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35 
NATIONAL LIBRARY OF MEDICINE
             Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
             Public Health Service 
 
 
OBSERVATIONS
ON THE
SCARLATINA  ANGINOSA,


           COMMON L'Y CALLED


   Tie  Ulcerated  Sore  Throat.


      By JAMES  SIMS,  ilf.D.
         Prefident of the Medical Society in London.


           With fome Remarks

                   b Y

  THOMAS  BULFINCH, M. D.

Printed and fold by Samuel Hall, No. 53, Cornhill, Boston.
                   1796. 

A
-•v.  ■-. 
OBSERVATIONS
                    ON THE

 Scarlatina  Anginofa, or Sore Throat.


        HAVING,   when  in  London, experienced
        great benefit from the ufe of the troches of
        nitre,  in a fore-throat,  I cleterrnined, when-
ever an opportunity fhould offer, to pufh  the trial of
it to its greateft extent.  And judging that its benefit
arofe from the fimple nitre, it was my intention to ufe
it  as limply as poflible.   Soon after my return to
America,  I  had an opportunity of afcertaining the ef-
ficacy of nitre by a fair experiment.  A lady, who had
for a number of years been fo unhappy as to labour unr
der a violent inflammation of the tonfil glands,  which
had  always luppurated and broke, requefted my affift-
ance.   My  vifits at firft were without  fuccefs.   The
inflammation came  on with fuch rapidity,  that it was
not  eafy to check it.  At length, however, I had the
happinefs of obtaining my wifhes ; for remonftrating
to her  that  timidity defeated my prefcriptions,. fhe
promifed to follow them implicitly in future.
   I  then  gave her  three or four drachms of nitre,
powdered very fine, and coloured with a few grains
of cinnabar, directing her to lay the half, or indeed  a
whole  teafpoonful  on  her  tongue, to  let it diffolve
gradually, and to repeat it  every two or three hours.
She complied ; the confequence was, a mofl copious
flow of faliva; which,  by  abating the  inflammation,
not only terminated her diftrefs at the time, but entirely
freed her from the diiorder.  According to her own
                                      information, 
                    C   4    ]
information, thirty years have already elapfed without
its return.
  Pleafed with  my fuccefs  on this fair trial, I have
continued the ufe of the powder  in many inftances,
and to very great advantage ;  particularly in the cafe
of Mrs. W *■ * • *.   This lady had, I may fay, been
tormented with the like diforder for three or four win-
ters fucceflively;  but ufing the nitre, as before direct-
ed, Ihe has been fo far relieved, as not to have had any
return of it, for the laft nine years.  I could enumer-
ate other inftances of like fuccefs ;  but  the perfons
already mentioned being ftill living,  they can fufh-
ciently tcftify to the circumftances as related.   Happy
in the fuccefs of thefe trials,  I have often wifhed for an
opportunity of making the  communication.   I have
been deterred, however, by  the fimplicity of the pre-
fcription.  Nor mould I have ventured, at this time,
tO ufFci my fcntimcntp to the publick,if I h^d not been
emboldened by a fomewhat  limilar communication of
the much celebrated Dr. James Sims, prefident of the
Medical Society in London, on the fcarlatina anginofa.
This valuable paper is in the  thirty-fecond  article of
the firft vol. of the  memoirs  of the Medical Society
of London.
   " Without attempting to propofe any conjectures
on this head," fays the doctor, (viz. on Jome peculiar
fymptoms juft related), " I (hall  proceed to defcribe
the method of cure of the firft fpecies of fever already
defcribed, and which I call the fcarlatina anginofa,"
(or in this country called the fore-throat diftemper),
  ' premifing,that but two perfons died out of above two
hundred, in whom it was ufed ; both of  which cafes
 fball be mentioned hereafter."
                                            *? I had 
[   5    ]
  *c I had been myfelf every winter, for many years,
liable to one  or  more attacks of the inflammatory
angina, for  which I had ufed many methods of cure
in vain, the diforder running its regular courfe in
fpite of all  my efforts ;  and to fhew that thefe were
not feeble ones, I fhall only mention, that I once had
about forty ounces of blood taken from my arm in the
fpace of eight hours, without its feeming in the leaft
to ftiorten the complaint.   At laft,  about ten years
ago, I  refolved  to try what the vitriolic acid would
do in the cafe : I therefore, on the next attack,  fent
for two ounces of the oil of vitriol, and mixing part
of it  with water,  I made  as ftrong a gargle as my
throat would  poflibly bear ;  I continued five hours
inceflantly gargling  with this, until  I had ufed many
quarts of water, and  alfo  the greateft  part  of the
acid.   That I might give the gargle the greater effi-
cacy, I from time to time, fwallovved as much of it as
I found my ftomach would receive.   The defign I
had of fwallowing  part of  it, was my reafon  for
choofing this acid, as I knew the ftomach would bear
a much greater quantity of it, than any other aftrin-
gent we are  acquainted with,  and  believe we cannot
apply a gargle fufficiently to the difeafed part, without
letting fome of it pafs into  theaefophagus.  So intent
was I in profecuting my fcheme, that I believe I would
have perflfted until I had ufed the whole of  the acid,
had I not been conftrained to leave  off  by  exceflive
faintnefs and fatigue.  When I had done, the inflam-
mation  had entirely fubfided, and my throat felt quite
parched and fhrivelled.   From that time,  I  have not
been once attacked  by the difeafe.   My fuccefs in
this cafe led me to prefcribe the fame acid in all other
                                             cafes 
                    [   6   J
cafes of angina, where I was confulted ;  nor have I
had, as yet, reafon to repent its exhibition.
  " In this courfe of practice,  however, I foon came
to rely more upon its inward exhibition than upon its
ufe  as a gargle.  In the prefent epidemic,  therefore,
I naturally had  fecourfe to a remedy fo  often tried,
and found fuccefsful ;  my common prefcription was
two ounces of tincture of rofes, a drachm of fyrup of
lemons,  and fpirit  of  vitriol twenty  drops,  or as
much as  could  be  added  to  the tincture without
making it too highly acid for the particular patient
it was prefcribed for.   This draught was ordered to
be taken  by an  adult  every hour and half,  or every
hour,  and even oftener, according to the exigence of
the  cafe j  and even children,  from two to three years
old, have fwallovved  much above two hundred drops
of the acid in twenty-four hours.
  ct As  I had always fccn the  grcatefi: advantage in
putrid or  malignant  difeafes  from the ufe of gentle
laxatives, and have ever found rhubarb moft confonant
to the bowels of a Londoner, I began, in the very firft
inftance, with ordering it ; my common  prefcription
confided of  equal parts of rhubarb and falpolychreft,
of which mixture as  much  was taken as  procured
about two motions a day.   Having already  faid that
the patients  in this difeafe were not  at all  inclinable
to coftivenefs, the exhibition of laxatives may feem to
fome  unneceffary ;  but I muft remark, that in moft
putrid fevers the cafe is the fame,  yet their ufe feems
ever attended with lingular advantage  ; and belides,
there was frequently a naufea and confiderable vomit-
ing attending the beginning of  the difeafe we are
now treating of.
                                        " I Ihould 
                    C    7   ]
   " I  Ihould  perhaps  have mentioned firft,  that
wherever this naufea took place, I always ordered a
gentle emetic of ipecacuana wine to be taken inftantly,
which ever  gave confiderable relief ;  this  remedy,
however, was fcarcely ever given but in that particular
circumftance,  and therefore  cannot  be enumerated
among thofe commonly ufed, as it was but a few  cafes
to which I was called in time to prefcribe it.
   " Upon the  above-recited draughts and  powders,
I loon found reafon to have fuch complete reliance,
that in  many cafes  I  never once varied them ; and
even where I did make an alteration in them, it was
fuch as contained their moft efficacious parts.  Thus,
as the difeafe proceeded, I fometimes ordered a ftrong
decoction of the bark to be fubftituted for the tincture
of rofes ; and to this, if the pulfe were very weak, I
added fome cordial confection, and ftomachic tincture,
ftill, however, retaining as  much of the fpirit of vitriol
as I thought convenient, and perfifting in the ufe of
the eccoprotic powder.
   " During  this whole courfe, I ordered the patient
to eat moderately of any food that the ftomach feemed
to relifh, not excepting broth or flelh, and to drink a
little wine, mixed with water, if  they felt at all  low ;
or porter or ale, if they feemed more agreeable to  their
palate, which was often  the cafe.  I have faid a little
wine, becaufe a large proportion of the fufferers being
very young,  did not feem to require any ; and I  have /
frequently obferved,  in putrid cafes, a large quantity
of wine do great mifchicf,  where half a pint would
have been highly ferviceable.  In all thefe  cafes, we
fhould ever keep in mind that our intention in order-
ing it, Ihould be to raife the ftrength, and that nothing
                                        debilitates 
                    C    *   ]
debilitates fo much, as too large a quantity of it, which
is extremely vifiblc in a perfon who is intoxicated.
  " Having proceeded in this manner during the rife
and height  of the difeafe, I found it  neceflary to
change my  plan,  as foon  as  the height was  pafTcd.
This was a  point of the treatment as  needful to be
known, and exactly attended to, as any  other in the
malady ; for as foon as the  pulfe, about the lixth day,
began to fall  to the natural  ftandard, if the  cordial
medicines and regimen were perlifted in, or increafed
with a view to keep up the linking pulfe, many vexa-
tious or even dangerous confequences enfued ; a new
fever,  often more violent than the firft, was raifed, a
great fwelling and inflammation of thc tonlils or paro-
tids, with acute pain, came on, and the fcarlet eruption
reappeared as copioufly as before.  In adapting our-
felves to this change, feemed one of the niceties in the
treatment of the diforder ; but as the change of ap-
pearances have been already pointed  out, I fhall not
recapitulate it.   Suffice it to fay,  that as foon as
the change began,  I always fubtracted fomewhat from
the wine and  cordials, and quickly prohibited them
entirely, diminilhing, at the fame time,  the fpirit of
vitriol, which feemed now unnecefla'ry, and  giving
the rhubarb  in fmaller quantity, and relying,  during
the  period of amendment, upon gentle, nourifhing
diet and broths, as the only medicines,  except where
fome particular fymptom feemed to require attention.
I have as yet faid nothing of gargles, liniments and**
blifters ; the truth is, I place very little confidence in
them ; not b»t that I have  tried them repeatedly.
At firft, I always ordered a gargle to be ufed of tincture
of rofes, with fome fpirit of vitriol, or acid of fea-falt.
                                       I afterwards 
C   9    ]
I afterwards  tried a folution  of alum, vinegar,  and
other aftringents ;  I  have likcwife ordered milder
ones, as fage or balm tea, or barley water; but cannot
fay that I have found much benefit from any of them :
On the contrary, when there were  many ulcers  and
floughs in the throat, I think  I have feen them of
diflervice,  if  much ufed.   The only gargle that I
think I have feen any fervice from, is brandy, with
a little water, or frequently without any mixture what-
ever ;  but even this could be  ufed in general only
feldom j a very  frequent ufe of it,  or any  walh, or
indeed any conftant exercife of the parts,  as in ex-
puition,  feeming to be prejudicial.   As to the fumes
of hot liquids, drawn in  with the breath,  I can fay
little,  having only in two cafes ordered the  vapour of
vinegar and water to be ufed, with no apparent bene-
fit ;  though I have prefcribed it. with great advantage,
in other cafes of quincy affecting the breathing.
  " Of bleeding, much need not be faid.
  " Strong purgatives feemed  at leaft as objectionable
as bleeding.
  " The fame may be faid of fudorifics ; for though a
gentleperfpirationdidgood,and ufually attended the turn
of the difeafe,yet great fweats werealmofteverpernicious.
  " With refpect to expofure to air, I found this  dis-
order, when the efflorefcence was confiderable, to agree
perfectly with the mealies, it being abfolutely requilite
to confine the patient  to his bed,  and to keep the
room moderately warm with fire.   In this  cafe,  the
drink  was allowed  to be a little warmed, which I
found was moft pleafing to the patient's palate j  but
when the efflorefcence was lefs,  the  precautions were
unrtcceflary, nor were they defired by the patient.   It
            B                                   is 
                   C    >°   ]
 is to be underftood from hence, that the expofure to
 cool air did not fecm at all to depend on the ftate of
 the angina;  for where  there was little of the fcarlet
 eruption, and the patients were low, I have found them
 evidently relieved by taking them out of bed, and
 having the air of the room cooled.   A ftrict attention
 to the paffions and affections of the mind  was exceed-
 ingly requifite in  all, but particularly in thofe  beyond
 the age of puberty.
   " After giving  this account of the method purfued
 moft fuccefsfully in this difeafe, I fhall  now mention
 the only inftances in which I knew it to fail.  Thc
 firft cafe of a young lady, about fixteen years of age,
 who was fo obftinate,  that  from the very firft,  fhe
 would fcarcely ever obey any one direction given her ;
 nay, fhe carried this fo far as to boaft to  her  fchool-
fellows, that  fhe  would  not.  She had addrefs and
cunning enough to fecrete moft of her medicines, and
to perfuade her attendants,  that fhe had taken them ;
and on the fifth day, fell a victim to her own miftaken
opinion, rather than the infufficiency of the  method."
   The other inftance  is omitted,  on  account of its
length ;  though  it tends - greatly  to Ihew a candid
acknowledgement of an  error in the doctor ;  for he
fays, " From this cafe I was more firmly perfuaded of
a maxim, which my whole former practice had ferved
to inculcate,  that it is  exceedingly dangerous in an
epidemic to deviate  in any meafure from  a practice
which has been found fuccefsful. A phyfician,it is true,
Ihould be attentive to every, the molt minute circum-
ftance ; but  this  attention  Ihould be of the fpecula-
tive, not active kind, until fome inftance of bad fuccefs
fhews that his former mode require* a change; in which
                                             cafe, 
cafe, the attention he has beftowcd will  furnifh him
with that change without the hazard of repeated trials.
  " There was one fymptom which I faw, in feveral
cafes, follow the crifis of this difeafe, and which de-
ferves  to be particularly noticed.   This was a moft
inconceivable degree of languor, which  attacked the
patient in an inrtant, when all diforder feemed almoft
gone ; it was without pain or uneafinefs ; nay, I may
fay, without dejection of fpirits ; for although I have
known fome take a folemn leave of their families, yet
it was with the utmoft tranquillity  ; and  on being
affured by me, on  my arrival, that it was unattended
with danger, they have continued  for feveral hours,
whilft  it lafted, converfing with thofe about them in
the moft placid, cheerful manner.
  " A watchmaker gave me  the  beft defcription of
this, by telling me that he felt as if all his inward works
were going inftantly to ftop,  his main fpring of life
being entirely  run down.  I am inclinable  to think,
that this feeling is connected with the angina,  from
having myfelf fuffered  it after one of the  attacks of
that diforder, which for many years I was fubject to.
As there were no other fymptoms but the mere languor,
I found proper encouragement  given to the patients
themfelves—and fome gentle cordials prefcribed, in
order to fatisfy them, and the  by-ftanders,  who were
more alarmed than the fufferer, together  with a little
time, a medicine that cures oftener  than we are willing
to acknowledge, always got the better of it."
  Having felected fome of the moft material obferva-
tions of the doctor,  I now take the liberty to  relate
the trials made in confirmation of them.   Although it
is well known that the world is greatly indebted to thc
                                              late 
                   [    12   ]
late celebrated Fothergill, Huxam, and others, for their
very valuable publications,  yet no one has written fo
fully and decidedly as Dr. Sims on this fubject, who goes
fo far as to fay, that in two inftances only, out of two
hundred, he has failed of fuccefs, and one of thofe merely
by her own imprudence.   Led, therefore, to the trial
recommended by him, I have the happinefs to fay, that
his method has anfwered my moft fanguine hopes and
expectations, having never failed me of fuccefs  in any
one inftance, but encouraged me to recommend it, with
only a few deviations.   To make thofe clear,  I will
relate them in their order.  When called upon early,
on the firft attack of the diforder, if naufea and foulnefs
of ftomach and bowels indicated, I have endeavoured
to cleanfe them by a gentle  emetic and  cathartic,
calculated for thofe  purpofes ;  but have of late  found
them frequently unneceflary previous to the exhibition
of the medicine, obfervmg that by its delay more hurt
than good has been  done by them.  I have, therefore,
of late, gone immediately on the ufe of the medicine in
the following manner.   Inftead  of adminiftring  the
medicine in the doctor's way, by giving it in draughts,
as is the cuftom in London, I have dropped from one
hundred to two hundred drops  of * oil or fpirit of
vitriol into an eight ounce vial,  nearly full of Am-
ple water, with the addition of fixt/ or eighty  drops
of compound fpirits of lavender, directing from  a tea-
fpoonful to a common table fpoonful to be given every
two or three hours, according to the age of the patient,
and urgency of the  fymptoms.   In fome cafes,  where
the foulnefs of the tongue and fauces feemed to require
it, I have recommended fome powdered nitre to  be

  *Nurfes Aould be cautious not to drop any of the medicine on the dodfesoT
linen of the fick. 
C    13    ]
occafionally laid  on the tongue,  which  has  caufed
a plentiful difcharge of faliva, and greatly cleanfed
them.   But this, from its difagreeablenefs, cannot be
ufed but by adults.   I have carefully endeavoured to
keep the ftomach and bowels clean by repeated doles of
rhubarb and fait of wormwood, neutralized by fome of
the vitriolic mixture ; or given caftor oil or brimftone
and molalTes to children, which has anfwered with them
very well ; occafionally giving  an anodyne at night.
  About the fifth or fixth day, I have generally found
a dilinclination  to  the  vitriolic medicine, and have
then either abated its ftrength, or given it with either
one or  two teafpoonfuls  of the  tincture, or two large
table fpoonfuls of the decoction of the bark ;  and by
this  means have got down more than I  could have
done fingly.  At times I have found a ftricture brought
on  the  lungs by  the acid when given freely ;  but by
thus giving it with  the bark, or giving a dofe of elixir
afthmatic occafionally,   it  has  foon  been removed.
After giving the acid regularly to the fixth day, I have
not been folicitous for its continuance, provided  I could
prevail  on the patients to take the bark freely,  and to
fupport their  ftrength by wine and  fuitable nourifh-
mcnt.   Where any external tumor of the throat takes
place,  by applying an embrocation of oil and  fal  vo-
latile, it has foon fubfided.  During my whole practice,
I have never had occafion to bleed, blifter, or give
any  other  cathartic than what is  mentioned  above,
nor had occafion to fatigue my patients with gargles
of any  kind  whatever.   At certain times, however,
one or more of thefe methods may probably be requir-
ed ;  but as I have  generally been applied to in  the
accefs or infancy of the diforder, thefe afliftances have
not been wanted.                           Happy 
                   [    14   ]
   Happy fhould I have been to communicate thefe
obfervations fooner ; but deeming myfelf not entitled
to recommend,  though from the beft authority, what
I had not fufficiently tried, I have been deterred from
doing it ;  but now thinking  myfelf fully juftified,
from the trial of the medicine, can with pleafure, fatif-
faction, and confidence, recommend it to the publick.
   I fhould not have thought it neceflary to add any
more  on  the fubject, had not a circumftance taken
place, which not only tends  to recommend, but alfo,
at times, to difcontinue the ufe of the vitriolic medi-
cine, by fhewing its nature and effect  ; and being un-
common, deferves  to be particularly noticed.   Being
defired to vifit a girl of twelve years of age,  in Mr.
V * * * * 's family, on Saturday evening, the 2d  inftant,
to whom, having had, among others* fome flight com-
plaint in her throat, for feveral days, I gave a febrifuge
powder ; and informed the family, that I feared a fever
of a bad kind would enfue.   On the next day,  finding
her wandering and defipient, 1 gave  her an  emetic,
which operated kindly ;  but on  the  day  following,
finding a general efflorefcence, with fome confiderable
degree of fore threat,  I put her on the liberal ufe of
the vitriolic mixture.  On the next  day,  a laxity of
bowels coming on, I gave her a dofe  of  rhubarb and
fait of wormwood,  neutralized  with fome of the fame
mixture, which  acted kindly,  and checked the dis-
charges ; and by continuing the mixture, fhe amended
daily, complaining only of weaknefs and tenderncfs of
her body, particularly in her legs and feet.  So far
relieved was Ihe, that  I am confident,  fhe would foon
have regained her health, had not  an unhappy accident
taken place to prevent it, for on vifiting her  on the
                                          evening 
[    '5    ]
evening of Thurfday, the  fixth day of her diforder, I
found the large front door of the houfe open, and the
wind, which was very cold  and difagreeable, palling
up the ftaircafe, and the door of the child's chamber
being alfo open, the cold air  was thus permitted to
rufh upon her, as fhe lay afleep, with her face oppofite
to the door.   From this,  I  feared and foretold fome
difficulty  would arife j  and  fo it happened ; for from
that time fhe complained  of the increafed forenefs of
her limbs and difficulty of  breathing.   Being loath
wholly to difcontinue the mixture,  I gave  it in  lefs
quantity, and interpofed fome febrifuge powders, hop-
ing thereby to anfwer both intentions ; but on vifiting
her the next morning, I was informed by her mother,
that a cough  (which was  a new complaint)  had kept
her from  fleeping all the night ; however, as fhe  was
then afleep, I left her, with  directions to continue the
powders, which had a good effect on her bowels, though
they did not relieve her breathing.  Judging, therefore,
that this complaint might be fpafmodic, I left, in the
evening, an anodyne draught, with directions when to
give it ;  but  before it was given, I was again called,
and  finding her complaints  greatly increafed, with a
fmall, quick and contracted  pulfe,  I bled her to about
four ounces, which fhe bore well  ;  after  which,  Ihe
took her anodyne, and had a good night.
   On examining the blood, the next morning,with Mr.
V * * * *,  it appeared fo extremely tenacious and lizy,
that though preffed with the  point of a fmall knife fev-
eral times, it did not yield in  the Ieaft to the imprelfion.
   Is not  then the effect of the vitriolic mixture very
apparent,  by reftoring the  crafis of the blood, in a  few
days, from a loofe,  difTolved, putrefcent ftate, to fuch
                                                an 
C    '6    ]
an one as to be liable,  by the flighteft accident, to
induce inflammation ?
  Is it not evident, that a new fever was hereby gener-
ated, foreign to the original  diforder ?  And is it not
from hence advifeable to recommend a trial of the ftate
of the blood, by drawing an ounce or two, into  a fmall
cup, on the feventh or eighth day of the difeafe, or
whenever fuch a ftricture is complained of, whereby
the further ufe or dffufe of the medicine may be hap-
pily determined ?
  As the doctor obferves, that the " difeafe was totally
at a ftand during fome days of fharp froft that happen-
ed, but recovered new vigour foon after that was over,"
does it not  feem probable, that if the cold, in  the in-
ftance  before mentioned, had been applied fooner, it
would  have had  a tendency rather to expedite than
protraft the cure ? He farther fays, " I never faw any
danger attend the diforder,  except where there were
ulcers of the throat."   This fhews the propriety of
ufing the medicine early in the difeafe,  to prevent
their formation.
  Having  now related  what I  had to  offer on this
fubject, I lhall only add, with the doctor, " that hav-
ing written in the hours of leifure taken from bufinefs,
I hope I may be excufed the irregularities apparent in
its compolition ;"  efpecially when I  add, that  the
poor girl beforementioned is entirely out of danger ;
and that the reception this may meet with, may ferve
as an encouragement to offer fome obfervations ort
different fubjects, equally deferving of attention.
  Boflont January  19, 1796.
                  FINIS. 
 
 
Med. Hist.
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