NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service OBSERVATIONS/ «r a / ON THfi SCARLATINA ANGINOSA, « COMMONLY CALLED THE ULCERATED SORE THROAT. BY JAMES SIMS, M.D. Prefident of the Medical Society in London. ——«eas<9@9©«e=— WITH SOME REMARKS, BY THOMAS BULFINCH, M. £>, ci>ec0nH euttton. boston : printed by munroe & francis, ■for Hall and Hiller, And fold at their Bookftore, No. 53,. Cornhill.—1803. 41. . EVERT family (efpedally thofe in the country) t jo wifh to be delivered from the fatal effecls of that dreadful malady, the throat distemper, will do well to be poffeffed of this invaluable Pamphlet. The perfon, that . thus recommends it, has repeatedly experienced the happy effecls refulting from an adherence to its direclions, in feveral inflames in his own family (fome, when the diflem- per threatened to be of the mofl fatal kind) and among' many friends and connexions, none of whom have found it fail in a Jingle inflance. He was affured by Doclor Bulfinch, fome few montht before his deceafe, that he had never loft a patient with this diftemper, fince he had praftifed as recom- mended in this pamphlet. % observations ON THE SCARLATINA ANGINOSA, or SORE THROAT. HAVING, when in London, experienced great benefit from the ufe of the troches of nitre, in a fore throat, I determined, whenever an opportu- nity fliould 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 efficacy of nitre by a fair experiment. A lady, who had for a num- ber of years been fo unhappy as to labour under a violent inflammation of the tonfil glands, which had always fuppurated and broke, requefted my affiftance. My vifits at firft were without fuccefe. The inflam- mation came on with fuch rapidity, that it was not eafy to check it. At length, however, I had the hap- pinefs of obtaining my wifhes j for remonftrating to her that timidity defeated my prefcriptions, fhe prom- ifed 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 wlfdle tea-fpoonful on her tongue, to let it diffolve gradually, and to repeat it every two or three hours. She complied ; the confequence was, a moft copious flow of faliva ; which, by abating the inflammation, not only terminated her diftrefs at the time, but en- tirely freed her from the diforder. According to her * . own [ 4 ] own 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 tor-, mented with the like diforder for three or four win- ters fucceffively ; but ufing the nitre, as before direct- ed, fhe has been fo far relieved, as not to have had arj 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 fuffi- ciently teftify to the circumftances as related. Happy in the fuccefs of thefe trials, I have often wiftied for an opportunity of making the communication. I have been deterred, however, by the fimplicity of the pre- fcription. Nor ftiould I have ventured, at this time, to offer my fentiments to the public, if I had not been emboldened by a fomewhat iimilar communication of the much celebrated Dr. James Sims, prefident of the Medical Society in London, on the fcarlatina anginofa. a This valuable paper is in the thirty-fecond article of? the firft vol. of the Memoirs of the Medical Society of London. c; Without attempting to, propofe any conjectures on this head," fays the doctor, (viz. on fome peculiar fymptoms juft related,) " I fhall 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 fhall be mentioned hereafter." " I had C 5 1 ^ 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 fhorten 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 poffibly bear ; I continued five hours inceffantly 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 efii- cacy, I from time to time fwallowed 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 v/ould 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 the sefophagus. So intent was I in profecuting my fcheme, that I believe I would have perfifted until I had ufed the whole of the acid, had I not been conftrained to leave off by exceffive 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 t 6 ] cafes of angina, where I was confulted ; nor have I had, as yet, re.ifon 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 recourfe 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 ; and even children, from two to three years old, have fwallowed much above two hundred drops of the acid in twenty-four hours. ■l As I had always feen the greateft 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 ^ infiance, with ordering it; my common prefcription 9' confuted 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 fmgular advantage ; and befides, there was frequently a naufea and confiderable vomit- ing attending the beginning of the difeafe we are now treating of. " I fhould C 7 J " 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 foon found reafon to have fuch complete reliance, that m 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 fpiritof 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 flefh, 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 laid 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 mifchief, where half a pint would have been highly ferviceable. In all the*fe cafes, we Ihould ever keep in mind that our intention in order- ing it, fbould be to raife the ftrength, and that nothing debilitates C 8 ] debilitates fo much, as too large a quantity of it, which is extremely vifible in a perfon who is intoxicated. " Having proceeded in this manner during the rife and height of the difeafe, I found it neceffary to change my plan, as foon as the height was paffed. 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 perfifted in, or increafed with a view to keep up the finking 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 the tonfils or paro- tids, with acute pain, came on, and the fcarlet eruption re-appeared 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, diminiftiing, at the fame time, the fpirit of vitriol, which feemed now unneceffary, 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 j the truth is, I place very little confidence in them ; not but 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 like wife 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 differvice, 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 j but even this could be ufed in general only feldom ; a very frequent ufe of it, or any wafh, 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 advan- tage, 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 gentle perfpiration did good, and ufually attended the turn of the difeafe, yet great fweats were almoft ever pernicious. " With refpect to expofure to air, I found this dif- order, when the efflorefcence was confiderable, to agree perfectly with the meafles, it being abfolutely requifite 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 ; but when the efflorefcence was lefs, the precautions were unneceffary, nor were they defired by the patient. It B is C 10 ] is to be underftood from hence, that the expofure to cool air did not feem 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 at- tention to the paflions and affections of the mind was exceedingly 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. The 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 infufiiciency of the method." The other inftance is omitted, on account of its length ; though it tends greatly to fhew 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 praftice had ferveel to inculcate, that it is exceedingly dangerous in an epidemic to deviate in any meafure from a practice which hae been foundfuccefsful. A phyfician, it is true, fhould be attentive to every, the moft minute circum- ftance ; but this attention fhould be of the fpecula- tive, not adive kind, until fome inftance of bad fuccefs fhews that his former mode requires achange; inwhich cafe, £ » ] cafe, the attention he has bellowed 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 inftant, 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 flop, 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 wil- ling 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 the late [ I* 1 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,hehas failed of fuccefs, and one of thofemerely 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 unneceffary previous to the exhibition of the medicine, obferving 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 adminftring 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 fimple water, with the addition of fixty 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 occafionally * Kurfa ftould be cautious not to drop any of the medicine on the clothes or linen of the lick. 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 dofes of rhubarb and fait of wormwood, neutralized by fome of the vi- triolic mixture; or given caftor oil or brimftone and molaffes 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 difinclination to the vitriolic medicine, and have then either abated its ftrength, or given it with either one or two tea-fpoonfuls 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- fnent. Where any external tumor of the throat takes place, by applying an embrocation of oil and fal vola- tile, 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 mould I have been to communicate thefe obfervations fooner ; but deeming myfelf not entitled to recommend, though from the beft authority, what I had not fufEciently tried, I have been deterred from doing it ; but now thinking myfelf fully juftified, from the trial of the medicine, can with pleafure, fatis- faction, and confidence, recommend it to thepublick. I fhould not have thought it neceffary 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, I gave her an emetic, which operated kindly; but on the day following, finding a general efflorefcence, with fome confiderable degree of fore throat, 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 dif- charges ; and by continuing the mixture, fhe amended daily, complaining only of weaknefs and tendernefs of her body, particularly in her legs and feet. So far relieved was fhe, 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 C iS ] evening of Thurfday, the fixth day of her diforder, I found the large front door of the houfe o^en, and the wind, which was very cold and difagreeable,- paffmg up the ftair cafe, 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 ; and fo it happened ; for from th.i: 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 fubrifuge 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, fhe took her anodyne, and had a good night. On examining the blood, the next morning, with Mr. V****, it appeared fo extremely tenacious and fizy, that though preffed with the point of a fmall knife feveral times, it did not yield in the leaft to the impreflion. 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, diffolved, putrefcent ftate, to fuch [ iS ] fuch an one as to be liable, by the iiighteit redden tj to induce inflammation ? »•■ Is it not evident, that a new fever was hereby generated, foreign to the original diforder ? And Is it not from hence advifeable to recommend a tri: 1 of the ftate of the blood, by drawing an ounce or two, into a fmall cup, on the feventh or eighth day of the d'.feaii;, or whenever fuch a ftricture h complained of, whereby the further ufe or dhufe of the medicine may be happily determined ? As the doctor obferves, that the '; difeafe was totally at a ftand during fome days of fharp froft that happened, but recovered new vigour foon after that was over," does it not feem probable, thr.t if the cold., in the inftance before mentioned, had been applied fooner, it would have had a tendency rather to expe- dite than protract the cure ? He farther fays, " I never £w any danger attend the* diforder, except where there were ulcers of the throat." This fhews the pro- priety of ufing the medicine early in the diioafc, to prevent their formation. Having now related what I had to offer on this fub- ject, I {hall only add, with the doctor, " that having written in the hours of leifure taken from bufine£, I hope I may le excufed the irregularities apparent in its compofition j" efpecially when I add, that th.5 poor girl beforementioned is entirely out of dange:; and that the reception this may meet with, may ferve as an encouragement to offer fome obfervations on different fubjeets, equally deferving of attention. Bo/ton, January 19, 1796. FINIS. ^ A. I v - i'&Wi!