluent on the face, discrete on the extremities and trunk. Not more than eight pocks appeared on the sites of the erythema. Instead of proceeding to maturation, the majority of the ])ustules aborted, and on the 11th di.v of the disease desiccation had begun. Q\6i] II. — T. C, ;ct. 2o, medical student. Vaccinated, one good mark. Admitted, December 15th, 1874. Initial symptoms, according to his own statements, had been tolerably severe. Papular eruption present on the lace and arms. On examining the trutdc a fadlnj; ervthoiiia was noticed over the thorax and abdomen. A diffuse ccchymosis existed over the anterior sur- faces of both shoulder joints, extending above over the acromion processes, and internally over the outer half of the clavicles. Continuing into the axilhe, it involved the greater part of the skin in these fossje, terminating below at the level of the fifth rib. A considerable amount of hyper;!eraia was present, and pressure with the finger revealed the fact that the ecchymosis was not uniform, but here and there left portions of the skii^ junaffected. THE IMTIAI. U.\^^ll^H dl' S.MALI.IMX. Numerous purpuric in the ii^vo'iun juid lateral thoracic nij^iona, sorno of wliicli wcro of coiisi(lcrul)Ie sv/.a ; none on tho extremi- ties, or inner sui-facxvs of tlio thiiijlH. TctuM. ICO.;')^ (loneral symijtoms ^ood. Pulse firm and strong. Course, of Di^enHc. — Pocks numevous hut irncroto, and pro- ceeded rc;^ulai-ly to pistulation. K(jchymo.^o3 faded {gradually Icavin,!' a vcliowisli-j-recn di-!colouration of tho skin over tho shoulders, and in the axilliV. Desiccation early. Rajiid recovery. No complications. The first ca?c5 adord-? an excellent example of tho condition under consideration. The exantlnMU oceupied the most usual situations, viz., tho anterior abdominal and lateral thoracic regions, together with the inner surfaces of the thigh-^. On auperlicial examination the ecchymoses wore not at first evident, becoming so, however, on the following day, when the crytl'.ouia had faded. The second case presents several points of interest. The initial symptoms were so severe, and such was tho intensity of the prodromal exanthem, and extent of the cutaneous extrava- sations, that tho gentlemm w!io attended the case, though poss- essed of considerable experience in small-pcx, believed it to bo of the true hocmorrhagic variety. On first seeing it I expressed a similar opinion. The remarkable extent of the ecchymoses in the neighborhood of the axillne was certainly very misleading,. more especially, as it was accompanied by an eruption of pur- pura in the thoracic and lower abdominal regions. Indeed, in such a case, within the first 48 hours, it might be almost impos- sible to decide definitely, whether we had to deal with a simple prodromal exanthem, or with the initial symptoms of genuine haemorrhagic small-pox, In the latter the exanthem would pro- bably be more general, of a deeper hue, and present a greater number of petechije, and even on the second day h.iemorrhago might take place from the mucous membranes. The two following casos are the only instances which have com'3 under my notice of a simple erythematous rasli unaccom- panied by petechiiie. Oddly enough, both subseciuently became haemorrhagic ; in one the extravasations were limiced to the • THE IMTIVL HASHES OV BMALL-POX. pocks upon tlio lon;». and a good recovery was made ; tlic other proved to bo of the ti-tio hicmorrha;^io variety. Cask III.— J, M.,si;t. 2"). Vaccinated, one j,'ood mark. Ad- mitted, January 2Sth. Initial symjitoms not severe. A difTaac erythematous rash existed over ab(h)mirial and thoracic regions. According to [>atient's statements, it had been hrightor. and wa* fadnig at tune of" achnission. It was unacconii-anied hy any purpuric spots, cither in the regions affected, or in other parts of the body. Eruption discrete, papular, very scanty upon the abdomen. Course of Z^iJf^flse.— Progressed favorably, b\it presented paculiar characters, inasmuch as extravasation took place about the pustules on the legs on the 6th day, and was followed b/ a subsidence and rapid desiccation of the eruption. Case IV.— A. McR., oet. 19, a strong Scotch girl. Unvac- cinated. Admitted January 31st, from the general wards, where she had been under treatment during two weeks for some iU-defined affection. Initial symptoms very severe. There was on admission a deep erythematous rash over the whole body, most intense on the abdomen and thorax, and unaccompanied by ecchymoses. Face and arms of a deep red colour. Papules very general. Temperature 103.3P. Pulse, 116. Kespira- tions, 22. Feb. 1st, erythema fading on the trunk. Course of Z^/scasi-.— This case proved to be of the htemorr- higic form, and is interesting from the fact, that a aim-pie erythematous rash was among the initial symptoms, the extra- vasation into the skin not occurring until the third day of the eruption, when the erythema had disappeared. Patients are usually s^nt to hospital on the third or fourth day of the disease. The initial rashes are often among the earliest symptoms, and may, if of the simple erythematous variety have disa,)pcarod, whereas, if purpuric in character traces of them will remain for days. In some instances, a fading erythema was noticed on admission ; in others, no history of any could be obtained, though the pctochuB were pre-.ent. The following cases illustrate this : TIIK INITJAI, IIASIIEH (>!•' SMALL.POX. 7 Cask V. — M. C, let. 15. Vaccinated, one j^nod mark. Ad- mitted Jan iHtli. Initial symptoms severe, well-marked ri;^or. Temp. 102 2". Pulse 102. Uosp. 24. Only a few papules viaible on the face and about the wrists. Pctechiixj on back, sides, ^^roin, and le;^3. Those upon the back were scattered and small, on the abdomen they were thickly set and lar<^e, especially in the hypo;^astric region. On the lower limbs they existed as small circular s{)ots of dark red colour on the inner surface of the thi^^hs and the extensor surfaces of the lo^s. In this case I could obtain no history of an erythematous rash. Course, of Dineasc — Favorable. Eruption discrete ; desic- •cation early ; recovery rapid. Case VI. — T. C, ret. 20. Vaccinated, one good mark. Ad- mitted Feb. 10th. Initial symptoms moderate. Eruption discrete, in the papular stage. Abundant petochiae in the lower abdom- inal region, and in the groins ; also a few over the serrati magni muscles. None upon the thighs, or legs. No trace of an erythematous rash, nor could it be gathered from the statements of the patient that one had existed. Course of Disease. General symptoms good ; pustules formed normally. Purpura faded within the first week. Case VII. — T. B., ret. 22. Vaccinated, one good mark. Admitted December Blst. Eruption discrete and in the vesicular stage. Temperature 98. 4. '^ 111 eince the 27th. Initial symptoms mild. Numerous small purpuric spots in the groins, arranged chiefly parallel to Poupart's ligaments, and extending internally over the recti muscles. Similar spots, though somewhat larger, existed in a line with the lower ribs, extending towards the navel. According to the statements of the patient, on the second and third day of his illness, there was a rash on the lower abdominal region. Course of Dlsaasf. — Pustules few in number. Recovery rapid. Case VIII. — R. W., vat. 20. Vaccinated, one indifferent mark. Admitted Jan. 10th. Initial symptoms mild. A plentiful eruption on fane, buttocks, and arms. A diffuse erythema pre- I 8 lUtt INITIAL RASHES OP SMALL-POX. el? " ' ''' '"^' '" "" ^'"'^^^^ <^^"^' «^«^ both ei..W3. Accompanying this wore ahundant petechia), esne- cially numerous in the groins, tho hu.bar region bel'dll ne postener surfaces of the the thighs. Jan. llth. Erjcl sul "oni "'"^^' , ^" ''' ^^uttocks,back, and extensor ^^'o-... .J/- Disease. -Vu^tuhs did not maturate fully; des^ Jhe iolnts ' " ''"' ^^""""^^ "^ "^^^ ^-^^^'"-^^^ ^'-^'^««« '^f Occasionally the initial rash i. late in appearing, and may iollow ratlier than precede or accompany the eruption. ^ Case IX.- II. a., ,x.t. 28. Vaccinated, five good marks A^^^d April 8rd, .ith a disseminated 'pnpui;^. oruplio: initial symptoms had been tolerably severe. ^ April m. At morning visit an erythematous rash, accom- pamcd by numorous petechi.c existed over the lower abdominal regions, and groins. Erythema not intense, petechia small, and closely set together. April ht/i.—Rash had disappearcrd, 8.30 a.m.— Temperature, 101" ; pulse, 112 ; respira- tions, 24. Most of the vesicles on the legs arc now haemorr- hagic, and the ecchymoses have extended in the abdominal region. The vomiting is still a very troublesome symptom. 5.30 p.m.— Pulse, 120, not irregular ; temperature, 102" ; respirations, 24. On the face and arms the pocks are develop- ing slowly, and only a ^'u in these parts are haemorrhagic ; melaena, haematuria fiud i\ tran-hagia (slight). Takes nourish- ment well. '► . ♦• ." t UiGMOiiRUAUlC HMALL-POX. 21 . ♦• >■ 4th, 9. a.m. — Pulae, 120 ; tcmpcraturo, 101.2" ; rogj-irations, 28 ; says slie fools hotter ; vomitin<^ has stopped. Blood in the urino passed through the night. Pocks are not developing, look dark, and the majority of thorn are haraorrhagic. 6. p.m. — Pulse, 124 ; temperature, 102" ; respirations, 36. The peculiar variolous odour very evident this evening. 6th, 8.110 a.m. — Tulso 110 ; temperature, 100" ; respirationB, 18. Slojtt well, and says she feels much better. Meliena and haematuiia through the night. Pocks much flattened at the top, and of a dark colour ; skin between them livid, and coverod with minute extravasations. G p.m. Pulse, 112, very weak and intermits every tenth beat ; temperature, 101". Is very dull and heavy, and does not care to take nourishment. Not much change noticed in the eruption, the majority of the pocks look like elevated haemorrhagic papules, no umbilication in any of them. Through the evening she lost a good deal of blood from the vagina, got much worse towards morning, and died at 7 a.m., on the 9th day of the disease. Tlie details of the above cases furnish a tolerably accurate picture of the clinical features of this truly terrible disease, and I shall now proceed to make some general remarks upon its symptoms, diagnosis, etiology, and pathology. Symptoms — Satisfactory evidence is wanting as to the period of incubation in hsemorrhagic small-pox. Most writers state that it is the same as in the ordinary form, i. e., 12 to 14 days. Zulzer,* however, states that it is shorter, having determined it in 9 cases to be from 6 to 8 days. In the majority of instances it is unaccompanied by any symptoms — perhaps slight languor and malaise — the disease breaking out suddenly in all its vio- lence- So it was in the case above reported of the young Englishman. The day before the attack he had walked round the mountain, (5 miles). The symptoms of the initial stage are those of the pustular form ; indeed, the disease may be regarded as an intensified and prolonged initial stage, combined with a remarkable tendency to cutaneous and mucous haemorrhages. The fever, pain in the back, and vomiting — that triple com- * Bei'liner klioische WocheoBchrift, 1872. t 22 niEMoRRiiAaro small-pox. bination, which we look upon as almost pathognomonic of small- pox-— are the prominent symptoms throughout, even after the characteristic extravasations appear. The fever i,'^ usually moderate, varying from 101° to 103" , only once did I observe a temperature of 106". It is fiequently ushered ia with a rigor, oi series of chills. The pain in the back is perhaps the most distressing symptom to the patient, and persists longer, and is more constant, in this than in the pustul- ar form of the disease, continuing in som.e instances to within 12 hours of death. All of my patients complahied of it, and when asked to localize it placed the hand over the sacrum. Proecordial pain was also common, m one or two cases much more severe than the dorsal. Headache is rarely absent during the first days of the fever. Vomiting constitutes a very troublesome symptom, and, in my experience, proves exceedingly obstinate, much more so than in ordinary small-pox. It was very unusual for patients with the latter disease to vomit after the appearance of the eruption, while, in cases of the hsemorrhagic form, it continued for 3, 4, and 5 days. Dry retching was frequently combined with it, and seemed particularly distressing. Early on the second day, or even in the most severe cases on the evening of the first, a bright scarlatiniform redness spreads over the skin of the trunk, sometimes extending to the extremi- ties, but not often involving the face. In some instances this is not universal, but confined to the lower abdomnial or lateral thoracic regions. It is difficult, or even impossible, to dis- tinguish this general or localized erythema preceding haemorr- hagic small-pox from the similar condition which, as an initial rash, so frequently ushers in the ordinary or modified forms of the disease. For a time simply hyperaemic and disappearing on pres- sure, the character of the rash quickly alters by the occurrence of numerous extravasai;ions, which begin commonly in the groins and lateral thoracic areas. At first punctiform or macular, and concealed by the general redness, they soon increase in size, and on the trunk form irregular patches, ranging in size from a si.x-pence to a penny, while on the extremities and face they remain discrete. In 30 hours the ecchymoses may have devel- , ^ . S \ HvEMORRIIAGIC SMALL-POX. 23 V f . oped to such an extent as to involve fully two-thirds of the cutaneous surface. The skin of the trunk is now of a rich plum colour, and by pressure very slight difference is made in the intensity, Ilajmorrhage into the tissue of the eyelids and beneath the conjunctivae is common, and adds greatly to the dis- figurement of the face, already puffed and swollen. The extra- vasations deepen until the end, forming throughout the most distinguishing feature, and the one which has so justly given the name of black smul!-pox to this variety of the disease. True papules of variola may nearly alwoys be discovered, if carefully looked for upon the forehead and wrists at the end of the second or upim the third day. They were present in all the cases which came under my own observation. In the most malignant hrm—purjjio'a variolosa — the rapidly extending •ecchymoses soon hide them, and it may be difficult or impossible •even to feel them ; indeed, in several instances, I could not, post mortem, convince myself of their presence. In the- other variety, v. Immorrliagica pustulosa, the eruption comes out ay usual, the extravasations occurring either in the vesicular or pus- tular stage, Hfiemori-hage from the mucous memhranes takes place in the majority of cases, and constitutes one of the most prominent symptoms. Epistaxis is common.especially in the early stage of the disease. Hvematemesis occurs in more than half of the cases. In my experience it is not copious, but the blood is mixed with the thick mucus brought up in the constant attacks of vomiting. Melcena was noticed in about one-third of the cases ; the blood in three was tolerably fresh and bright ; as a rule, however, it was dark, and mixed with the mucous discharges. ILemorrhage from the urinary ^^assages occurred in a large proportion of the cases, and was often profuse, the blood coagula- ting in the chamber-pot. Metrorrhagia is stated to be exceedingly common in women. It was only noticed in one out of six females. H.emopti/sis occurred in five cases, in one it was profuse and arterial. The sputa hawked up are frequently streaked with blood from the bronchial tubes and fauces. f 24 II^EMORRUAGIC SMALL POX. These hemorrhages from the mucous membranes do not always occur. In five of my own cases (Nos. 16, 18, 20, 22, 23,) they were absent, and yet these were among the most severe and rapidly fatal cases of the disease, death ensuing on the 6th, 5th, 6th, 7th and 4th days respectively. In two, (Nos. 22, 23) post mortem examination revealed extensive haemorrhages into the mucous membrane of the stomach, intes- tines, and urinary tract. The pulse in the first d?.ys of the disease ranges from 110 to 120 beats in the minute, and is full and compressible. Gradually the arterial tension is increased, the pulse becomes more rapid, 120 to 140, small, hard, and irregular, and at last uncountable or imperceptible. The respirations ara unusually increased in freqiience in the early stage, without any discoverable disorder in the lungs, and are out of proportion to the intensity of the fever. In the case of a negro whose respirations the morning after admission were 32, and^the temperature 101°, after examining the lungs and finding nothing to account for the acceleration, my suspicions were aroused, and on careful inspection I was able, even on the dark skin, to detect the hsemorrhagic condition in and about the papules. This symptom alone directed my attention to his dan- gerous condition, which rnight otherwise have escaped observa- tion, as there were no haemorrhages from the mucous membranes. An interesting, and by no means unfrequent phenomenon,was the disturbance in the respiratory rhythm, first drawn attention to by Drs. Cheyne and Stokes, consisting in a series of superficial respirations, sometimes almost imperceptible, followed by a deep inspiration. This was noticed chiefly during the last 24 or 30 hours of life. A short hacking cough was not an uncommon symptom. Many of the patients complained of sore throat, which, in some instances, appeared to be due to the constant gagging and vom- ting, in others to a foul, horribly foetid, diphtheritic pharyngitis. Consciousness is commonly retained until near the end. la only six cases was delirium a prominent symptom. A hyperaes- thetic condition of the skin, mentioned by Zulzer* as common,, was not noticed in any of the cases. ^ ^ "• Loc. Cit. 2|* • HiEMORRHAGIO SMALL-POX. 2& In the true petechial form the patients seldom outlive the sixth or seventh da,y ; where the haemorrhages do not come on until the vesicular stage, they, of course, last longer. The cases upon which this paper is based died on the following days : 1 on the 3rd day ; 2 on the 4th day ; 5 on the 5th day ; 6 on the 6th day ; 5 on the 7th day ; 4 on the 8th day ; 4 on the 9 th day. The disease, in both its forms, is spoken of as invariably fatal, and such has been our experience in the small-pox department of the General Hospital. Diagnosis.— In an epidemic of small-pox characterized hy the presence of hs^morrhagic varieties, there is rarely any doubt of the natureof a case of fever presenting extensive cutaneous extravasations, and, perhaps, mucous haemorrhages. ^ Given, however, an individual case, when no epidemic was raging, and the matter would not be so easy. We must be careful, in the first place, to remember that the initial rashes, which so often precede the milder forms of the disease, may be general and purpuric, closely resembling, or identical in appearance with, those at^companying the true pete- chial variety. It might be impossible to decide definitely for 24 hours on the nature of a case of this kind, In the latter the erythema would probably be more intense, the ecchymoses more extensive, and the general symptoms more aggravated. In many instances the progress of the case would alone deter- mine its nature. The bright, rosy-red, rash appearing on the second day might be mistaken for the eruption of scarlet fever, unless the mode of onset of the disease had been carefully watched. The diagnosis between haemorrhagic scarlatina— fortunately a rare disease— and petechial small-pox offers still greater difficulties. Close inspection might discover in the latter papules about the forehead or wrists, and, I think, the characteristic odour of small-pox, which is well developed in this variety, would aid in arriving at a conclusion. Cerebro-spinal meningitis is another disease which, in some of its forms, is apt to be confounded with purpuric variola. The pains in the head and back in the latter simulate those of 26 HEMORRHAGIC 8MALL-P0X. meningitis, in which disease also cutaneous ecchymoses not unfrequently occur. Indeed, I have the permission of the phy- sician in charge to state that in case 25 on the list the error in diagnosis was made. I remarked to him at the pos« mortem examination upon the similarity of the pathological changes to those in haeraorrhagic variola. The mother, wl^o had nursed the child, a short time subsequently took small-pox, and died. With true Purpura hcemorrhagica — the Morbus maculosus Werlhofii,— this variety of small-pox has many points in com- mon. In both there are cutaneous and mucous haemorrhages, but in the former the extravasations begin on the lower extremities, the skin is not so hypera3mic, the fever not so high, and there may be cedema about the joints, diarrhoea, and ascites. Etiology. — From the table subjoined some interesting facts with reference to the general etiology of the disease may be drawn. It is most common between the ages of 15 and -30. Thus of the cases there were — Under 10 years, 3 ; between 15 and 20, 4 ; between 20 and 25, 9 ; btween25 and 35, 6 ; between 35 and 45, 3 ; above 50, 1. Young, vigorous, muscular persons form the majority of the victims, and this remarkable fact was noticed also in the late epidemic in Germany. (Zulzer, Ponfick). Several of my patients were above the average muscular development, most of them belonging to the artizan class. The predisposing causes mentioned by Aikman,*viz., sudden change of residence, debilitating ner- vous influences, unhealthy dwellings, were not speciallyobserved. Men appear to be more frequently attacked than women. With regard to vaccination the table shows that 14 were un- vaccinated, while 13 showed marks of a by-gone vaccination. In none was there a history '^f re -vaccination. That is, the whole of these cases were unprotected, for I hold that we have no right whatever to say that a man is vaccinated because he has cicatrices on his arm. The proof that these 13 Avere not vac- cinated lies in the fact that they died of the worst form of small- pox. No properly vaccinated person, one in whose tissues the impress of vaccina persists, can, I maintain, take small-pox. Similarly fZulzer's cases, 35 in number , all sh owed scars, • Glasgow MedicalJournal, 1871, p. 00. t Loc. Cit. . ", I n^MoaaiiAaic small-pox. 27 1 but none of them had been re-vaccinated. Other observers state that persons without cicatrices of a former vaccination form the majority, or even all, oft he number attacked. The proportion of haemorrhagic cases has been unusually large in this epidemic, not only here but in other parts of the world ; indeed, it has been the most virulent type of small-pox known since the beginning of the century. In the small-pox department of the Montreal General Hospital there were admitted from Dec. 14th 1873, to July 21st 1875, one year and seven months, 260 cases. Of these 24 died of the variety under consideration, or 0.23 per cent. ^ Case. Ago. Sox. 1 '27 P. 2 28 F. 3 yo M. 4 53 M. 5 20 F. 6 19 M. 7 35 M. 8 La M. 9 ]9 M. 10 24 M. n 12 13 14 15 16 17 18 19 20 21 22 23 24 2.'> 26 27 Uuvac. Vac. Uuv. Uuv. 23 22 20 21 19 44 24 36 6 35 16 30 4 36 6 M. F. M. M. M. M. F. M. M. M. I. Uuv. Uuv. Uuv. Uuv. Unv. Uuv. M. ': Uuv. M. M. M. F. M. M. II Y. Y. Y2 Y Y, V, V. Uuv. Unv. Unv. Unv. Uuv. Day of Death, 8th 6th 8th 3ra 6th 7th 9th 6th 7th 8th 9th 8lh 7 th 4th 9 th .nth 9lh 5th r)th 6th 4 th 7th 4th 7th 6th 6th 5th REMARKS, t Deliriuin. UiemateiuPhis. Epistaxis.MeUena.Hfemoptysis. Delirium. Mela-na. Xo papules evident. Died 3i hours after adiuissinu. Epistaxis two days before. Slight couvultiioup. Uajmaturia. Much Delirium, var. hrem. puat. No mucous heemorrhagen. Delirium. Melajna, Irequeut. Hrematemesis. Meleeua. Epi.staxis.Melaiua. llfemateraesia, Vai hmn. pustulosa. l:a3mop- Ivsis Old Imig disease. Hremat uria. Melffina. Hoemoptysis. Epistaxis. Hoemoptysis. lIpematuria.HfEmoptysis.Melseiia. Y. hanu. pu-itulosa. Hoomaturia. Hajuuitemesis. No mucous hiBinorrhages. Y. hrem. pustul(»sa. Ha;maturia Haamateiuesia. No mucous hEcmorrhago,''. Htematuria. Metrorrhagia. Delirium. No mucous hsemorr- hages. H«iuaturia. Hfematemesis Mel- ,Tua. Delirium. No mucous hffiraorr- bages. No mucous bremorrbages. Htematuria. Hannatemesi?.H89- moptysis, HfBmatemei-is. Uiematuria. Melajna Hicmatuiii. Hteiuatemesis. • The figures indicate the number of scars. t Cutaneous extravasations occurred in all. 28 HiEMORRUAaiO SEALL-POX. Pathology — The condition of the internal organs in this disease has received a good deal of attention within the past few years. The remarks which I shall here make are based upon seven carefully performed autopsies.* The prominent characteristics in all were the hjemorrhages into the various tissues and organs. The hlood during life was carefully examined in six cases, but no change of importance noticed in the corpuscles. Post mortem it was dark in colour and generally fluid. In the meninges of the brain scattered ecchymoses were noticed in five instances. The venous sinuses of the dura mater and the vessels of the pia mater were full. In cases 21 and 22 thin coagula of blood existed on the surface of the pia mater. The brain appeared normal, the consistence remarkably good. In case 22 there was a small clot in the right ventricle. The spinal cord was examined in one instance, when nothing abnormal was found. On the pericardium maculae were present, often quite large on the visceral layer along the tract of the coronary vessels. The heart substance was firm, dark in colour ; in several instances minute ecchymoses were observed on the endocardium, and in the muscular walls. Both visceral and parietal layers of the pleura contained ecchymoses in 6 cases. The lungs were crepitant, and contained much blood in the posterior parts. In case 23 there was a patch of catarrhal pneumonia. In five instances apoplectic spots were found, none of them larger than a walnut. The spleen in all was firm, about the natural size, in two a little enlarged. On section the substance was compact, smooth, of a dirty-purplish red colour, and in six of the cases the Mal- pighian corpuscles were remarkably enlarged, appearing as round white bodies on the dark background of the pulp. The kidneys appeared of normal size. Ecchymoses on the capsule common ; in one instance a thin clot existed upon the organ. The consistence of parenchyma was good. In three cases minute haemorrhages had taken place into the substance. * For two of these I ve to thank Sister Rosalie, apothecary at the It. C. Civic Small-pox Hospital, who kindly informed me when any of these.case* occurred. HiEMORRHAOIC SMALL-POX. 2» T o The vessels as a rule were full. The pelvjs of th) kidneys in four instances were plugged with dark clots, which extended up into the calyces, and down the ureters. In all ecchymoses were present on the mucous membrane. In the mucous membrane of the bladder small haemorrhages were met with on five occasions. In case 21 the walls of the whole organ were uniformly infiltra- ted with blood, not a trace of normal tissue could be seen on section. The liver in five cases was of normal size, unusually dense and firm, lobules moderately distinct, of natural colour, and con- tained a good deal of blood. In two oases it was large, pale in colour, very friable, and on examination proved fatty. The gen- eral condition in both these cases accounted for the state oi the liver, one had suffered from chronic disease of the leg, the other was a drunkard. Ecchymoses upon the capsule were common. The mucous membrane of the stomach in all the cases showed sn enormous number of extravasations, some small and capillary, others as large as a bean, and projecting on the surface. Similar appearances were found in the small intestines ; in two instances the ecchymoses were most abundant in the ileum, in the others the upper region of the bowel was most affected. Peyer's glands were swollen and prominent in four instances. In the large bowel the extravasations were only noticed in three cases. In two instances the mesenteric glands were uniformly infiltr*" ted with blood, looking like dark-purple grapes. Extravasations occurred in all the cases in the retroperitoneal tissues^ about the aorta, along the iliac arteries, and about the lumbar nerves. In most they were small and confined to the adventitia and parts about the vessels, in one, however, quite a large suggillate was found in the region of the right psoas muscle. Similfl^r appearances were noticed twice about the thoracic aorta. Such are the chief pathological changes in the internal organs, and they correspond pretty closely to those described by Ponfick* in the Berlin epidemic. In addition to the haemorrhages, the firm, dense condition of the heart and abdominal glands seems peculiar, and stands in marked contrast to the appearances of these organs in variola vera, in which they are swollen, soft lieiiiaer klinischo Woobeuschrift, 1872. 30 HiEMORRHAGlC 8MALL-P0X. and friable, and in that state of cloudy swelling common to pro- longed fever. So impressed is Ponfick with the pathological and clinical differences between these extremes of small-pox, that he is inclined to group them as distinct diseases. But, just aa transitions are met with clinically between the macular hoemorr. hagic form and that in which extravasations take place in the vesicular and pustular stages, so also, I think, in a more extended series of post morterna appearances would be found intermediate- between the extremes, and where the disease h?d lasted any time the same pyrexial changes would occur. Indeed, Cursch- mann* states that he has noticed them in variola hcemorrha gica pustalosa. On the intimate pathology of this disease I can offyr no sug- gestion. We are, as yet, profoundly ignorant of the conditions of its genesis, and do not know whether it depends on the in- tensity of the poison or the extreme susceptibility of the patient. Most histologists are agreed that in these purpuric disorders the red corpuscles pass through altered or thinned and not- ruptured vessels, but as to the causes of this general diapedesiSy as the process is called, we have no data upon which to form a judgment. The treatment of the disease is eminently unsatisfactory, the patients almost invariably die. A few instances are recorded of recovery from variola hoemorrhagica pustulosa. All the usual medicines i dicated under these circumstances were tried, gallic acid, ergot, turpentine, acetate of lead, &c , without the slightest benefit. Quinine was used in large doses, and in three cases I used the cold pack. Since the closure of the wards I have met with an article in the Glasgow Medical Journal by Mr. Aikman, formerly assistant medical officer at the Hampstead Small-pox Hospital, in which he recommends strychnia in large doses, and states that under this treatm3nt mmy of these ca-5es recovered. He- gives as much as a drachm and a half of the liquor strychnise in the twenty-four hours in severe cases, combined with iron and quassia. • ZieniHsen's Encyclopedia, Vol. J I., Art. Small-pox. p. 387. Loc. Cit. . ^. A FORM OF ILEMORRIIAGIC SMALIrPOX. . **. Six cases of a modified hjemorrhagic form came under my notice, which present common features and peculiarities, and are, I think, worthy of record. They were all characterized by haemorrhages into and about the pocks— chiefly those of the lower half of the body— in the vesicular stage. This, instead of being as it was a't first regarded an ominous symptom, was followed by abortion of the eruption and speedy recovery. The following was the fourth case observed : J. G., set. 27. Vaccinated, one indifferent mark. Admitted June 8th. Eruption appeared on the 5th, and is present as a tolerably plentiful crop on the face, more scattered on the trunk and limbs. A few petechiae exist in the groins. Symetrical clusters of papules are observed about the middle of the inner surfaces of the tibise, upon the internal maleoli, and also on the inner edges of the soles of the feet. General symptoms good. . Pulse lOG, full and strong ; temperature 99^. 9^7i._yesiculation proceeding normally in the papules en the face, which is becoming much swollen ; the neck also is very large, almost obliterating the angle of the chin. Haemorrhages have taken place around many of the vesicles on the legs and thighs, the areolae of hyperaemia have become purpuric, and a similar condition is observed about several on the arms. Pulse 96 ; temperature 99.5°. 10«/i.— According to the nurse he was a little delirious at times. Pulse 88 ; temperature 99.2*^. ll^/i.— Almost all the pocks upon the limbs and abdomen are purpuric, those upon the face show no signs of pustulation, but liave become firm and hard. 12^/i.— The 8th day of the eruption ; appearance in the evening was as follows : Face and neck much swollen, eyes almost closed. Varioles isolated, yet nearly in contact, of a firm, hard feel, and of a semi-opaque, somewhat tr-^nslucent 32 A FORM OF II^MORRUAQIC SMALL-POX. aspect. No true pustule is present, with the exception of a few about the roots of the hair, — but the face has a rough nodular appearance. Over the legs, arms, and to a less extent the trunk, there arc numerous small, dark-red spots, about the size of a pin's head, which on superficial examination, looked like purpura, but on closer inspection prove to be small papules into which extravasation has taken place. On passing the finger over them a slight hard elevation can be felt, and in some a small semi-opaque, vesicular top is observable. Other larger ones, the size of a split pea, flat, with vesicular tops, and situated upon haemorrhagic bases, are common on the legs. Here and there over the trunk and arms true pustules occurred but they are small and have not hyperaemic bases. The symetrical clusters, mentioned as situated on the legs, are elevated into bulla filled with a sero-sanguineous fluid which gives to them a bluish look Upon the walls of the bullae the remains of the septa of the original vesicles are distinctly seen. The separate varioles of the clusters on the tibiae have not coalesced, though they are filled with a fluid of the same character. Another large bullae filled with a sero-sanguineous fluid exists on the radial side of the ball of the left thumb. The bases upon which these various clusters and bullae are situated are haemorrhagic. Examination of the contents of the bullae and of the larger pocks of the legs showed a large number of normal-looking red-blood corpuscles, and numerous granular leucocytes, many of which were grouped together. The sharply-defined, dark-red spots scattered over the white skin gave a remarkable appearance to the eruption. General symptoms good. Pulse 86 ; temperature normal. lith. — Desiccation proceeding in most of the pocks, and those of an haemorrhagic character present small dark scab8,(repre3enl>- ing the contents of the vesicle) situated upon a base of fading extravasation. A few genuine pustules exist upon the chest. Face not so much swollen, but remains rough and uneven from the dry hard pocks. Temperature normal. Got up for a short time. 16fh. — Eruption drying up rapidly. 17