AN ACCOUNT, &c.
ABOUT the 15th of July, a Sore-Throat of the malignant kind, nearly ſuch as deſcribed by Dr. Fothergill, and Dr. Huxham, (only without the effloreſcence, and attended with coſtiveneſs) made its appearance among children from three to ſeven years of age, by which many were cut off in the ſpace of ſix or eight days; ſome by ſuffocation, and others by vomiting of blood: at the ſame time, a complaint of a roughneſs in the throat,
moſt probably ariſing from a deprivation of its mucus, prevailed among adults, without the leaſt appearance of ulceration or malignancy, which however in a few days yielded to an external application of the volatile liniment or camphorated oil.
About the beginning of Auguſt, the ſame Sore-Throat extended its baleful influence more generally, chiefly attacking children from three to ten years of age, and alſo a few adults, of a lax and ill habit of body; in ſome it was very malignant, joined with an eryſipelatoſe inflammation and a diarrhea; the degree of malignancy however ſeemed to have been more adapted to the ſituation than to the conſtitution of the patients, inſomuch that the diſeaſe was very fierce in low, marſhy, and confined, and extremely benign in high and open places; thus in Hampſtead and Highgate it was very ſlight, whereas in Kentiſhtown it raged with great fury, and in Endfield-Chace
it ſwept away many in the ſpace of twenty-four hours.
The diſeaſe was not uniform, but ſeemed to have been of two kinds; in ſome there appeared only a ſuperficial whiteneſs on the uvula Tonſils and velum palatinum, whilſt in others thoſe parts were beſet with thick ulcerations, running very deep in the fauces, ſo as to be almoſt inviſible; in both ſpecies however, about the ſecond or third d y, hard ſwellings appeared externally on each ſide the neck, almoſt meeting together upon the throat, which occaſioned a ſtiffneſs of the neck, laſting in ſome for a month.
Though the attack of the diſeaſe was different in different perſons, yet moſt of them were taken with a nauſea and ſhiverings, ſucceeded by heat and an effloreſcence over the breaſt and extremities, and often the whole body was of a crimſon red; ſome were ſpread over with a kind of little millets, ſimilar to that in the miliary fever, and which ſcaled off the ſkin the ſixth or ſeventh
day; in which caſes the ulcerations were very ſlight, as alſo all other ſymptoms of malignancy: in all the different kinds of the effloreſcence, moſt of the patients complained of a violent itching, and had a dry and hot ſkin; the pulſe was commonly ſmall, quick, and ſometimes fluttering and unequal; the mouth full of ſloughs, the teeth black and covered with a cruſt; the tongue white, ſometimes a little furred, but frequently beſet with bliſters; the lips parched; the tonſils and uvula were often ſo much enlarged, that every thing attempted to be ſwallowed was ejected by the noſe; the urine was commonly diſcharged in ſmall quantities, high coloured, and a thin cloud ſuſpended in its middle; ſome diſcharged a ſmall quantity of blood for a few days out of the noſe; the noſe was ſtuffed up with a greeniſh ſanies, which dropped out continually, and ſeemed not to be of an excoriating nature, but rather to occaſion only a ſlight titillation, as a conſtant picking of the noſe was obſervable
in all thoſe caſes. Some were coſtive, whilſt others were afflicted with a ſpecies of an autumnal dyſentry, as their ſtools appeared knotty, ſuch as deſcribed by my ingenious and ſagacious friend, Dr. Wilſon, in his treatiſe on the Autumnal Dyſentry; the purging and effloreſcence however did not ſeem to correſpond with one another; for, firſt, the diſappearance of the one ſeldom aggravated the other; ſecondly, they were often concomitant; thirdly, ſometimes a coſtiveneſs attended, though there was not any effloreſcence; nor did the effloreſcence appear to be a critical diſcharge, as is the caſe in eruptive diſeaſes of the malignant kind, for the effloreſcence and the Sore-Throat were often met with ſeparately. A cough attended in moſt throughout the whole diſeaſe, probably occaſioned by the irritation of the larynx; great depreſſion of ſtrength, dejection of ſpirits, a total inactivity, a delirium, a pulſe that beat 140 or 145 in a minute, and a great diſponae, were fatal omens.
It was remarkable that though moſt of the young patients had a great averſion to all manner of food, yet they ſeemed not unwilling to take medicines, which made me imagine that immediate relief was found from it.
The diſeaſe had neither an apparent criſis, nor any regular progreſs; for all the ſymptoms often vaniſhed of a ſudden about the eighth or ninth day, whilſt at other times they were at a ſtand for about 14 days; but frequently they diminiſhed or increaſed from the 10th to the 14th or 15th day, when either a total recovery was ſeen, excepting the external ſwelling, which laſted often for weeks; or the ſcene of life was cloſed, the patient ſuffocating or expiring in a lingering way. In one caſe only, which I ſhall mention hereafter, I beheld all the malignant ſymptoms in the higheſt degree, the patient labouring under them for three weeks, and at laſt recovered.
An oedematous ſwelling, after the abſence of all the fatal ſymptoms, and when nothing but an entire recovery was expected, appeared to be very frequent in children of an ill habit of body; the lips, noſe and face were bloated, ſallow, ſhining, and greaſy, as it were, which ſwelling ſpread itſelf ſometimes over one ſide, and at others over the whole body, eſpecially the abdomen; the ſwelling I have obſerved to increaſe always in the morning, and to abate towards evening. Dr. Huxham, in his diſſertation on the Malignant Ulcerous Sore-Throat, has obſerved the ſame; but only "before the fatal period," not after a total recovery; nor does he take notice of that particular circumſtance concerning its increaſe and abatement, different from all other dropſical ſwellings: however, ſome have been carried off by it a month after the firſt invaſion of the diſeaſe, whilſt many recovered by the uſe of proper cathartics and full doſes of the bark.
This diſeaſe was ſometimes miſtaken for the meaſles, not only becauſe the cough being an idiopatic ſymptom of the ſame, but becauſe the effloreſcence in the benign kind was ſo very ſimilar to thoſe of the meaſles, and which were alſo epidemical the latter end of Auguſt: great miſchief would have been done in treating it according to the miſtake, with expectorants, opiates, and antiphlogiſtics; but the very aſpect of the throat, even in the benign kind, the external ſwellings, and the cough itſelf ſo different from that of the meaſles, where it is much ſtronger and deeper, if I am allowed this expreſſion, could ſoon detect the error; though I had often occaſion to think that ſome patients were attacked with both diſeaſes at once, and then I have treated them accordingly.
If we conſider that in this epidemic the effloreſcence appeared often independent of the angina, and was ſimilar to the miliary or ſcarlet fever, that further, no
great connexion has been obſerved between the diarrhoea and the effloreſcence, and the diſappearance of the latter did not always aggravate the former; moreover, that often a conſtipation accompanied the whole diſeaſe, notwithſtanding the abſence of the effloreſcence; again, that both the angina and the eryſepelatoſe inflammation often appeared ſeparately, and that the ſtools were ſimilar to thoſe of the autumnal dyſentry; I ſay, conſidering all theſe circumſtances, it ſeems as if the effloreſcence were not always a critical diſcharge, as is the caſe in moſt putrid diſeaſes of the puſtular kind; but that the genuine and principal diſeaſe was the epidemic Sore-Throat, which began early in ſummer, and conſequently, to ſpeak in the language of Sydenham, was either an early autumnal, or a late vernal epidemic, to which in autumn two other epidemics, namely, either the ſcarlet or miliary fever, and a purging, like the autumnal dyſentry were joined; the firſt, and genuine
epidemic, namely, the Sore-Throat, being at the ſame time predominant, as often obſerved by the great Sydenham; and though that great obſerver attributed epidemics to the occult, and not to the ſenſible qualities of the air, yet latter obſervers favour the contrary opinion, as it appears from the writings of Dr. Shaw, Arbuthnot on Air, Dr. Hale's Statical Experiments, Dr. Huxham de aere et morb. epid. and others; and it is very probable, that the preſent aroſe from the frequent ſhowers and ſtormy winds, which continued the greateſt part of June and July, though often with eaſterly winds, yet the ſun piercing through the clouds in the intervals of the ſhowers might have much contributed to the epidemic in queſtion, warning the floating vapours, and producing a change in the conſtitution of the air, which, when bred in, has in adults, only affected the mucus membrane of the Throat, and occaſioned there a roughneſs; whereas in child
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en, and thoſe of a laxhabit,
it has introduced its malignancy deeper, and brought on putrid ulceration; the ſultry and warm autumn then approaching has rouſed again, as it were, the lurking epidemic, which then ſpread itſelf more general, and more malignant joined with two autumnal epidemics: theſe, however, are only probable conjectures, which I ſhall quit, and return to the method of treating the diſeaſe.
As the principal diſeaſe was of the malignant kind, antiſceptics, the king of which the bark may juſtly be called, were the firſt indications, a vomit has ſometimes cut the diſeaſe ſhort, and which, in the firſt onſet of the diſeaſe, ought never to be omitted, as it rouſes the nervous ſyſtem, and the principles of life, the energy of which it ſo much depends upon in the removal of putrid diſeaſes; and as it clears the ſtomach of its crudities; for the powers of digeſtion are always impaired in putrid attacks, eſpecially in the
preſent caſe, where moſt probably the oeſophagus, and perhaps the ſtomach itſelf were affected: however, as moſt commonly phyſical aſſiſtance was ſought for ſome days after the invaſion, emetics could not always have been adminiſtered with ſafety, eſpecially when the fauces were much ulcerated. The admiſſion of free and pure air was highly recommended, as many patients panted for the free air, and which I never found doing any harm, inſomuch that three children afflicted with the diſeaſe came to me every other day at the Aſylum, which Caſes I ſhall mention here-after. The room in which the patient lay was frequently ſprinkled with vinegar; a gargle, or rather an injection in the Throat, was adminiſtered of a ſtrong decoction of the bark and the tincture of myrrh, with which alſo the mouth was continually waſhed: internally, the bark was given, ſometimes with the ſpirit of minderery, and at others with the cardiac confection, according to the degree of the
fever. The camphorated oil, or the volatile leniment, was applied to diſperſe the external ſwellings; for as they ſeemed to be of a malignant nature, it was not adviſeable to invite, by poulticing them, more humours thither, for fear of converting a greater quantity of matter into a malignant nature, and conſequently increaſing the diſeaſe; nor did bliſters ſeem to have been of any efficacy in either leſſening the degree of the malignancy or the ſize of the ſwellings, though, in compliance with common practice, they were ſometimes ordered, when they occaſioned a great diſcharge of a thick matter, but without the leaſt relief to the patient; bleeding and antiphlogiſtics were ſeldom requiſite; and thoſe who have been treated in the ſtrict cold regimen were only protracted in their miſery. In caſes of coſtiveneſs, I ordered for the patient to eat prunes boiled with ſena and a little of the powder of ginger in it, as they ſerved alſo for nouriſhment, eſpecially as there was an averſion to all
manner of food. Where a purging atten
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ed it was moderated by cordials, and often only by the bark, with the addition of the confect. card. or a few drops of the tinct. thebaic. and which relieved the patient often by bringing on a gentle diaphoraſis, to promote which, plenty of warm and diluting liquors were alſo recommended.
The oedematous ſwelling, that appeared in many eight days after a total recovery, was beſt removed by repeated doſes of calomel and rhubarb, and full doſes of the bark; and as far as I have been able to obſerve, that dreadful ſymptom ſeldom happened where proper cathartics were adminiſtered after the diſeaſe, to carry off the remainder of the putrid colluvies, lodging in the inteſtinal tube.
As in many caſes the young patients could not be prevailed upon to take medicines, a foot, bath of bran, and ſometimes cataplaſms of horſe-radiſh and muſtard were
ordered with ſucceſs, both in promoting by their ſtimulus the energy of the nerves, and in bringing on a revulſion: and indeed, as in Germany ſuch methods are too frequently uſed, ſo are they here too much neglected. That applications to the lower region have a great influence upon the upper parts of the ſyſtem, is evident from the following ſimple experiment: I felt often a coughing and a diſpon coming on ſuddenly, upon holding may feet in cold water, which ſhews the great ſympathy between the nerves of the feet and thoſe of the lung, diaphragm, and of the trachi, ſo that cold applied to the feet will irritate the nerves of the lungs, &c. Upon the ſame principle, any ſtimulus applied, to the feet will rouſe the nerves of the upper region, and give them energy. Such remote applications muſt even have a better effect than when the ſtimulus is applied immediately to the affected parts, or near them, for it may often bring on alarming ſymptoms, by increaſing the
weakneſs of the already debilitated and tender parts, as I have ſeen putrefactions take place where the bliſter was, when applied near the affected part, and which putrefaction made ſo rapid a progreſs, that it was not in the power of art to ſtop it; remote applications therefore, ſuch as cataplaſms and ſemicupiums, are certainly more ſalutary and leſs dangerous: not to mention the inconvenience ariſing from bliſters, when the cantharides are abſorbed in a ſyſtem that has a tendency to putrefaction. Even in deliriums, applications to the feet, ſuch as mentioned above, are preferable to either bliſters or opiates, for the former may often increaſe the delirium by increaſing its cauſe, debility, as obſerved before, and the latter may aggravate the diſeaſe, by diminiſhing the ſenſibility, and conſequently the energy of the nerves, ſo requiſite to counteract all putrid diaſthaſis. The ſemicupium is frequently uſed in Germany in the beginning of eruptive diſeaſes, eſpecially in the ſmall-pox, where
it often relieves the nobler parts from their fatal invaſion. Dr. Wilſon aſſured me, that he always ordereth it, and never found any dangerous conſequence of a paralyſes, as has been inſinuated by ſome; but as the diſeaſe in queſtion is ſomewhat ſimilar to the ſmall-pox, might not the ſemicupium be of the ſame uſe?
CASE I.
A YOUNG lady of a delicate habit of body, about ſix years old, was taken September the 22d, 1777, with all the ſymptoms at once; a nauſea, great fainting, and an effloreſcence all over the body, much like little mellets, a difficulty of ſwallowing, ſtiffneſs of the neck, and coſtiveneſs; under which ſymptoms ſhe laboured three days, on the fourth I ſaw her, and found a ſmall ulceration on the uvula and tonſils, with a large ſwelling of each ſide the throat; her pulſe was 130, the ſkin dry and hot, the urine high coloured, and a cloud ſuſpended in it, no ſanies diſcharge of the noſe, though ſhe picked it continually; the palate much inflamed, and the tongue white; I ordered a vomit, bliſtered the top of the neck, recommended the admiſſion of free air, and the bark was
miniſtered, with the addition of 8 drops of the theb. tinct. in the night draught; there was neither a diſponoe nor the uſual croaking noiſe; the volatile liniment was applied to the ſwellings, and the mouth was continually waſhed with a decoction of the bark, and tinct. of myrrh; the ſymptoms began to ſubſide daily, and the ninth day ſhe was quite recovered, only that a ſtiffneſs in the neck remained; the effloreſcence alſo remaining till the fourteenth day, when it began to ſcale off. I have ſeen many other caſes in which either the effloreſcence or ſwelling laſt for near a month, after all the other ſymptoms; in ſome there was a hoarſeneſs remaining for months. The effloreſcence therefore does not ſeem to be a critical diſcharge, as is the caſe in putrid diſorders of the puſtular kind.
CASE II.
MERRYMAN, a girl about ſeven years of age, was taken, October 14th, with a nauſea, vomiting, and a diarrhoea, the ſecond day the ſickneſs abated; but a purging of knotty ſtools ſtill remained; a ſwelling appeared on both ſides the neck, which almoſt met together upon the throat; her pulſe was 135; there was a diſcharge of a ſanies matter through the noſe; the mouth full of ſlime and ſlough, the teeth very black, the tongue furred, ſhe picked her noſe conſtantly, and the uvula and tonſils were ſo much enlarged, that every thing taken in the mouth could hardly be ſwallowed, but was ejected by the noſe. Here the great uſe of medicines was ſo obvious, inſomuch, that whenever the child could not be prevailed on to take them, all the ſymptoms grew worſe; yet as ſoon as the
medicines mentioned in Caſe I. were taken, an amazing change followed. As I ſaw the child in this ſtate of alternate relapſe and recovery for fifteen days, I would not truſt any longer to her whims, but ordered glyſters, which her mother would not give her; I had then refuge to ſemicupiums and cataplaſms, by which means all the ſymptoms gradually abated; and though that child ſeemed to recover in a lingering way, yet in the beginning of November ſhe was ſo much better, that ſhe condeſcended to take the bark, and which in a few days reſtored her entirely.
CASE III.
OCTOBER the 5th I was called to ſee two ſiſters, the one eight and the other nine years of age; both had the confluent ſmall-pox ſix months before;
they were ſo malignant in the youngeſt, that the apothecary then attending deſpaired of her recovery, which proves that her conſtitution was much diſpoſed to putridity: however, both were ſeized with nauſea, ſhivering succeeded by heat, great depreſſion of ſtrength and inactivity. They were in a comatoſe ſtate; the throat was ulcerated, but the ulceration was ſo deep in the fauces as to be hardly perceptible; the tongue was full of bliſters, white, and a little furred; the lips black and parched; the teeth very black; an effloreſcence all over the body; great ſwelling on each ſide the neck, and a purging of knotty ſtools attended; the pulſe of the youngeſt beat 140 in a minute, and that of the eldeſt 130, and in general all the ſymptoms were more violent in the youngeſt. I ordered, a vomit; the cortex with the confect. card. to be taken internally; the mouth to be waſhed, and the throat to be ſyringed with a decoction of the bark, and the tinct. of
myrrh; and a bliſter was laid on the back; the ſymptoms were at a ſtand till the twelfth day, when after the bliſters had diſcharged plenty of a thick matter, a mortification came on, on the place were the bliſter laid, and which carried the youngeſt off in three days, in ſpite of all antiſceptics that were adminiſtered to ſtop it, as ſhe was really putrified; for bliſters were tried, a few days before the mortification came, on different parts, which did not draw at all. The eldeſt, however, mended gradually, and was entirely recovered the 19th, went abroad, eat and drank hearty; but to my greateſt ſurpriſe, the 25th, her noſe and lips began to be bloated, and of a greaſy look; an oedematous ſwelling ſpread itſelf over her right ſide and abdomen which increaſed remarkably towards morning. Repeated doſes of calomel and rhubarb were adminiſtered, and the bark in full doſes; the ſwellings, ſeemed to, abate the third day after
its invaſion; but the fourth and fifth day the child could not ſwallow at all, and convulſive fits, the laſt ſtruggle of life, cloſed the miſerable ſcene on the 29th of October.
CASE IV.
OCTOBER the 20th I was called to ſee a girl about three years of age. I looked in her throat, and found it ſlightly ulcerated; her pulſe beat 130 in a minute; ſhe was attacked with nauſea, and ſhiverings ſucceeded by heat, and an effloreſcence all over the body; a coſtiveneſs and great thirſt attended throughout the whole diſeaſe: there were no outward ſwellings, nor any great anxiety. I ordered her prunes boiled with ſena to keep the body open, and to afford her ſome nouriſhment,
a great averſion againſt all manner of food, and the bark with the ſpirit mind, were adminiſtered along with the uſual ſyringe and waſh for the mouth and throat. The ſymptoms were at a ſtand for eight days; the 28th the effloreſcence diſappeared, the coſtiveneſs ſtill remaining along with a hoarſeneſs, which laſted for three weeks; ſudorifics and the bark were given, and ſhe recovered entirely. Both her ſiſters, one eight, and the other ten years of age, were taken two days after, with all the ſymptoms, ſimilar to the firſt, excepting they had large and hard external ſwellings, and a great ſtiffneſs of the neck, which was inclined to the right ſhoulder, and whi
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h they could not move without the greateſt pain; they were treated in the ſame manner, with the addition of the camphorated oil to the ſwellings, and they recovered nearly at the 30th of October; five days after they were all attacked with the oedematous ſwelling, as mentioned in Caſe Ill.
but by the adminiſtration of cathartics and the bark they all recovered ſix days after the attack.
CASE V.
JEREMIAH WRAY, aged three years, of a weak conſtitution, was recommended to the Aſylum, October the 22d, by Mr. Babbs; the child was ſeized two days before with nauſea and vomiting, ſucceeded by ſhiverings and heat, an effloreſcence all over the body, and a purging; when he came to the Aſylum I found his throat ulcerated, and ſwellings on both ſides the neck, his pulſe 130 ſtrokes in a minute, and he was in a comatoſe ſtate; the decoction of the bark, with the confect.
card. was ordered to be taken internally; the ſame decoction, with the tinſture of Myrrh, was adminiſtered for a gargle; a bliſter was put on his neck, and the outward ſwellings rubbed with the camphorated oil; the child came every other day (my days in attendance) to the Aſylum. The ſymptoms were at a ſtand till the 14th of October; when the effloreſcence and the purging both abated, the ſwellings began to ſubſide; and the 3d November he was quite recovered, and returned thanks.
CASE VI.
JAMES BULLOCK and William Bullock, two brothers, one of five and the other of ſeven years of age, were recommended by
Mr. Aſhburner and Mr. Hart, September 28; they were taken with nauſea and vomiting, which ſucceeded by a ſlight degree of fever and ulceration in the throat, hardly perceptible; neither of them had any outward ſwelling, nor an effloreſcence, but both had a purging till the 9th day, when by the uſe of the medicines, nearly like thoſe mentioned in Caſe IV. they returned thanks the 8th October.
CASE VII.
WILLIAM ROOTER, aged ſix years, came recommended by Chamberling, Eſq. October 14; he was attacked three days before with a ſickneſs, ſucceeded by a ſlight fever; I found his throat deeply ulcerated, the uvula and tonſils covered
with ſloughs, an outward ſwelling on the right ſide the neck, but there was neither an effloreſcence nor purging; on the contrary, he was coſtive throughout the whole diſeaſe; laxitives were ordered to keep his body open, and the bark was adminiſtered, he was treated nearly as thoſe mentioned in Caſes IV. and V. excepting the bliſter, which I omitted; he came every other day to the Aſylum, and returned thanks the 29th October.
MY ingenious friend, Dr. Lettſom, whoſe practice is extenſive and obſervations accurate, informed me, that he generally obſerved that a fever, with alternate ſhiverings and hot fits, and a pain and difficulty in ſwallowing, attended the firſt onſet of this diſeaſe; a nauſea, head-ach, reſtleſsneſs, and a ſenſation of general ſoreneſs of the body, and other ſymptoms of fever, were, alſo preſent in greater or leſs degree, even before any ulceration of the tonſils took place; its approach however might be aſcertained by the enlargement of theſe glands, and the livid appearance and turgeſcence of their veſſels. An effloreſcence of the ſkin moſt generally appeared at this time, and a fluſhing and bloatedneſs of the face.
The ulcerations of the tonſils uſually began to ſlough off about the fourth or fifth day, but a low remittent fever continued frequently for ſome days afterwards, as did
likewiſe the effloreſcence; and as the fever ceaſed, this gradually vaniſhed, and fell off in bran-like ſcales, and all the ſymptoms ſubſided.
When the angina was more violent in its attack, the ſloughs were not removed till the ſeventh or eighth day; about which period, when the patient appeared more favourable, conſiderable and unequal ſwellings in one or both ſides of the neck aroſe, and theſe, if not diſcuſſed in two or three days, formed large tedious ſuppurations, which either diſcharged externally, or behind the uvula, or carried off the patient by ſuffocation, or by debility; but moſt generally in theſe malignant caſes the ulcerations ſpread inferiorly, producing the angina trachaealis, which often proved fatal in grown perſons, as well as in infants. Theſe ulcerations likewiſe extended along the whole, membranes of the mouth and noſtrils; in ſuch inſtances particularly, a delirium almoſt
conſtantly ſupervened, and many died in a ſtate of raving, which made him ſuſpect that the eryſipelatous inflammation might extend to the membranes contiguous to the brain.
The eruption often put on a peculiar appearance in this virulent ſtate of the diſeaſe; inſtead of falling off in ſcales, numerous little ſuppurations might be diſcovered upon the ſkin, a little larger than the miliary eruption, and ſometimes as broad as a ſilver penny; they contained purulent matter, which might be diſcovered upon opening them.
A dyſentery ſometimes preceded the angina, oftener however it came on about the third or fourth day; the diſcharges were dark-coloured, offenſive and thin. Dyſenteries alſo prevailed with angina, particularly in October. While it was requiſite to evacuate theſe foetid congeſtions in the abdomen by mild means; large
and ſudden evacuations were apt to augment the debility.
Dr. Lettſom alſo obſerved, that the country in the vicinity of London, ſuffered much likewiſe, eſpecially in the villages, in low marſhy ſituations, wherein the diſeaſe raged through the ſummer, as well as in the ſpring and autumn of 1777, and proved full as fatal as in the metropolis.
When he was conſulted at the commencement of the diſeaſe, he generally began the cure by an antimonial emetic, given in ſmall and repeated doſes till it vomited, by which much bilious fluids were diſcharged; and as ſoon as the operation was over, he did not heſitate to exhibit the bark, either in decoction or in ſubſtance, although the fever was then conſiderable; it ſeldom appeared to him to increaſe it, or the dyſpnoea which often attended the angina. Occaſionally,
however, where the fever was very violent, he intervened emotic tartar in ſmall doſes as a relaxant, and joined neutralized lemon juice with the cortox: when a diarrhaea was alarming, the confectio cardiaca was added, and ſmall doſes of thebaic tincture; ſometimes with rhubarb, or ſmall doſes of ipecacoanha inſtead of the emetie tartar; but throughout the whole progreſs of the diſeaſe the bark was ſeldom relinquiſhed. Cordial drinks and acidulated liquors formed a part of the diet. He uſually preſcribed the volatile liniment to the fauces and throat; but where there was danger of ſuffocation, he applied bliſters to the neck. They ſometimes appeared to him to have beneficial effects; but he obſerved, that moſt of thoſe anginas which terminated in tedious glandular ſuppurations of the neck, had been previouſly treated with viſicatories; from whence it was ſuſpected, whether the ſtimulus of the cantharides had not excited this troubleſome and dangerous
ſymptom, and thereby rather increaſed than leſſened the danger of ſuffocation.
He ſeldom found the delirium and reſtleſſneſs which accompanied the angina, yielded to an opiate, they were ſometimes increaſed by it, but that pediluvium and fomentations of vinegar and water to the legs produced a more ſalutary effect; when both were uſed together, the opiate uſually produced a more ſalutary effect.
Out of ſeveral caſes of glandular ſuppurations which have occurred to him in practice, he has favoured me with the following caſes and diſſection.
Mary Pulling, aged nine years, was attacked on the 13th of May, 1777, with rigors and vomiting, which were ſucceeded by fever, and effloreſcence of the ſkin. I firſt viſited her on the 17th; the
heat was then exceſſive, and the effloreſcence general; the pulſe beat about 130 in a minute; a ſlight cough was occaſionally excited, and a delirium now and then prevailed: ſhe complained of a ſoreneſs of the throat, which I found to be ulcerated.
Cordial remedies were adminiſtered, with preparations of the bark. Laxatives were occaſionally preſcribed, and mild opiates when neceſſity required. The volatile liniment was applied to the throat and fauces, and gargles were carefully uſed. About the 6th day, a bliſter was applied behind each ear.
In about ten days time no ſymptoms of the angina appeared; the fever had ſubſided, and the effloreſcence of the ſkin had vaniſhed; but the ſtrength was reduced, and the nouriſhment and drinks which the patient ſwallowed were diſcharged by
vomiting; at the ſame time neither a difficulty of breathing nor of ſwallowing occurred. Opiates did not ſubdue the vomiting; mineral acids had no effect, and laxatives did not divert this by opening another diſcharge; and even quickſilve
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was ejected. The want of nutrition would augment the debility, to obviate which broth clyſters were recommended; and to take off the determination to the ſtomach, a bliſter was applied to each foot. The vomiting, however, never ſubſided till the 12th of June, when the emaciated patient expired, without either previous dyſpnoea, catarrh, or difficult deglutition.
On the 13th, the patient was opened by Surgeon Vaux, in the preſence of Dr. Hulme, and other medical gentlemen.
The brain was found in a perfect ſtate. The inteſtines alſo did not appear diſeaſed; the omentum was almoſt diſſipated; what
remained of it was flaccid, and not indurated. The gall-bladder was conſiderably enlarged. On the leſt ſide of the thorax an effuſion of water appeared, and the left lobe of the lungs afforded a tubercle of conſiderable magnitude. The heart was in a healthy ſtate, and ſo were the liver and ſtomach.
Upon opening the throat a conſiderable tumor was found on the right ſide, immediately behind the tonſil, but it had no duct or paſſage into the trachoea; the tumor contained about three ounces of foetid pus in its cavity. The child continued ſenſible through the diſeaſe, but for the laſt fortnight never complained of any affection near the throat; or that the conſtant inclination to vomit all food or liquids, proceeded from irritation near the part diſeaſed, and deglutition continued familiar to the exit of the patient.
About the ſame time I was attending another child with very ſimilar ſymptoms of the angina trachoealis; the tumor of the neck was however much larger, and a ſlight dyſpnoea attended the child, which increaſed to ſuch a degree one night as threatened ſuffocation. On the next day the fever and dyſpnoea very ſuddenly diminiſhed; and, upon examining the throat internally, I obſerved a quantity of pus diſcharging from behind the tonſil of the ſame ſide of the neck, and this diſcharge was augmented by gently preſſing the tumor externally. The child from this period gradually recovered.
Suppurations of this kind do not unfrequently accompany the angina maligna, or appear during its ſeceſſion, and continue ſometimes feveral days after the mucous membrane, which was firſt affected in the angina, has recovered its natural ſtate. In ſuch inſtances, wherein a fatal tendency
is ſuſpected, would it not be adviſeable to open the abſceſs that is formed, either by an inciſion through the tonſil on the ſide affected, in imitation of the natural operation which occurred in the laſt inſtance, or through the external integuments where the tumor points externally?
On the extremes of the cold and hot regimen in the Sore-Throat, and other putrid Diſeaſes.
SYDENHAM and MORTON practiſed at one time in London; the former introduced the antiphlogiſtic, whilſt the latter continued the alexipharmic, regimen, in the ſmall-pox as well as in different putrid affections; both perhaps with equal grounds and ſucceſs, as the practice of the one was moſtly in the airy and court part of the town, where all diſeaſes are leſs malignant, and where the air is purer than it is in the cloſe part of the town, the city, full of gaols and impure air in which the other reſided. An obſervation communicated to me by Dr. Fothergill, who inſiſts even now upon the hot regimen in
the malignant Sore-Throat, and has aſſured me that notwithſtanding, in compliance with other phyſicians, he often tried the bark, yet never found it to anſwer the deſired effect and was obliged to have recourſe again to his method of treating it with cordials, &c. He obſerved further, that even animal food ſeemed not to be ſo hurtful in this diſeaſe as is commonly thought; for he has taken notice that the patients have a particular longing for it, a call of unerring nature for ſupport and ſtrength, and the Doctor thinks that acids are not ſo beneficial, and ſo great antiſceptics, as is imagined: all which remarks are certainly not theoretical, but founded on the ſolid baſis of a long and great practice and repeated obſervations; other practitioners however, inſiſt much upon the bark, and ſome even upon the antiphlogiſtic regimen.
It is true, that the indications of cure, according to the ſtate of the patient, his ſituation, and the degree of malignancy of the diſeaſe and its ſymptoms, and not this or that regimen ought to be the guide of the artiſt. It is alſo undeniable, that even nature which is ſo much talked of, cannot always be conſulted as the true guide; for if we were to encourage nature in all her endeavours, ſhe would lead us often aſtray. In many eryſipelous caſes, and cutaneous eruptions, where nature endeavours to throw out ſome peccant matter upon the ſkin, experience has thought not to aſſiſt her by ſudorifics and warm medicines, but on the contrary to uſe cathartics. In the putrid Sore-Throat, and the confluent ſmall-pox, the diarrhea often attending, muſt be checked and moderated; and ſo in many caſes where nature muſt be oppoſed, as ſhe often acts not upon wiſe, but upon mechanical principles,
and it is the buſineſs of the phyſician to watch her only, and to let experience be his guide, in encouraging, moderating, and counteracting her efforts; it is only therefore practice and not theory that enables the artiſt to diſtinguiſh between the critical and ſymptomatical appearances of diſeaſes. But when practitioners differ ſo widely, even thoſe who practiſe in one and the ſame part of the town, and all appeal to facts, then I ſhould think, theory might have ſome right to interfere, and bring in its verdict. I know that I am far from being equal to the taſk; nor do I propoſe to decide in ſo important and intricate a ſubject, but mean only to throw out ſome thoughts, and vehemently wiſh that the ſubject might be handled by my ſuperiors both in knowledge and practice.
The antiphlogiſtic regimen, in the confluent ſmall-pox eſpecially, is hot ſo modern
as it is commonly thought. The Arabian phyſicians have already recommended the free and cold air,Primus eſt cum nimium tecti et coöperti aegri ſuffocantur, et in Lipothymiam incidunt, tunc aeri frigido, vento etiam paulatim tamen, aegri exponendi. Alter eſt, fi dum erumpunt variolae, non ſubleventur aegri; ſed perſeveret, vel augeatur inflammatio interna; & lingua nigreſcat: tunc cavendum eſt a calefactione aeris: frigidus et ſuſſitu quodum cordiali alteratus eſt imperandus. Avicen. Fen. 1. Can. 4. Tract 4. Cap. 10. evacuations, and large bleeding, even ad ſincopium.
Vid. Rhazis, C. 5. C. 47.—234. Sydenham has only renewed and introduced it more generally, which regimen, as it was at firſt ſo much oppoſed, ſo has it afterwards been too much embraced and extended to too great a length, as we are commonly apt to run to either of the extremes, eſpecially when we are actuated
by the evil ſpirits of novelty and contradiction.
Though there is a great difference between the nature of the confluent ſmall-pox and the diſeaſe in queſtion, as the latter conſiſts chiefly in the conſtitution of the air, evidenced by its attacking the fauces, whereas the former lies dormant and lurking, as it were, in the ſyſtem and the whole maſs of blood, obvious from the nature of inoculation; yet are they in ſo far ſimilar, as all putrid diſeaſes, or thoſe which appear with great depreſſion of ſtrength, are related to one another, and therefore what holds of the one, is caeteris paribus, applicable to the other, as in both, the view of the phyſician muſt be directed in ſupporting the ſtrength of his patient, and in avoiding every application that may in the leaſt tend to increaſe the general debility. Either of the extremes
will often increaſe the diſeaſe; for to confine the patient to his bed, heat his body with wine and cordials, and debar him of the air, muſt certainly rarify the blood, relax the fibres, and increaſe the tendency to putrefaction, by increaſing its too great principles, heat and moiſture; as on the other hand, the too cold regimen will greatly contribute to leſſen the energy and motion of the ſolids as well as of the fluids; and indeed many young and tender patients have periſhed by cold, and been frozen to death, as it were, though others have often recovered under the coldeſt regimen, yet this will prove no more than, that nature often cures diſeaſes in ſpite of all miſmanagement of art.
Bleeding can ſeldom be proper, for the ſpontaneous naſal hoemorrhage, in the onſet of both diſeaſes, the putrid Sore-Throat and the confluent ſmall-pox, does not ſeem
to be a hint of nature, inſinuating the neceſſity of emptying the veſſels; but I ſhould imagine its being merely ſymptomatical, owing to the looſe texture of the blood, as is evident in caſes of great malignancy, where the blood when drawn from a vein is ſo watery and putrid, that it does not coagulate as uſual, and might be divided and moved any way with the ſlighteſt touch of a feather, like water: the air confined in the blood encreaſes its elaſticity is ſet looſe by the heat and fermentation of the fluids, and expands itſelf to ſuch a degree, that it compaſſes a much greater room than uſual, by which means it ſtretches the fibres, and forces them to dilate beyond their natural dimenſions, which, in the ſmaller capillary veins, occaſions their burſting, and conſequently hoemorrhages that are only ſymptomatical and indicate antiſceptics, bracers, and free air, not bleeding; though the Arabian Phyſicians
have conſidered ſuch diſcharges as critical, and accordingly recommended the opening of the veins of the noſe in the beginning of the ſmall-pox.Et cum erit conveniens flebotomare venas narum i
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principis, eſt ſatis utile. Rhazis d'wis. P. 209.
The ſame obſervation holds of the diarrhaea, often attending the ſmall-pox, as well as the putrid Sore-Throat, which is ſymptomatical, owing to the weakneſs and irritable ſtate of the inteſtinal tube, and to the ſtimuli of the juices corrupted by the diſeaſe, but is not a critical diſcharge, and therefore muſt be moderated.
In all putrid diſeaſes, the principle of life and the nerves are chiefly concerned, inſomuch, that Aſtrue thought, from examining the brains of thoſe who died in putrid fevers, that the ſeat of the diſorder lies originally in the brain itſelf; but if
even that alteration found he in the brain was only (as it moſt probably ſeemed to be) the effect and not the cauſe of the diſeaſe, yet has no phyſician ever diſputed that all putrid diſorders impart much to the eneaphlon and the nervous ſyſtem, as is evident from the anxiety, dejection of ſpirits, and proſtration of ſtrength attending the very onſet of putrid diſeaſes, clearly painted upon the eyes, and languiſhing and pityful countenance of the patient, and which, by itſelf, is ſufficient for a good obſerver, to give him an exact idea of the diſeaſe and its degree of malignancy, without examining the ſtate of the pulſe, and inquiring into all other ſymptoms. Whether the nerves are primary or ſecondary affected it matters not, the indications of cure, coeteris paribus, remain notwithſtanding the ſame, namely, to excite and rouſe the motion and energy of the nerves, and to brace the whole ſyſtem, which may be
done either by applications acting with their ſtimulating quality, ſuch as cordials, ſpirits, and bliſters, or by adminiſtering ſuch as are able to corroborate and compact, as it were, the looſe and relaxed fibres, as are all the bitters, the bark, cold air, &c. Either of which applications however are not attended without ſome diſadvantages; for what concerns cordials and ſtimuli, it is well known, that although they wonderfully rouſe the ſpirits, yet that great exertion of the nerves is only a temporary tumult, as it were, which ſoon ceaſes, and leaves commonly behind it a great langour and relaxation of the fibres; as on the other hand ſtrengtheners and bitters alone, without the junction of ſome ſtimuli to exert the fibres into motion and action, will ſometimes have no effect at all, and often do great miſchief; for I have elſewhereSee the Author's Eſſay on the Blood. endeavoured to ſhew, that all
medicines and application to living bodies can act only in degree and proportion to the reaction of the living fibres, and as long as the fibres are too weak to react, the effects of corroborating medicines will be juſt, to make uſe of a familiar ſimile, as a heap of coals thrown upon a little fire, which, inſtead of making it burn briſker, will extinguiſh it entirely.
The immediate effects of the bark, when given to patients, whoſe lungs are affected, in bringing on an inſupportable dyſpnoea, is a plain proof that it diminiſhes the irritation of the fibres, and which I have ſeen often reſtored by adminiſtering what are called expectorants and ſtimuli, eſpecially a ſolution of gum ammoniac, with the ſal. c. c. Seeing therefore, that there is ſome difficulty attending in each of the applications and regimens ſeparately, the moſt rational method, I ſhould imagine, would be
to hit upon the medium of both regimens, and to join the bark along with ſtimulants and cordials, by which means, both intentions might be anſwered at once, namely, that of rouſing the fibres, and exerting them to react, when at the ſame time they are coroborated and ſtrengthened by the bark; practice convinces the truth of this theory. That the bark doth often not anſwer the expectations of the phyſician, is moſt probably owing to, either of its not being properly guarded with ſtimulating and warm medicines, or, which I believe is too often the caſe, to its not been given in full doſes, and not being perſevered in, though it muſt be allowed, that whenever an anginal dyſpnoea is at hand, that the bark cannot be adminiſtered without bringing on alarming ſymptoms. But might it not often ſucceed when joined with balſamics and aromatics?
FINIS.