"Case of malignant hæmorrhagic small-pox"

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By John Snow, M.D. Londin.

Fellow of the Royal Medical and Chir. Society.

(For the London Medical Gazette.)

The following case from my note-book, of a form of small-pox which, I believe is happily now very rare, is, I think, not devoid of interest; and will be still less so, if examined in conjunction with the "Case of Pupura Hæmorrhagica, probably arising from variolous contagion, by N. Adams, Esq." in the last number of the Medical Gazette, which occurred in the country nearly at the same time as my case, and which resembles it in several particulars.

I was called at 7 o'clock, on the morning of Saturday the 8th of June last, to a boy named Cannell, living at No. 2, Chapel Place, Crown Street. He was a fine stout boy, seven years of age, but had been affected with asthma from his birth. His brother, aged 5, was labouring under small-pox in the same room; they were of the distinct kind, and in the maturative stage. Neither of the children had been vaccinated. The subject of this case took ill on the Thursday morning previous to my seeing him, with pain in the back, and fever. On the evening before my visit, an eruption appeared on the skin, and he became delirious; afterwards he had bleeding from the nose. He [586/587] was delirious all the night, and was insensible of what was said to him, and vomited a liquid mixed with blood. I found him in a muttering delirium, incapable of being roused, although he resisted any attempt to give him drink. He was vomiting almost constantly small quantities of blood, and of a thinner liquid, apparently serum, tinged with blood. The face and neck were swollen, and of a purple colour--were occupied, in fact, with one large vibex. There were other vibices on the body, and the rest of the trunk and extremities was spotted with numerous petechiæ, many of which had a lightish coloured spot in the centre, and appeared like pimples till they were touched, but there were only a very few on the trunk which could be felt to be a little elevated. The skin was hot, and the pulse frequent, small, and feeble; the tongue was coated with a brown fur, and the rest of the interior of the mouth was of a bluish white colour; he had passed motions in bed; cold applications were directed to the scalp denuded of hair, and sinapisms to the legs.

He was visited again in three hours; the vomiting of blood continued; the breathing was stertorous, and the pulse almost imperceptible. He died in half an hour more.

I made an examination of the body eleven hours after death, with the assistance of my friend Mr. Marshall, of Greek Street. The vibices and petechiæ remained as before; the scalp was very vascular, and blood flowed from it when cut; the veins on the surface of the brain were much distended, and the pia mater dipping in between the convolutions was much engorged, and there were little spots of extravasated blood in this situation. The red dots were found to be rather more numerous and large than natural on slicing the brain; there were one or two drachms of clear serum in each lateral ventricle, a little in each of the other ventricles, and a drachm or two at the base of the brain; the lungs were extensively emphysematous, they did not collapse on the chest being opened, but, on the contrary, rather bulged out, and many of the lobules were paler and more prominent than the rest. This emphysema of the air cells was most extensive at the lower part of the lungs; there were a few partial adhesions of the pleuræ, and the lungs were engorged with blood, as were the right cavities of the heart, which was healthy. The stomach contained a little bloody liquid, and all over its inner surface were dark purple spots averaging about the size of a pea, and situated about half an inch apart. They proved to be small portions of blood extravasated beneath the mucous membrane; this condition did not extend to the intestines. The feces in the small intestine were of a very dark colour, most likely from the presence of blood. The bladder was empty, and the viscera not mentioned were in the normal condition.

The row of small dwellings, in one of which this boy lived, are damp and ill ventilated, and all the illness I have seen in them has been more severe and intractable than in the rest of the neighborhood. I have treated two cases of sporadic cholera there, as bad as any cases of the epidemic disease which I have known to end in recovery; and one case of purpura hæmorrhagica with inflammatory symptoms in a child about five years of age, which I understand did not recover from the illness.

Frith Street, Soho Square,

Jan. 22, 1845.