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DISSERTATION.
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A

DISSERTAT ION
ON THE
?W3V
CYNANCHE MALIGNA.
-o^^^^^^*^^*
by GEORGE  ASPINWALL,

?»
       Decant:
PRINTED BT MZXN AND AP.*M3
I798. 
                      T O
   OLIVER  PRESCOTT, jw*
Physician, in Groton ; member of the Mas-
   sachusetts Medical, and Middlesex Acri*
   cultural Societies*
        S I R,
              JtjV the repeated solicitations of seve-
ral friends, I have ventured tc publifh ibis imperfect
Diffcrtation  on the Cynanche Maligna.
         Imperfections always need candor and
protedion :—For the former I appeal to the public,
who will consider that it was  written during the
second year of my  pupilage,  though under some con-
siderable advantages, as there were many sick with
the disorder at that time :~—For the latter  J with
confidence look up  to you ; convinced that your singu-
lar moral and medical character, combined with year
approbation, would be my most sure defence.
         Accept, Sir, this  small  testimony of the
obligations and esteem of
            Your obedient and humble servant, 
  A    DISSERTATION.




             Notwithstanding Ac Cy-
runche  Maligna has made its  appearance in so
many parts of the world,  has made such terrible
devastation, and has been described by so  many
authors; Vet it  is but lately that its nature rias
been well understood, and a proper mode of treat-
ment adopted.  In some parts of the world  it has
proved almost as mortal as the  plague ;  but it ic
probable the great fatality  depended more on the
improper mode  of treatment, than on the disease
itself.   Blood-letting, purging, and the antiphlog-
istic regimen, in general,  were  formerly  adopted
as an universal  practice;  no wonder  the  disease
proved a fatal one.—If  the same absurd  method
was now in vogue,  we should have sufficient rea-
C 
                    t  6   I
son to dread its appearance among us.   Dr. Foth-
f-r-jil'l wrote the  first treatise on  this disorder in
England, and proposed a  more  rational method
of treating the disease, than was before practiced.
He condemned blood-letting, and the antiphlogis-
tic regimen, till which time the  lancet  proved as
fatal as the guillotine in the days  of'Robespierre.
   The many opportunities which have occurred
to me, since I commenced my medical studies, of
seeing this disease in its different  stages, and  the
successful mode of treatment, which I  have seen
pursued, induced ine, to attempt the present imper-
fect (ketch.
  The Cynanche Maligna has been denned a pu-
trid,  remittent fever, accompanied with  an  ulcer-
ated sore throat,  or with  an inflammation of  the
mucous membrane,
  It  is  a matter  of dispute among  physicians,
whether it is an universal  or  local  disease.   Dr.
Rowley says, it is a local  one,  and supposes  all
the terrible symptoms attending it, to be the effect
of an absorption from the ulcerated fauces.   This,
however,  is not probable ; for it is sometimes the
case,  that all the other symptoms attend the  pa-
tient, without the ulcers in the throat.
  He  also  says,  " it  is possible, after receiving
the infection, th:it,  like the small-pox,  the venom-
ous Davticles mav  circulate two, three or more da\ i 
                     C  7   ]
 m the blood, before the symptoms appear  su£-
 ciently evident,  to determine the disorder is pre-
 sent."
   If  the  particles, which  produce  the disorder,
 &Te received into  the blood, and circulate  there
 several days, before any symptoms appear, conse-
 quently,  before  the fauces become diseased, his
 hypothesis is  left without  foundation; for  it  is
 presumed that  no contagious and putrid matter
 can circulate in the general mass of fluids, for sev-
 eral days, without producing some alteration in
 them; and  if this alteration takes  place, before
 the fauces become  diseased, certainly an absorp-
 tion from them cannot be the cause of the disease ;
 but in fact, the ulcers  must be  the  effect,  and
 claim  no  title to the cause of the disorder.
   We shall consider the proximate  cause of the
 disease to be a contaminated air, received into the
 constitution  by inspiration ;  whether it  circulates
 in the blood several days,  before it produces its
 effects, I cannot say ;  but that it is in  the habit*
 either  in an  active, or dormant state, we  have no
 reason to doubt.
   This contagion, after it is  received into  the
 habit,  appears to have no limited time  to remain
 there,  before it produces the symptoms  of the  dis-
order.   One person, exposed to  the  contagion,
may be attacked with the disease several days  be- 
                   [   8  ]
fere  another,  who has  been  equally  exposed*
What this contagion is, and the manner in which
it operates, in producing its effects, I shall not at-
tempt to determine -, but  rather enquire into the;
nature of the disease it produces.
  The question, which is to be determined, and
which  is of the  greatest  importance, is, whether
the Cynanche Maligna is of an  inflammatory, or
putrid nature ; prior to which  it  is impoflible to
establifh any proper mode  of treatment: for what
would be of advantage in the one  case, would do
irreparable injury in the other.
  The fauces,  when viewed  in an early period
of the  disease, appear to be in a high  state  of in-
flammation ;   this appearance, without  attending
to the other symptoms,  often leads to  unconquer-
able error.  That inflammation can arise from de-
bility,  appears in no disease more   evident than irt
the present.   While the fauces are in  this high
State  of inflammation,  the pulse are small and
weak,  the spirits dejected, and the strength great*
ly diminifhed.   We have no  reason to suppose a
diathesis phlogistica to prevail in the system,  when
we consider,  that tonics  and  stimulants are the
only  medicines, which  will  afford relief,  which
they do very effectually, when given in sufficient
quantities.   On the contrary, "all  debilitating me-
dicines,  instead  of giving relief,  aggravate  every 
                   C   9   ]
Symptom j  and if persisted' in, will  soon prove
fatal.
   An instance of this nature will appear from the
following  narrative.  In the  winter  of  1795, I
called on  a physician  in the state of New-Hamp-
shire, with whom 1 had a  partial  acquaintance ;
he informed me, he  had  buried a daughter the
day before, about fourteen  years of age.  She died
of a disease he  called the canker-raih.  He called
in several of his  neighboring physicians,  to visit
her,  after the disease had considerably advanced ;
they  being ignorant of its  nature,  agreed  that it
was an inflammatory disease, and  must be treated
as such.  Accordingly, the antiphlogistic regimen
was rigidly pursued ■; but through  their good in-
tentions,  false theory, and bad  practice,  their pa-
tient soon expired.   Grieved at the  death of his
daughter, and fearful of the loss of two  other of
his  children,  who lay  sick of the same disorder,
like  a drowning  man, willing  to  grasp a straw,
 he requested  my opinion.   On examination, their
 throats  appeared  very  much  swollen,  and  the
 greater part  of the fauces put  on  a livid  appear-
 ance, and  in several  places  were  affected  with
 dark-colored  ulcers.   The  fcetor  of their breath
 was insupportable, and the  heat  of  their bodies
 excefhve.  Their situation appeared to me not a
 little precarious,  and his  mode of treatment add-
 ed   strength  to  my apprehensions.   The  anti- 
                   E   10  ]
 phlogistic regimen had been pursued with avidity -j
 and he informed me that he had been  very  care-
 ful to administer nitre frequently, and  that too in
 large doses; but instead of abating the  fever, he  j
 declared that  its violence kept pace with  his  pre-
 scriptions.-
   Instead of  nitre, and the  saline antiphlogis-
 tics, the most powerful tonics and stimulants were
 substituted.  It appeared strange to the good  Doc-
 tor to prescribe  such large doses of bark and wine,
 when the fever ran to such a hei0ht.   He entered
 on the practice,  however, wkn  he found all other
 means to prove  abortive, and saw the  imminent
 danger  with- which they were threatened.  1 soon
 afterwards had the  satisfaction to hear, that the
 medicines had immediate and  salutary effect,  and
 both the children had  entirely recovered, which,
 without doubt, must have  fallen  sacrifices to the
 disense, unless the practice had been reversed.
   Convinced from these  and   many  other  cir-
 cumstances, that the Cynanche  Maligna is of an
 highly putrid nature, I shall next describe the pro-
 gression of symptoms, as they generally occur in
 this disease, and then proceed to the  cure.
   Although  the attack may vary  in  some in-
 stances, yet cold shiverings, anxiety,  sickness and
 vomiting, are,  for the most part,  the first appear-
ances of the disease.  These are soon followed by
 stiffness of the neck, soreness of the  throat,  diifi-
 culty of swallowing, and a hoarseness. 
                   C   ii  3
  The  fauces, when, viewed  in this recent state
of the disorder, appear of a deep red, which com-
monly soon become affected with  small  spots  of
an ash color ;  and unless  a proper plan  of  treat-
ment be adopted, to prevent  their further prog-
ress, the parts will soon be covered  with deep ul-
cers, of a very putrid and dangerous tendency..
   The pulse  are small, weak,  quick, and irregu-
lar.  The spirits dejected,  and the strength great-
ly diminiihed.  A delirium frequently comes on
in the  evening,  at which  time, all the symptoms
are commonly aggravated, and in  the morning a
remission takes place..
   On  the second day, and  sometimes  later, ef-
floressences appear about  the face and  neck, and
by degrees spread over the whole body.  There
are some  cases  where this efflorescence  does  not
make its appearance; ai'd when it does,  is consid-
ered by Dr. Rowley as artificial.
   A coryza is often a very distressing  symptom
in this disease, which sometimes discharges a mat-
ter so  acrid, as  to corrode and inflame  the parts
over which it  passes.   We have accounts of its be-
ing of so corroding and malignant a  nature, as to
produce mortification  in the  parts of  those  to
whom it has been applied.
   These are the symptoms which  generally ap-
pear at the commencement of the disease,  which,
»f judiciously  treated before iliey have pi acceded 
                  [   .2  ]
too far,  are  very speedily removed ;  but if the
disease should be mistaken for an  inflammatory
angina,  and treated as such, symptoms of general
putrescency will  soon take place,  and continue to
increase, till  death puts a stop  to their progress.
   After, the contagion  has  been  received, and
begins to  discover itself by the  above symptoms,
it is then  the province  of the  physician to stem
its progress, and bring the disease  to a  solution
as soon as possible,
   What first demands our attention is the sick-
ness and vomiting ;  and till these  symptoms are
removed, we shall not be able to make such med-
icines remain on the stomach,  as are necessary to
remove  the disease.
   Dr. RuiVs method of administering a  vomit,
joined with calomel, is, perhaps, as  proper as any
that can be contrived to accomplifh  this end.  By
the operation  of the  puke, a  quantity  of viscid
phlegm,  and bile, which is the cause of the sick-
ness,  is thrown  from  the  stomach,  and the calo-
mel,  by  cleansing the  intestines of  any putrid, or
other offensive matter, which  they  may  contain,
prepares  them to receive whatever  medicines are
thought proper  for  the subsequent part  of the
cure.
   Although a lenient  purge  mould prove  in
some degree debilitating for the time, yet the ob-
vious advantages resulting from a gentle operation, 
                   C   «3   ]
will  more  than balance any  objection which can
be brought against it.
   In what manner calomel  operates,  to  entitle it
to a preference in this disease,  I cannot tell; but
when used in a gargle, it appears to operate in
such a manner on the  fibres of the parts,  as to
cause  a  discharge of their  acrid  contents, more
than any other medicine ; perhaps the same may
be said of  it  when passing through the intestines.
   One  veiy drmgerous practice, which is adopt-
ed by  some,  requires particular  attention, viz.
the checking too  suddenly with opium,  the purg-
ing^ which sometimes  take  place in  this disease.
These purgings are commonly the effect of a quan-
tity  of putrid, acrimonious  matter irritating the
intestines,  the danger of which, if too long retain-
ed,  is very evident.   Whenever this purging takes
place, it is neceffary, as soon as  possible,  to put
a  stop to it,  which must be done  by  some gentle
antisceptic laxative.   If detained  by opium, the
putrid matter will  either be absorbed  into the
system,  or by its irritating nature will soon  pro-
duce an inflammation in the  alimentary  canal;
the  consequence  of which  k  h  unneceffary to
mention.
   After  the stomach and  Intestines  have been
cleansed (when this  has been  deemed neceffary)
oar  ne.v.t indications  are to support  the vis vilae,
Stud  ;.f.:;.avd the fluids against putrefaction. 
                   C   i4  3
   Several  particulars are neceffary to be attend-
ed to in fulfilling these indications.
   The saliva,  which, becomes contaminated,  by
passing over the ulcerated fauces, is to  be contin-
ually ejected, and  not  allowed to  pass into the
stomach.
   The cleansing the  ulcerated fauces, bv  some
astringent antisceptic gargle, cannot be too strong-
ly inculcated.   The  advantages  of this  practice
are sufficiently evident.
   The room,  in which the patient  is  confined,
should be kept continually ventiltated  with  fresh
air,  which greatly revives the sick,  and abates the
tormenting  heat with which  he is afflicted.  Un-
less this be attended to, the air in  the  room  be-
comes very  noxious,  and  tends, not only to  in-
crease the putrid symptoms of  the patient, but
greatly exposes the attendants.
   The changing the bed-clothes, and body linen,
should be particularly attended  to.  The  patient
should be kept as cool as circumstances will admit;
want of attention,  in this  particular, is a frequent
and  fatal error.
   To  ensure success,  each of those  particulars
are strictly to be attended to ;  but what we are to
consider  our chief support, or sheet  anchor, is
the Cortex Peruvianus.  This  medicine has been
thought by some to be  injurious in the Cynanche
Maligna.  This opinion has arisen,  either from cu 
                   C   '5  ]
 ignorance of the nature of  the disease, or from a
 dependence being placed on too small a quantity.
 Administering the bark in the  form of a tincture,
 or in very small doses in substance, is only trifling
 with the lives of our  patients, and plunging  into
 discredit one of the most  noble medicines in the
 materia medica.
   Dr. Rush,  in his account of the Scarlatina An-
 ginosa, as it appeared in Philadelphia in the years
 1783 and  1784, observes, that he saw but three
 cases which required the bark as an  antisceptic,
 and thinks it sometimes  hurtful  in  the disorder.
 These observations,  however, I do not think have
 the least tendency to lessen the  character of the
 medicine in this disease.  Whoever will take pains
 to read this  account  of the Scarlatina  Anginosa,
 will readily perceive that it was blended with the
 symptoms  of an inflammatory angina, and was of
 a much less malignant nature than it  generally is.
   He  observes,  that the symptoms of  several
 of  his patients  were so  inflammatory   as  to
 require blood-letting ; and in one  case he was
 obliged to  perform the operation twice.  It would
 be  as reasonable to  suppose the  bark would be
 injurious in thfe typhus gravior  of Dr. Cullen,  be-
cause it had been known to increase the symptoms
of a violent synocha.
  In  the account  of the  Ulcerated Sore Throat,
communicated  to the Massachusetts Medical Soci- 
                   [   i6   2
ety, by the Hon. William Bayli-<, :hr:c is rio rnen*
tion made of the bark ; but I think  v/o i.ieve sea-
son to suppose,  if he had used it in some wt.es,
in sufficient quantities,  he would have discovered
a medicine, which he declares he  never wa» ies-
timate enough to find*  He  says, " on the thud
or fourth  day  of the disease, should  the pulse
grow  weaker and softer, the face and  neck put on
a very bloated appearance, respiration  grow more
laborious, with  a  peculiar  kind of catching the
breath, or double  breathing,  and an  anxiety  o£
five or  six  minutes continuance come  on three
or four times in an hour, such as induces  the pa-
tient to bite his hands and arms, death may be ex-
pected on the fifth day.  This  alteration in the
disorder is sudden, and not  to be  foreseen ; and,
when it takes place, I never was  so  fortunate as
to find a medicine, that  would  prevent,  or even
retard the fatal catastrophe.  The skin, after death,
would immediately  turn  very black,  and some-
times, previous thereto, would be  spotted in ma-
ny places with green."  Is  there a medicine in the
materia medica, which  would  have been  so like-
ly to  put a stop to these  putrid  and  fatal symp-
 toms, as the Peruvian bark?
   The bark, when  used  in this disease,  is to be
given from  the beginning in substance,  and in  as
 large quantities as the age of the patient, and othrrr
 circmn-Lanccs, will admit.  Dr. Cullen says, th<t 
                   C   '7  3
rrood effects are to be expected from it almost on-
ly- when given in  this way.  It should always be
given in vinous or distilled spirits, when these can
be procured ; in this way the less quantity of bark
is required ; it sits" more easily upon the stomach,
and  its effects are more sudden.
  Dr.  Moore, speaking of the Cynanche Malig-
na, says,  " I have seen the weakness  so great in
this disease, that the patient could not  sit up in
his bed, that his throat might be accurately exam-
ined, without danger of fainting ; yet after a  few
doses of the bark, mixed  with  Port or Madeira
wine, his  pulse  became stronger and  fuller,  and
he raised himself with little assistance, and sat up
firmly ; but in others, in  nearly the  same situa-
tion,  double the  quantity  of  the bark  taken in
any  of the simple waters, hardly produced  the
same effect, and never so soon : and where  wine
was not to be got, or could not be afforded, rum
or brandy diluted seemed in all respects equivalent." %
  The bark, wdien given in wine,  or other  spi-
rits,  may  be acidulated with the oil, or elixer of
vitriol; care being taken not to make it too strong
of the acid.
   Wine  or other spirits may be allowed in every
stage of the disorder, the great  heat of  the body
being no contra-indication.
   This is the manner  in which I have genera':!)
seen the disease treated by  a  very judicious  and 
                    [   '8   3
fortunate practitioner,  whose  singular success in
this  disease, has  established  the justice  of his
method.
  There are not many disorders,  for which there
have been  more nostrums in  vogue, than for the
present j and there  have been no practitioners so
unfortunate as those who have ever been trumpet-
ing abroad and publishing to the world the infal-
libility of their quack medicines.
  In time of great danger,  help is always desira-
ble ; but people are too apt to apply for assistance
tp those ignorant impostors, who are for the  time
in great, though undeserved  reputation ; or with-
out the advice pf a physician, apply  some patent
medicine,  from a  belief that  it can cure  almost
every disorder ;  for the fact is,  this kind of medi-
cines are generally inclosed in papers, filled  with
pompous  descriptions of their  many and singular
virtues, which a well bred physician would call a
catalogue  of impositions  and lies ;  for  they are
often declared to cure disorders requiring  exactly
opposite treatment.
  It cannot" be doubted, that our government
are  too condescending, in granting patents for  med-
icines.   The authors are,  in general, very illiberal
and  ignorant  men ;  and I  do not  believe  ifyjit
there ever  was an hontst physician, who  was a
man of real knowledge, that would permit  a  mod.
icine, which  would be of advantage to his  fellow 
                   C   «9  3
 creatures to remain a secret;  for he  would  wel|
 know that a judicious and well meaning physician,
 who  wished to avoid the breach of the sixth com-
 mandment, would not  venture to administer a
 medicine he knew not what, unless from  good au-
 thority, he was convinced  that it  was a  safe and
 useful one ; but this, with a very few exceptions,
 seldom happens; for those quack medicines which
 in their infancy  have such a  splendid character,
 soon  contract their  orb,  which was  almost un-
 bounded,  to a point of detestation.  And it is my
 humble opinion,  that  millions have  fallen  sacri-
 fices  to the unhappy trust which they  have  placed
 in this description of medicines, who might have
 had  their lives preserved if they would  have follow-
 the  directions of some fkilful physician.
   It appears to me very probable,  if those gentle-
 rnen  of pretended faculty could see the portrait  of
 their characters perfectly delineated, they would  be
 willing if " possible,  to  retract their  past imposi-
 tions  ArvcLcrimes, and live the remainder of their
 days   in jsorfowful  repentance.
  v Perhaps this may be considered  too uncharita-
-Mc;  buf what crimes can be  more heinous ? Do
 fj^ey mot impose upon mankind the belief that they
"Will soon be cured by certain  medicines, of which
 theVAre the authors; which very belief,  with the
       w of those measures which should have been
        for  their  recovery, deprives them of  ih-iT
        what is this but indirccl murder ? 
                   [   26  3          ;
   Do they not exact from the hand of the indi-
 gent  the last shilling, for that which will be of no*
 advantage to tftem ?  What is this but theft ?
   Do they not pu^h themselves forward into poor
 distressed fam lies, and by their insinuations' and
 vndcrband intrigues often persuade them to dismiss
 worthy and skilful physicians,  with a prornife that
 they will cure  them in a very short  time ; and if
 they do not succeed, do they not attribute  the want
 of  success to the improper prescriptions  of their
 predecessors,  which they  declare have produced
 some  fault in the constitution,  which no medicine
 can remove ? (They are very careful, however, to
 keep  this to themselves, till they see death at  the'
 door,  or think their bills will" ballance  the estates
 of their "patients.)  What-is this but theft, slander
 and murder combined ?   '.  ■
   If  what has been  advanced be fiate.( and none
 but the  aforesaid description of men  will think
 otherwise.)  it  is  undoubtedly the duty-.of every
 physician, who wishes to consult the welfare  and
happiness of  his patients,  to warn-..them of the
 danger of prescribing  medicines, the -virtues  and
effects of which they arc equally ignorant,  without
medical  advice,  which is always, proper  when it
can be had from any but those of the above clasa
in which case, it would  be more  safe to  trus'tto
nature herself, though in this disorder she is Vat
a very poor agent.   Jpiru&

 
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