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*.»-*•.'
 
 
/W*>~     AN  INAUGURAL J0£zr   /?
DISSERTATION
                   ON  THE

SCARLET    FEVER

                Attended with an

 ULCERATED  SORE-THROAT:

      Submitted to  the examination of the
 Rev.  JOHN  E  W I N  G,  S. T. P.  Provoft;
The Truflees and Medical Profeflors of the Univerfity of
            Pennfylvania ;  for the Degree of
      DOCTOR   OF   MEDIC IKE,
          On the Tenth Day of May A. D. 1793.
  By MATTHIAS   H.WILLIAMSON,
                    Of New-Jerfey,
Member of the American   Medical  Society  of Philadelphia.
Rather JIand uf>, ajfuted -with confcious firiJe,
Alone—than err ivitb mi/lions on t'yj-d:.
                              Churchill.
             PHILADELPHIA:
Pointed  bt -JOHNSTON tf JUSTICE, at Franklin's Head*
               No. 4I> CHE8NUT-*TR6-T»
_J 
a .m <;

,0      ■  '.  i i  U -i  -






       ■  j ii  ni i/






               ) '»'  '
1 \u
n >:n
)
' it
^ii;l} ji.i;               >('S 
T o
    WILLIAM  SHIPPEN,  Jun. M. D.

         CASPER  WISTAR, M. D.

   Profeifors of Anatomy,  Surgery, and Midwifery <

          ADAM  K U  H N,  M. D.

          Profeflbr of the Practice of Phyfic ;

      BENJAMIN  R U S H, M. D.

   Profeflbr of the Inftitutes and of Clinical Medicine t

    JAMES  HUTCHISON, M;D,

               Profeflbr of Chemiftry;

SAMUEL  POWEL  GRIFFITTS, M.  D.

           Profeflbr of the Materia Medica ;

          In the Univerfity of Pennfylvania.

   To you, Gentlemen, I feel peculiarly indebted for the
 nfeful information, which I havederived from your valuable
 Lectures ; and the many private favours received during
 my ftudies under your direction; it is not cuftom,  but a
 fenfe of gratitude, which prompts me to acknowledge,
 and thank you for the fame ;  and permit me, to take the
 liberty of dedicating to you,  this Inaugural Diflertation,
 the firft fruits of my medical education;  as a fmall mark
 of efteem and refped, due from

                 Your fincere, and obliged

                             Friend and Pupil,
M-  H» WILLIAMSON. 
(
.  i a
 
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                        A N


  INAUGURAL  DISSERTATION


                    O N  T H E


SCARLET    FEVER,   &c.
                   Definition.
        %

 A DEFINE this difeafe to be; a contagious fever, arifing
 from a Ipecific  contagion;  attended, with more  or lefs
 of an ulcerated fore-throat; and a fcarlet rednefs, on the
 external furface of the body.

   When I firft chofe the difeafe before us, for the fub-
jedl  of my inaugural diflertation, I was not aware, that,
 previous to entering upon it, I fhould be  under  the ne-
 ceflity of combating with fome of my raoft learned teach-
ers at home;  as well as, men of the firft rank in the pro-
f eflion abroad, to fupport an opinion, from which, I can
fee no room to admit, or facts to  fupport a contrary one; 
[  «   1
 what I allude to, is;  that the fcarlatina anginofa and the
 cynanche maligna of authors are one, and^the fame gene-
 ric difeafe ;  the reverfe of which they endeavour to fup-
 port ; but although I refpect their opinions in meditine,no
 lefs than their names, as  men  of deep  penetration rand
 found judgment,, yet, in confidering thefe two  difeafes,
 as different in their nature,  and  consequently in their ori-
 gin, I cannot agree,

   ift. Becaufe it anfsversno ufeful purpofe, either to af-
 certain their nature or cure.

   ad. It is multiplying unneceflarily, and improperly, the
 difeafes, now almoft innumerable, which the human race
 are daily afflidled with, and  incurring upon  themfejves 2
 and likewife, the  technical terms, which are trnly  pux-
 ^Kng to the ftudent, and fuperfluous in many parts of the
 fcience. (1)

   3d. The two;difeafes (if they are two)  are not,  nor
 cannot be diftinguifhed  in practice,  diftinclly enough to
 conftitute a generic difference, even by thofe who boldly
 aflert, that this difference does really exift.
                                                    '■w
  4th. There does not appear to me, to be any real difFerp

  (1) Note.  " Who would not be alarmed on being informed
that fiicb a formidable band; fuch a febrium cohors as the follow-
ing had invaded the earth—febris  inflammatoria, fcorbutica,
foporofa, putrida, nervofa, typhus petecbealis, fteva, fudatoria,
colliquitiva, ardens, heftica,  cephalalgia, beliofa, eryfipelacea,
 fynocha, fynochus, paludofa,  verminofa, maligna, &c. &c.  And
after being thus informed, who could be furprifed to find that
death walked with a haftened ftep through the land.-j-  To lay
hold of the occafional fymptotns which anfe from the difference
ofconftitation aod  other  urcomft$frceiftVRjttd erefit them into
new difeafes with terrifying names, burdeflB the  memory, and
 tends to darken rather than elucidate. - ' "
            f------  Nova  Febriuni
          Terris incubuit cohorsr' '•
           Semotique j>rius tarda- neceffitas
          Lethi, correpuit gradnm.    Hor. lib. i. ca nn. 7.**'
                          Moor's Medical Sketches P. 270. 
                       C  7   ]
f&te  in their nature or quality ; but, only in the degree,
pr quantity jof the difeafe.
 qui ..     iv£3!'
or; On this 1 aft point, the three  preceding principally
turn; the truth of this therefore is next to be afcertaiiu-
ed j wfeich I fhall attempt by obfervkig j        .<(_ bnuol
                                               ^libr."
   ift. That when either difeafe appears as an epidemic;it
js always  accompanied with more or fewer cafes of the
other ; which proves next ta»a. demonftration, that, they
jnuftboth arife from the famecaujfe, and; the fame caufe,
ceteris paribus, always produces the fatne effect.

  ftd. The cyhanche maligna or ulcerous fore-throat, if
it was a difeafe of its own peculiar nature, would invaria-
bly produce the fame difeafe, in all the perfons  who re-
©sire its contagion;  but this is  far front being the  cafe, .
for fome of the infected have only the fimple fcarlet  fevei*
pf Sydenham,  (2) which, is without any affection of the
throat, with a fever fo flight as to continue  bttt  a day or
two,  and is not attended with the leaft danger—in ano-
ther, it produces a more formidable fet <rf fymptoms, or
the fcarlatina anginofa of Sauvages (3)—-while a  third
will be feized with the difeafe, in its moft aggravated and
dangerous form, or the cynanche maligna—And, are we
|hen  to fuppofe, that thofe three, perfonsy all infected by
the very fame contagion, can  have three different difea-
fes?—Will one,  and the fame caufe produce three differ-
ent effects?—When the fmall-pox will produce  the mea-
zles, or the nieazles the chicken-pox, I will anfwer in the
affirmative.
 s
  3d. As the cynanche maligna often produces the fcar-
latina anginofa, or a ftill more mild form of the difeafe j

  (2) See  Sydenham's works.
  (3)  Sauvages J^pfrlogia Medthod,  ed. 4. to.  Clafs. iii. G.
yiii. Sp. 6.       ..,*4     .. ...
               .&m*lA z-100%    ______________ 
 To will the latter, and the fcarlatina anginofa produce the
 cynanche maligna, or the raoft dangerous form of the dif-
 eafe ;-»-this may be added to the fecond obfervation, and
 admit of the fame conclufion.

.  From thefe facts then,  (which I believe no perfon can
 deny) it appears, that at .whatever time this difeafe is epi-
 demic,  it is accompanied  with  all  its poffible varieties,
 from the raoft mild to the ihoft malignant; and, that dif-
 ferent perfons, after  being expofed to any given form or
 variety of the difeafe, are liable to be affected in any form
 whatever; and,  that becaufe a  perfon has received the
 infection from another in it's mildeft  degree,  we cannot
 prognofticate from this  circumftance, what will be the
 danger of their approaching difeafe (4).

 v. It is not to be  underftood from what I havefaid;  that,
 becaufe the difeafes are the fame, the fymptoms muft alfo
 be the fame; or that the difeafe requires, or will admit of
 the fame treatment in different perfons,  or  even  in the
 fame perfoiratdifferentperiodsof the difeafe: by no means,.
 for in one the difeafe appears inflammatory, and, in ano-
 ther putrid ;  the firft requiring the antiphlogiftic ;  while
 the other demands the antifeptic plan of cure.

   This may to fome, feem fufficient to conftitute a differ-
 ent difeafe; for in the  two patients,  the  remedies are
 directly oppofite, and confequently (fay they) the difeafes,
 for the  cure of which they  were prefcribed, muft be
 oppofite;  but to this I have only to obferve ;  that there
 is fcarce a difeafe we are acquainted with,  in which the
 treatment indifferent perfons,oreven in the fame perfon,at
 different'times, is not diametrically oppofite, and in fome,

 . (4); N'jts>  This is to be taken with a certain limitation, as  it
 is evident,that if the contagion,whkh is thecaufe,is iaore pow-
 erful ; the difeafe, which is the effect, will, ceteris paribus, be
 xnorefevere.                        "-£• 
C  9   1
 to greater extremes than in  the  fcarlet fever (5).  Are
 there not an inflammatory and putrid f mall pox, meazles,
 purperal fever, pneumonia, &c. ?  Do not topical inflam.
 mation of the eyes,  throat, &c. rheumatifm, gout,  con-
 fumption, dyfentery, apoplexy, palfy, &c. require,like the'
 difeafe before us, an oppofite treatment, depending  on
 the ftate of the fyftem in the  different  perfons  affected,
 and in the fame perfon at different  times?—And  muft
 they from  this  circumftance, be confidered as different
 difeafes, and receive a new name? certainly  not.

   But, there is another argument adduced againft my op'K
 nicm, which is infilled upon,  as in fome  degree conclu-
 sive : it is this;—That the fcarlatina anginofa feizes per-
 fons but once in their lives ; whereas, having the cynan-
 che maligna is no fecurity againft a fecoud attack-

   This may at firft feem  to have fome weight;  but I de-
 ny the pofition, and very much doubt,  whether the cy-
 nanche maligna was ever attended wh&  the pathogno-
 monic fymptom of the difeafe, viz.  the fcarlet efflorref-
 cence,  twice in the fame perfon ;  if this was not the cafe,
 and the patient had only a fore-throat, with what is cal-
 led a putrid fever,  he could not be faid to have had the
 difeafe—Every phyfician, who has feen it epidemic muft
 have obferved, that it is  the  reigning  difeafe of the fea-
 fon, as it were;  and, that fcairce an acute diforder occurs
 at this time, without more or lefs of pain or forenefs of the
 throat  (6)-—But, becaufe this baftard fymptom  intrudes
 jtfelf in thefe cafes, can it change the name or nature  of
 the original difeafe ?  Or,  fhould this fymptom feize a per-
 fon, at the fame time with a  common  putrid fever in  a
 crowded jail or hqipital,  would it  be proper  to  conclude
 that this perfon had thecynanche maligna ?—No, its diag-

  (5) Note. WhenI fay fcarlet fever,!mean, that attended with
an ulcerated fore-throat, unlefs the contrary is  exprefied.
  (6) See Huxham's works, vol. 2. 
                      [  io   ]

noftic fymptom is not prefent,  and the others are not Ef-
ficient to conftitute the difeafe without it.   During the
laft fummer, after being frequently expofed to the conta-
gion of the difeafe, 1 was feized with a violent ulcerated
fore throat,  but had not the  fcarlet  efllorrefcence, nor
cp;.;id the difeafe be called any thing except an  ulcerated
/pre throat; but if accidentally,  I had been affected with
a, typhus fever at the fame time, I have no doubt, that my
difeafe would have been filled the cynanche maligna, but
with as little  propriety,  and as little fecurity  againft a
,fecpnd attack, as if the feyer.had been abfent--


          Hiftory  of the Difeafe.

   The" contagion of this difeafe attacks  perfons  of  all
ages, but more frequently children than adults ; it feldom
however, affects the former, under two years of age, or
the latter when more'than fifty.—Among children, it is
almoft equally incident to the male  and female,  but in
adults the number of the latter, confiderably exceed that
of the former, perhaps owing to their greater delicacy ;
or, with more probability, on account of their being more
frequently  employed in attending the  lick, and conse-
quently, more expofed to the contagion.

   At the firft approach of the difeafe,  the  patient is af-
 fected with a great degree  of  languor, laffitude and op-
 preliion at the pr-cordia, with a deje&ed  countenance
 and ff>irits,,and irregular flying pains over the body,  par-
 ticularly in the  back and limbs :  To thefe precurfors,
 fucceed  giddinefs  of the head, chillinefs and fhiverings
 like thofe preceding an ague fit, which are foon followed
 by flufhes of heat,  and thefe  alternately  fucceed each
 other for fome  time, till  at  length,1" the latter becomes
 conftant  and intenfe,  and forms a principal complaint
  t: .j^o'-r  us.   :"r if-.- _TV-:->jr thjs time,  there is a 
£   ii  J
  great.diminution of ftrength, attended with great anxie-
  ty, violent; naufea,  fometimes vomiting, or diarrhoea or
  both ;  though very often neither, particularly in adults,
  who are fometimes very coftive.—The patient complains
  of an acute pain in the head ;  of heat and forenefs, ra-
  ther than pain of the throat;  a  ftiffneL of the neck ;
  difficult and painful deglutition, attended with a quick and
  laborious refpiration ;  and  frequently, a hoarfenefs  of
  the voice  and a cough :  In fome, the face  is red arid
  fwelled ; in others  pallid and funk ;  the eyes are fome-
  times inflamed, and frequently watery as in the meazles ;
  the breath is hot and burning toTthe lips, and at length,
  becomes intolerably offenfive, even to the patient's felf :
  although the heat be great,  they generally complain lefs
  of thirft  in this, than any  other  accute  difeafe—The
  tongue is foon  covered  with a white, cream-like furr ;
  famtimes it is dry and furred, with a yellowifh or brown
  coat in the middle and at the root, while the fides and
  edges are moift and red ; fometimes however, the whole
-.tongue appears of a red colour like raw flefh ; and in
  thofe, in  whom the malignancy of the  difeafe  is very
  great, the tongue, together  with the whole internal fau-
3- ces, put on a black, gangrenous appearance.

    If the mouth and  infide.of the .throat be  examined
  foon after, or at the fame time with the firft attack of the
 .difeafe, the uvula and tonsils appear fwelled ;  this fome-
  times takes place to  fuch a degree, as even  in the beo-in-
  ning, to threaten ftrangulation ;  and  thefe parts, toge-
  ther with  the velum pendalum palati, the cheeks en each
  fide  near  die entrance into the fauces, and as  much of
  them, and the pharynx behind as   the eye can reach, ap-
  pear of a gloffy red colour, which is commonly moft ob-
  fervable, on the pofterior edge  of the palate, in the  an-
  gles above the tonfils, and the tonfils thenifelve:.
rV.;:  «,„:—/" 
C   12   J
   But fometimes, inftead of this rednefs, or foon after it,
 the  parts  are variegated  with feveral broad  fpots or
 patches, of irregular figures, and of a pale white color,(7)
 furrounded with a florid red ;  and they foott lffiC4?eafe to
 fuch a fize, as to cover one or both the tonfils^  '< <qu n'qr
   » «q «-                                        ""iJainol
   This white color by degrees,  becomes more afh-color-
 ed, and it  may  now be  difcovered,  that  it is  really a
 flough, concealing an ulcer  of the fame dimenfions.

   All the parts of the fauces above mentioned, are liablel
 to thefe  ulcerations; but they generally are firft difcern-
 able in the angles above the tonfils, and on the tonfils them-
 felves, though they are often to be feen in the arch formed
 by the uvula and one of the tonfils;  and alfo on the pha-
 rynx  behind; on  the infide of the  cheeks; and on the
 bafe of the tongue, which they cover in the manner of
 a thick furr.                                   jiIJ nO

   The appearance of the "ulcers are  greatly diveffrfied in
 different patients, according to the mildnefs or violence
 of the difeafe; in fome, inftead of thefe floughs, only 3:
 fuperficial  ulcer, of an if regular figure, appears  in one*'
 or more of thefe parrs, fcarceto be diftinguifhed from the5 *
 found, but by the inequality-of the  furface it occafions ;'*
 in others, they put  on  a more  virulent appearance, are
 deeper and  greater in n&mbetfpand  they difcharge an
 acrid  fanies, which excoriates the parts, with Which it
 comes in contact.

  In thefe fevefe cafes,  the infide of  the noftrils as  high
up as can be feen,  frequently appear of a deep red or al-
                             'NO03*
  (7)  Note. "This whitenefs commonly appears like that of
u the gums, immediately after having been preffed with the fin-
 *' ger; or, as if matter ready  to be difcharged was contained
*l anderneath."—Fothergill's Works,"vol/ i. ^ 
C  13   ]
mofl: U^id color; and after  a day or two,  a thjjvcorro-
fiye fanies, or with it,  a white putrid matter,.of a  thick-
er confiftence, flows from them.  The trachea is fome-
times excoriated, and  pieces of its internal membrane is
fpit up, with much blood,  and corrupted mucous;-and
fometimes it occafions a troublefome cough, with a pecu-
liar found of the voice.                      ■-.,- ySl
                                               -..-l .b-i
  The parotid glands on each, fide commonly  fwell, and?
grow hard and painful to the touch :  If the difeafe is vio-
lent, the neck and throat are furrounded with a large a:-
dematcms tumour, fometimes esctending itfelf to the breafly
which,  by ftraitening the  fauces, increafes the danger;
and  fometimes the whole body is aedematous to fuch a de-
gree, that an impreffion made by the finger  will remain
a confiderable time.                                  \ i

   On the fecond day  of the difeafe, though fometimes as
late as the fourth, and in fome violent cafes on  the firft, ef-
florefcences appear upon the fkin, of a erjmfon or fcarfet
hue, as if the juice of rafpberries had been fmeared over
it;  fometimes in fmall points hardly eminent, but for the
raoft part,  in patches of an irregular figure,  firft on  the
face, neck, and breaft,.frem  thence gradually threading
to the upper,  and lower extremities ; affecting particu-
larly the hands  and fingers, which feel -ftiff and fwelkcL;
and are very painful when artificially bent, or otherwife
roughly touched.

   During the progrefs of the difeafe, all the fymptoms
are aggravated; the fever, anxiety, and reftlefsnefs become
more confiderable; the difficulty of fwallowing greatly
increafes;  the head becomes  more  giddy, painful,  and
heavy., with conftatjt ^atchfulnefs  and  frequently  de-
lirium ; and fome are in a ftupid,  comatofe, and almoft'
mfenfible fta'te, often ftarting  and  muttering to  them-
felves. 
D  14  1
   In fome[|h%fkin is fmooth,  without the leaft appear-
 ance of pimples or puftles ;  in others,  a great number of
 fmall red  points, of a color more intenfe than that which
 furrounds them, appear on  the arms and other parts-
 They are larger,  and more prominent in  thofe fubjects,
 arid in thofe parts of the fame fubject,  where the rednefs
 is lean* intenfe, which is generally^ on  the  arms, breaft,
 arid1 lower  extremities  ;  fometimes,  they are  fo  very
 ftnall, as not eafily-to be feen,  but at  the fame time may
 be felt, as they give a fort o# rotoghnefs to the  fkin.   >^,

   By this time the vomiting .and diarrhxa, if they have
 been prefent, commonly abate ;   but  this  is not always
 the  cafe, for an univerfal fcarlet eruption will fometimes
 appear without the  leaft abatement,  nay  even with  an
 aggravation of fome of the  fymptoms; (8) it may how-
 ever be confidered as a good fign, when a kindly  erup-
 tion breaks out on the fecond or third  day*
 -tt            #voh                           -«-, 3l£3iib

   The duration or the efflorefcence varies confiderably
 in different  fubjects ;  it however in general turns brown
 in three  or four days;  the  fkin becomes  rough, and
 peels off in fmall branny fcales, though very frequently
 in large, thick, and jagged pieces ;  but notwithftanding,
 it does not always afford relief! to the patient, particular-
 ly in more malignant cafes-   ,;b 4lom              .iiyin

   Befidcs the fcarlet  color  already defcribed, there are
 frequently,  fmall circular  or  irregular fpots  of  a livid
 color about the breaft,  thighs, knets,  and  elbows; there
 Hkewife fometimes appear about the wrift and fingers, a
 great number of  little  white  vifcicles, which  on exami-

   (^) Ntc. Dr. Huxam  informs us, thatp.heifaw two patients
 die of a moil raging phrenzy, who were covered with tjie rnoft
 univerfal fcarlet ram, he ever law, fo that, as in the rnoft h'lffh-
rbr confluent fmall-pox, it feemed only to denote the quantity
 of the difeaic.—Huxham's Works, vol, 2. 
                      r   15  y
tion, are found to confift of an elevation of the cuticle,
and to contain nothing but air.
 iJlii v 3cdi n
  With the fymptoms mentioned, the fever continues,
with  a hot and  dry fkin :  the pulfe is generally weak,
quick, and irregular ; in fome, it is hard and fmall ;  in
others, foft and full, but without that ftrength and firm-
nefs, which ufually attends equal quicknefs  and heat,  in
genuine inflammatory difegfes. no i

97A great debility appears in the animal functions ; the
 fpirits are confiderably dejected ;  the eyes and counte-
 nance fhew evident marks of langour and depreflion.

   The urine  in fome is very little different from the na-
 tural ;  in others, it appears  crude like whey ;  but, as* the
 difeafe advances,  it becomes more yellow,  and foon  af-
 ter marks of recovery have appeared, it commonly grows
 turbid, depofiting a lateritious fediment.

  , Towards night, the fever  and reftjleffnefs increafe ; a
 delirium now comes on, if it hath been abfent during  the
 day ; this fymptom appears in fome, eyen on the firft
 night; and, in the moft dangerous cafes, it is among  the
 firft fymptoms: the delirium feems to differ confiderably,
"from  the like affection in other  difeafes ;  the fick com-
 monly anfwer the  queftions properly, that  are put fo
 them ; but, with an unufual quicknefs ; and they talk to
 themfelves incoherently,  when left alone.

    In the  morning the fcene is  changed;  the-fymptoms
 which were aggravated, the night before, fuffer a remifli-
 on ; which take* place to fuch a degree, as to be noticed
 by perfons not convergent in medicine :—a fweat;more or 
[   i4  3
  lefs profufe, fometimes breaks out: from this" time, they
  are eafier during fome hours, and complain of a faintnefs,
  more than the reft of their fufferings ;  but this refpite is
  of fhort duration, for as night approaches, an exacerbati-
  on of the fever, &c. take place, fometimes with redou-
  bled violence.

    This is a hiftory of the difeafe in its moft ufual appear-
  ances ; but, there is fcarce another difeafe mentioned by
 nofological  writers, in  which the fymptoms vary more,
 in different perfons  : in fome, jr. is  fo  mild as fcarce  to
  confine the patient, having only a flight naufea and fever,
 with a few mild, fuperficial ulcers in the throat; which
 are fometimes totally removed, by an emetic and a few
 gargles:  in others,  thefe fymptoms will be fomewhat ag-
 gravated, with  a good pulfe, &c and by a proper treat-
tinent, the difeafe will vanifh in a very fhort time—But,
 m others, from the original feverity of the difeafe, from
 neglect, or ill treatment, or from all of them combined,
 the difeafe mews all the  marks of an exalted putrefacti-
 on ; the eyes are dead and gloffy ;  the teeth fhining and
 black;  the gums grow fpongy, and loofe their  natural
 color and confiftence;  th^jvhole internal fauces put on
 a black,  gangrenous appearance;  a  diarrhaea exhaufts
 what  little  ftrength is remaining ;  the arteries flutter,
 rather  than beat;  their ftrength and vigour being ex.
 liaufted,  are unable to  withftand the  impetus of their
 femivital contents,  the  blood ; which is difcharged from
 the nofe, ears, eyes, and other parts : with thefe inaufpi-
 cious fymptoms, a fubfultus tendinum, delirium, and coma
 will continue;  with cold,  clammy  fweats on  the face
 or extremities;   the heart  and lungs deprived of +kmm
 their due vitality,  and unftimulated with their accnfto-
 med force, refufe to perform the offices diftined to their 
t  :*7   ]
 tharge, when death, by clofing the tragic fcenej relieves
 the miferabk fufferer.

 .; The dif^^fe has no regular  crifis;  fome  grow  better
 %pm, the^rft day of its attack; but, more commonly un-
 der proper treatment, the difeafe is removed on or before
 the feventh ; fometimes however, it will continue to the
 fourteenth, or fifteenth day ;  and inftances have  occur-
 red, of their being carried off in lefs than twenty-four
 hours.
                      tli d^iriv/
   When the difeafe has run its courfe, and the patient be-
 gins to recover, the fymptoms proceed in the following
 .©rder: After a gentle eafy fweat, the heat  and rednefs
 ^©f the fkin, grow  lefs; the  pulfe becomes  more flow,
 equal, and firm ; the breathing foft and  free ; the exter-
 nal fwellings of the neck, except thofe  of the parotid
 glands, fubfide; the tongue becomes clean;  fome  degree
 of vigour and quicknefs return to the eyes; gentle fweats
 continue, with a defquamation of th£ cuticle, and plenti-
 ful expectoration ;  the floughs caft^off in a kj^odly manner,
 appearing clean  and florid at  the bottom; the ulcerati-
 ons fill^fup; the fleep is natural, and without confufion ;
 the patient is compofed during the waking ftate; and the
^appetite for natural food returns.
 rf                      ,Mtl*'       :uon->
   The prognofis, or  the'probable event  of the difeafe
 may be learned from what has been  faid—in proportion
  to the violence of the difeafe,  or the inability of  the pa-
  tient to bear it, we are to expect the danger.

  In the d: agnofis,  it is neceffary that  we fhould diftin-
 guifh the difeafe-froia the inflammatory fore-throat, mea-
 zles, croup, &o. in this however, there will be no  difficul-
  ty ; when we compare  the fymptoms of  the difeafes,  and
 at the fame time take into qanfideration,  the predifpoiition
 of the patient, and the  nature of the prevailing epidemic: 
C   i«"J
 ^atfhould tfeefota any doubt, we fhould be very cautiotf*
 in applying debilitating remedies, as a few hours ^ftH'pg^
 wilLalways decide,                       aoi'^jnoo  <
                                         '■■i )ud .lit, 5
            Caufes of the Difeafe.
:roi^itno?                                       .1 <
 nf^Tfcefeare  ift.  theremete:  2d. The predifpe-fing 03
 j)fedifpofttion : 3d. The occafional or exciting:  4th. The
jkwdmate :  The firft produces the fecond, and  the  third
 acting upon the fecond, produces the  proximate; which
is in reality, the difeafe itfelf* ^s^ .
                   '  znK  ;,■-"*
   The remote caufes are afoajry and various ► among, which
however, the moft common are,  intemperate  weather;
expofure to  damp or cold night air ; a deficiency of good
 aliment, or  a fufficiency of fuch as is not of a nutritive, or
healthy quality ; other difeafes of which the perfon is re-
itovering; impure  air, arifingfrom putrid animal or vege-
^eable fubftances;/fear frpmany caufe ;  improper  or tyran-
 nical treatment 1 to children ; (9) inattention to cleanli-
nefs, &c.—thefe are never fufficient of themfelves to pro-
 duce the difeafe, but  concur towards it by producing ;

  The predifpofing.caufe; which I fuppofe to be, debility,
Combined with a fpecificmobility of the nervous fyftem ;
 without the latter  the difeafe can never be produced, and.
 the  former in a certain degree,Teems- to be neceffary, to
render the latter more fufceptible of ;

  The exciting or occafional caufe ; which every perfon
 knows to be a contagion fui generis;  but, from whence
 this contagion arifes;  after being abfent twenty years or
longer, or wrhat gave rife to it at firft, is a matter not eafy
                                    .//
  (9) Note. I altudfe more particularly tp the tyranny of fchool-
mafters, which to my certain knowledge, is often inhuman ; this
therefore, is a fraitful  fource of difeajje^  as well as jnifcry t<T
the unfortunate little fufferers,   .■>■*■■■& 
■I   i9  1
 *oconceive—-perhaps, it may be produced' by \ chemical
 ^combination of two other contagion; or, by fome particu-
 lar contagion,  combining with fome unknown quality of
 the air, but this is only conjecture.

    How, or in what particular  manner, this  contagion
 when applied, opperates fo as to produce the difeafe, jftiay
 he difficult to explain;  I however,  think  it fuffieifcm'y
 probable, that it is not neceflarjrfor it  to be abforbed,
 and conveyed to the circulating mafs ;  but that it acts
 primarily on the throat, luttgkj: mid  ftomach,  where it
 produces its morbid effects ;  and from fympathy, more   *
 particularly with the latter, the whole nervous fyftem ir
 .brought into confent (10)-

    That  fhre or any ether contagion,  has any fpecific cr
 •^fermentative power, in diffoiving or putrifying the bloc®
 *>r an&wal fdlids  of  the body, I cannot allow ; but rather
 >feppdfe, that it does it, by directly deftroying the energy of
 thebram, and diminifhing the vitality or living principle of
 thofe parts,  and' confequently their properties  as living
 •organized matter ; and this I  confider as the proximate
 eaufe of the difeafe.

    Havi ig faid  what I think fufficient, refpecting the de-
 scription, caufes, dtagnofis, and pregnofis ; and proved, as
 I expect, the identity of the fcarlatina anginofa  and the
 cynanche maligna, I mall next treat of the cure;  but
 previous or  preparatory  to which, would wifh  to make
 fome obfervations and enquiries, concerning the difeafe ;

  (to)  Note.  Dr. l>ind mentions  the cafe of-a boy who died of
 of  a malignant; fever:  during the latter part of his illnefs, a*
 Sir John Pringle  was feeling his pulfe, he (Sir John) was ftid-
 4enly affe&ed withnaufea delirium and other fymptoms pecu-
 liar to  the difeafe.  In this cafe, the difeafe muft hare been
communicated dTiretfly through the medium of the nervous
 iyftem.—Lind on hotVlunates. 
LT 2®   31
in order if poffihleyto afcertain its true nature,  anddnoft
proper method of-cure.                   jootblii :
                                         'in 11 j v
   i-  The  difeafe is produced by contagion, which is:».
fedative, and tends directly to deftroy that energy of the
brainr which keeps up the healthy equilibrium,  between
 the (Excjtability and excitement of the fyftem ; therefore,*
the natural tendency of it is to debility, putrefaction, a nd
death : or, what amounts to the fame,  the vitality or liv-
ing principle of the b4oe,daan4<iiii*i»al folids is  fo much di-
 minifhed by  the  dcktea-ioUs.'ieffects  of  the contagion/
 that they are, to that,df^M«f fubjeft  to the laws of in-
animate Primal matter,  om  {(.                      " 10
                                                   ■joI
  . 2cl. This contagion, thus acting on the nervous fyftem,
would deftroy it; but, as there is a power in the living
animal body to preferve  itfelf; or an effort to throw off
whatever is inimical; it is here excited,  provided there is a
fufficiency of ftrength in  the body; or, if the vis  morbi or
effort of  the difeafe, is not fo great, as to ftrangle the vis
prefervatrix or healthy effort of the fyftem ;  if the  for-
mer is the cafe, the difeafe puts on the form of the  fcar-
latina anginofa ; but if the latter, that of  the cynanche
maligna.           -- X™? -•' -  :                   ;ii
                 "to ft'j'bb a  io  ; ynf-  &j          -nw.cA
  •3d.  This healtliy effort of the fyftem,'as it depends on
jts own ftrength for fupport, cannot continue long ; unlefs
its antagonift, the contagion, is very mild ; for,  it hath a
direct tendency to wear itfelf out; and at the fame time,,
the excitability and excitement of the fyftem.

   4th. Is this a ftate of  direct, or indirect debility ?  cer-
tainly the latter  ; though not owing as many fuppofe,  to
the direct  ftimulus of the contagion, but  to the exceffive
re-action of the fyftem.—This I fhall apply to practice in'
another place.                                         -, 
r  21   ]
  ^ 5th* When this effort or re-action of 'the' fyftem hath
 worn itfelf out, by  the  exceffive exertion which-was ne-
 ceffary ;  it  muft  then yield to its deftroyer, unlefs fup.
 ported )hjr/ medicine.
  arii  - -
   6th From what  caufe are we to expect death-in this
 difeafe ?  does it not, in almoft every inftance, depend 6i\:
 debility and putrefaction ? .  ■                    "" -^ 3riJ
                      .,... j:Ij ol .-                   '-r-b
   7th. Is it ever produoedfeyJ^feet excefs of arterial  action
 or excitement, which I  Call the Wealthy effort of the fyf-
 tem ; by inducing topical inflammation of the brain, lungs,
 or other  vital organs;  or by  mortification like exceffive
 local inflammation ? I  believe  never,  unlefs improperly
 treated by heating, ftimulating, and what are called fti.
 dorific medicines, and even then very rarely.

  £ c                  ,                         :'~V?'J£ltW
  ,/               The  Cure.,    ,,,-       .^rmjt

   In treating of this,  I  fliall divide r^ difeafe into two
 Species.

   ift, Where there  is a deficiency of excitement,  and
fometimes of excitability ; or a defed of action, with de-
^jjy»-and  fymPtom?,.tf;'PU,trefaction ,•  which may be dis-
covered in the temperament, pulfe, countenance, appear-
ance of the fkin, tongue, throat, gums, ftate of the  bow-
els, &c. as fpecified in the hiftory of the difeafe.

   2d. Where it is attended with too much   excitement
and excitability, or inflammatory fymptoms :  which may
be difcovered in" the temperament, pulfe,,fkin, counte-
nance, appearance of. the throat, tongue, &c- &o

  The firft I matt* call'the typhus, and the fecond the ty-
phoid fpecies. 
                       C  6«t  3

   The generat indications.of cure in the  typhm fp«cies
are;                                     .-.■•»*  i


   ift.  To evacuate ftomach, in which the b&ter'U&moc*
bi feems to exift.                             ,:'J --
e .v.:.                                ■         '  •■•  '  .:
^i&d.  To remove or obviate debility, and the fymptOiile
*>f putrefcency.


-.  The firft is to be effefted^*^ an emetic ; but as a vomit-
ing frequently attends  the  beginning of  the difeafe, it is
not always neceffary to have r«cou*fe to  artificial means $
bere we may  ufie camomile  tea, or any other warm) difab
ent, with the  addition of a few grains of  Ipecac, if neet&
fary, till we have obtained the defired «ffe&; -after which,
if the vomiting fhould continue, it would be moft prudent
to check it;  as it  would  be apt to debilitate to  no good
purpofc                                          J3J1'


  But,  fhould nature be dormant in thisrefpect ; it is-a
practice, as proper perhaps-, as it is general;  to begin the
cure by an emetic (n), which ftrikes at the very roots
of the difeafe, and if adminiftered early, will frequently-
put an end to its ppogrefs immediately (12).        i3b oJ
                                                 •  zmh

  (it) Note.  Ipecacrinha is preferable to tart. emet. as it Is
notfo apt to pafe over the pylorus and affect the inteftmes";
which is much to be feared.

  (12) After the operation of the  emetic; bathing the feet
and legs with warm water will be proper, and if called in the
very beginning, a fudorific anodyne may probably aflift the eme-
tic and pedeluvium, in obtaining a folution of the difeafe ; this
they do, not only by fimply evacuating the ftoriiach and produ-
cing reft ; but the firft effect of an emetic is to raife the excite-
ment of the fyftem ; which being affifted by  the warmth of the
•water, andftimulus of the opiate, produces deep and perfjpira-
tion, by railing the fyftem to its natural healthy point.


                           ...Aiisq b&itaitjCi.".. _ 
T  *3  1
 ?-. As tip© w&ers of the throat are continualfyr generating
 the very feeds of the difeafe ;  which falling into the oefo-
 phagus, are fwallowed, and adl as a new caufe upon the
 ftomagk; and by;paffing to the inteftines produces, or in-
 creafes the diarrhaea : it  will therefore be  proper/ to
 give an  emetic every day or  two, and oftener, unlefs
 extreme weaknefs  fhould eontraindicate it; the relief
 they afford is furprifing ;  it would feem, that they :gafc
 ftrength and vigour  to the fyftem during  their opera-
 tion ;  they remove the  langour,  anxiety,  pain of the
 head,  delirium and naufea ; they prove ufeful  by pro*
 Jnoting expectoration, when  theolungs or  trachea are
 afle&ed ;  in all cafes  they greatly relieve and cleanfe the
 throat ;  and they moreover prepare the ftomach for the
 reception of fuch medicines, as may be deemed neceffaryi

    But, the praftice of giving antimonial wine, or tare*
 emet. hourly, through this fpecies of the difeafe, to keep
 ttp a determination to the furface, or remove the fpafin of
[ the extreme veffels, as it is called* does not appear to me,
 to be founded in reafon, or fuppqrted by any proper expe-
 rience ; for, inftead of anfwering any  good  purpofe,  it
 not only proves an irritation to the inteftines, but tend*
 to deftroy the tone of the ftomach; and the proper medi-
 cines are either rejected by vomiting, or their effects are
 counteracted or deftroyed by the continual naufea arifing
 fsQm  the  antimony—Who,,eyen in health,  under fuel*-:
 circumftances, could digeft a beef-flake ; or relifh a glafs of
 wine?—Would all the tonics of the materia medica cure
 a-fimple dyfpepfia,  if given with antimony ?  What are we
 then to expect in a difeafe, where  the powers of  life are
 nearly exhaufted,,for want of proper fupport i
                 '     j                •_■■'.' *IK!
   That this medicine  anfwers any good purpofe as a fu-
 dorific, I cannot ■ beHc^e^^-It is the opinion of many, that
 fclmoft, all acute difeafes depend on, or at leaft  are  fup-
 ported by, a fuppreffed perforation or a fpafm of the ex* 
                        [   *4   J
 treme veflels* ih this however they are grofsly miflaken j
 for if that was the cafe, they would always be cured, after
 the caufe was removed ; but a fweat often  occurs in this
 difeafe, without any fuch effect.—Dr. Robinfon (13) as
, well as Sir John Pringle(i4) on malignant fevers* which
 in this particular: are not materially different from the dif-
 eafe before us; obferved, that a profufe fweat often broke
 out; without affording  any relief; a  fuppreflion of this
 difcharge, therefore, could not,  in thefe inftances, have
 been either the caufe, or fupport of the difeafe.

    AfupprefTed perfpiration, fpafm, or whatever it may be
 called, is an  effect, and not the caufe of the difeafe ;  it is
 therefore unphilofophical  to nfe fuch remedies for  ks
 removal, as  fhall prove injurious, and   ftill   leave  its
 caufe remaining—Although I before faid a gentle, univer-
 fal perfpiration was  a  favourable fymptom, I  now fay
 that it is not to be brought about by thefe means,  or by
 hot ftimulating fubftances ;  but rather by  the relaxing
 powers of the warm bath, or pediluvium ; or a yet more
 certain and durable method is, by fuch medicines, as fhall
 reftore tone  to the fyftem,  and raife the excitement to the
 natural healthy point (15).

   Before returning from  this digreflion,  I  muft take no-
 tice of a very faihionable remedy for the cure of  this dif-
 eafe ; I mean calomel; this is by almoft every phyfician,

   (13) Note.. Robinfon on Jail or Malignant Fevers.
   (14)  Pringle on the difeafes of the Army.
   (15)  If the  fyftem is either  above, or  below  a certain
 point of excitement, fleep cannot take place :  If in a fit of grief
 the fyftem is either above or below a certain point, tears can-
 not flow : Neither can a fweat arife under fimilar circnmftanceS.
 In the firft cafe, to produce fleep, would it not be rediculous to
 tie the perfon in bed, and plaifter  up, his eyes ; and in  the o-
 ther inftance, would it not be equally fo, ir we fhould attempt
 to produce tears by fticking needles, or throwing fand in hia
 eyes I Not more  fo, than attempting to raife  a iweat by tha
 means commonly employed. 
                   ._.t-ai..l
 (at leaft as far as my acquaintance extends;)  confidered as
 a (peti&c; It was firft fuggeited by a Dr. Ogden of Lorg-
; Jfland, who publifhed his difcovery fhortly after ;  but,  as
zi have noC had an opportunity of perufing his effay, I know
. not how he accounts for its favourable operation.
-lib atfj iriju                               '■-.:<;t .--riH
- a  I am fcrry to doubt the Doctor's experience, hȣ, J muft
 jTay this much of his fpecific; that I have feen it given re-
 peatedly, but never perceived \|fee leaft benefit from it;
 neither do I believe it is p^fl^ qf any fpecific virtues; or
 a medicine to  be  depended  on  in  any dangerous cafe,
^-without the afliftance ojf.pthers;  and from. its.known, eva,
 cuating powers, it may,  and  I  am  certain often  does,
 proye. highly injurious—Dr. Barcl, of New-York, it is faid,
 lays much ftrefs upon its attenuating virtues; but I fhould
 be, glad to know, what neceffity  we havfe here for fuch
^medicines;

    By.t l^grcury is auniverfal  ftimulus, particularly tp the
 glandular fyftem;  (16) upon  this principle, it is a valuable
 remedy in the venereal difeafe,  , clropfy, epilepfy, and  I
 think I have feen it do fervice in the typhus fever in the
 Pennfylvania Hofpital: upon  the faraepi-inciple, it may, if
 given with caution, be of fervice in this fpecies of the fcar-
 let fever,              .^i/ n:vM;-gfcffrt%'^
                        fbi      >iav' ■ -ir,'* ^"*L     >
    I cannot think It of any life-as. producing  a falivation
 for it would come in too late ;  as children, who are com-
 monly the fubjects  of the difeafe, are not fo eafily affected
 in  this way by  mercury;  and even if this could be pro-
 duced, it is certain, that every preternatural evacuation
 be it ever foifr*a^-:muft be injurious.
             ■•■/mn n bioov              ""
   But to gh-c the.medicine every chance, I have no objec-
tions to its.being combined with  the emetics, as it might

  fr6) Note. Cullcn's Materia Medica»
                         D 
                      \   26   J
  at Teaftbe qfeful as a topical application to the ulcerated
  parts : and it may cautioufly be given to anfwejr, otjfrer. in-
  dications where it could do no harm ; but what I  have
  principally in view in giving my opinion thus freely, is,
  not that it fhould be entirely rejected without further  tri-
  al ; but, that it fhould not fuperfede the administration of
 ,'Other. remedies. (17}.

   The fecond general indication is to be effected by tomes
 or antifeptics, and ftimuUiiats; the chief of which are, Peru-
 vian-bark,  wine, mineral, acids,  opium,, vol. alkali, aad
 vitriolic ether.

  After an emetic, it is the general practice to order adofe
 of calomel to be given  every four or five hours; but this
 medicine, as it is not to be depended on, fhould never in-
 terfere with our fecond indication.

   Bark is a moft valuable, and.uidifpenfible remedy; whe~
 fcher it acts" primarily upon the ftomach. and by fympathy
 on the whole fyftem, or whether it  is abforbed,  it i&a
 powerful tonic and antifeptic ; .and a few drachms  of it
 given in time, before the toh4fci^*^citability of  the fto-
 mach are entirely deftroyed by the ravages of the difeafe,
 will have more effect, than as many ounces given  at a lat-
 er period.  There is no propriety in  waiting for a remif-
 fion of the fever and a moift fkin; but it is to be  given
 immediately after the operation  of the emetic or the next
 morning without any regard to this ; and the higher the
 fever, the more neceffity is there for this excellent febri-
 fuge ; as it  abates the  heat, diminifhes the quickness,
.and increafes the fiowuefs and vigour of the pulfe.
                                  • "l r * ' - ■
   (17) Note " Where fafhion leads, the language ofreafon fel-
 " doni prevails.  To fwim with the ftream, is confidered by the
** majority of mankind as the eafieft paflage through life."
               Rowley on the difeafes of the eyes, P. 114, 
                       I  *7  1

   When an intenfe heat of the body is prefer*:,  what 3
 Tjave juft recommended may, and I have no doubt will ap-
 pear to many, contrary to plain reafon and found philofo-

 phyj  but tojae it is certain,  that tlvsrreternatural heat

 may arife from two oppofite remote caufes ;  one requir-

 ing tonics, and the other debilitating remedies ; the truth

 of this may be eafily feen after giving nitre in this fpecies

 of the difeafe ; for it never fails to increafe the heat''arid
 reftleffnefs;  and if that is the fact, which no perfon of ob-
 fervation will deny ;  it is an unavoidable'cpnclufion, that

 bark is in thefe cafes, the moft natural and effectual reme-

 dy :  (18)  This will  not only apply to the fcarlet fever,
 .but to every febrile difeafe of that type.


   ^Neither the infufion, decoction, or tincture of the bark

 are to be depended on; but let it be given in fubftance, in
 large quantities, and often repeated,  both day and night,.

 withoutany long intermiffion;  and fliould it be rejected

 by the ftomach,  or the patient refufe to take it in fufficient
 quantity; let it not on this account be laid afide, but tne

 extract is to be adminiftered "by injection 'in  large dofes,
 with the adclition of wine and a few drops oflaudarium :—•
J Like wife cataplafms, compofed of bark and camomile flow-

 ers boiled in vinegar, Wi«k the  addition of a little  cam-
 phor, maybe applied^ to the throat, and other parts of the

 (l8)jVbft? " The bark has a purgative effect on fome conftitutions,
 " and is very apt te increafe a diarrhsea when there is a previous
 ii tendency to it: an fuch cafes it is proper to add the powder of
 " Cafcarilla, which generally anfwers all the purpofes of an af-
 %t tringent,and is preferable te the Elect, e Scordio,or any other
 " medicine of that clafs, becaufe  it operates with the bark in
 ".all its other intentions : If the Cafcarilla fhould not fucceed,
 '• as it is of the utmoft  importance to flop the evacuation, Wc
 " muft  give fmall dofes of ipecac, joined with  the ext. li^ni
 f< Campachenfis4 una uar other of thefe remedies-is generally ef-
 " ficatious  ; at leaft it  is always right to try them before we
•<(rJxave recpjirfe to opiates,  which fhould be the laft refort."
  f              **  r   Manning's PraSife of Phyfic p. 247. 
 body, and IhouldrbQ. renewed'every four or five hours.—.
 The feet and legs fhould be bathed in a fimilar defection,
 five or fix times a day ; and cloths impregnated  with the
 fame, may be applied round the legs and thimj^          ,,
                                                    "no
   Wipe is to be given at  the  fame  time with the bark,
 either  combined, or in alternate dofes :  it removes the
 depreflioo cf fpirits, anxiety, heat, and reftleflhefs of the
 patient;  renders the pulfe lefs frequent and more firm  ;
 fupports the vis vita:; promotes eafy perfpiration; and re-
 fills putrefaction :—It fhould be of the belt  quality, and
 igiven in large quantities ; it  is  furprifing  to fee how
 much may be drank in this difeafe,  without any figns of
 ebriety ; and if a fufficient quantity cannot be taken in-
 ternally,  as is often "the cafe,  it will be proper  to bath
 the whole  external furface of the  body  with  it, feveral
 times during the day.
 3.'                  j.                       ,
   If there mould-be a tendency to a diarrhuca, Port wine
 mulled jvith fpices, as poffeffmg an  aftringency,  would
be moft: ufefui ;  but:otherwife Madeira  would be pre-
ferable.            .,Vr ...  .
               • ., ■'■* djuy/.ntivj;
  Mineral acids are  excellent tonics and  antifjepjtids j
the vitriolic is moft commonly ufed; the marine,  howe-^
ver,  is  highly recommended  by  Dr. Fordyce (18) and
others—they may both be given with advantage, either
 with the bark and wine, or Separately diluted with water*

   Opium being  a very valuable 'medicine  in low  fe.
vers,  (io}: may With the fame intention, be given in this:
           •  ~j}  :)i            <:Iqqc n03t
  (\$) N$tt. Fardy^eon fevers.        -t-~)L ■  :
  (19) Wall on the ufe of opium in low fevers.
                           ; ;lb Isoibsia 8'lcvi.. j -■': 
                      r  2fi •
It removes irritation, and prevents the tendency  to, or
checks th&prefent diarrhsea.;  and by railing the excite-
ment to a certain point,  produces a refrefhmg fleep ; it
raifes  the  fpirits  which  are  commo nly languid ; it in-
creafes the  force of the  circulation  which is weak and
quick,  and  a more  proper  fudorific  cannot be employ-
ed ;  whether it proves fo by  relaxing the fpafm,  or by
raifing the excitement of the fyftem to a certain height or
point, is a matter of very little confequence to me;  all I
wiih to fhew at prefent.is, that \t is a ufeful medicine in
this fpecies of the  fcarlet fever.     ;,

  Volatile alkali may be ufed, where a ftimulus is  want-
ed, particularly in the latter ftage  of the difeafe ;  when the
vital powers are languid,  and the excitability and excite*
meat are greatly deftroyed.

   This medicine being the product of putrefaction, we
are  cautioned by the learned  Dr. Huxham  againft ufmg
it, as he thinks it will  affect the  fluids of the body, fo as
to diffolve and render them alkalefcent; but I  will  ven«
ture to affert that  there  is no foundation for this ;  and
that the medicine may be given with evident advantage,
in almoft every low fever, without any .reftri&ion on this
account.

   Vitriolic ether may hkewife be ufed, as a diffufible fti.
mulus and antifpafraodic.

  Whether blifters^as a general rexnedy may  ever be
admitted, I am not able to determine j  it isrfaid, however,
that they have  been applied with benefit, to relieve the
throat and head (20); for which intention they feein ve-
   (20) Percival's medical effays, vol. 1. page 154. 
I  3°  1
ry well adapted ; but, their ufa as a general ftimulus may*
be obained with more fafety, by ftimulating cataplafms;
though both in general I believe might be difpenfed with:
and the frequent inftances of the former producing mor-
tification, ftrangury, and other diftreffing fymptoms^;  to-
gether with the want of fuccefs attending their applica-
tion, I think fhould have very great weight in  deterin^
us from their ufe in any cafe.

   To what extent cold air may  be admitted, is  not to a
certainty  afcertained ; It Witt however depend in a great
meafure on the ftate of" the patiept; 62 deg. of heat win*
generally be fufficient, and when the  temperature of the
body is above  o£ deg. we may apply  cool air in propor-
tion ;  viz. in the ratio  as the heat of the body is above
98 deg. we may diminifh that of the air below  62 deg.
but no guide  is fo certain as the patient's own  feelings,
and to them we  muft temperate  the air  if  poffible.Ji(2i).
1                                           Vjlq  A3  ■/
  Pure air is abfohitely neceffary  : the room muft therefore
be properly ventilated; the bed fhould be placed in the mid-
dle of the room, and without curtains ; the patient fhould
not be confined  to  it, but fhould fit up  as much as poffi-
ble; and when this is impracticable, the lying pofture fhould
be attended to; as the moft natural, which is upon one fjeje^,
is the leaft debilitating ;  the bed and body  linen  fhould
he frequently changed ;  no  more perfons  fliould bdlfcid-
mitted into the room than are riec-effary in attending on the
fick, as they  diminifh the purity  of the air ; branches-of
trees,  or what is better, fhrubs in a vegetating  ftite may
be placed in  the room  with advantage, during the day,

  (21) Tfoti. Chemiftry teachesks that e^ap^at'meis a pow-
erful means of producing cold ;  we may therefore haye the pa-
tient's apartment Yprinkled with water^oVvmegar for this pur-
pofe ;  and keep t|ie hands and feet  ofUHkrpatient moift with
the fame, by way.of anfwering artificially the purpofe of per-
fpiration, which is a natural evaporatibm  '    - -  - *:  ' - - 
                        Z  31   1
 as they abforb the mephitic air, and emit ih its place what
 is pure.
        . ilnotc
    The air  may  Hkewife be rendered more pure, oral
 leaft agreeable, by the acid air or fpirit of fea fait; which
 may eafily be  procured by the decompofition of common
 TaTt with the vitriolic acid; and alfo the fteams of vine-
 gar are very agreeable, antifeptic, and refrefhing.

    The food fhould be light, nourifhing,  and antifeptic;
 principally from  the ferinaceous vegetables, as panado,
 fago, falep, &c. with Madeira or Port wine—The fum-
 mer fruits, fuch as apples roafted or boiled, peaches, oran-
 ges, cherries, currants, mulberries, &c, unlefs contraindl-
 cated, may be plentifully eaten.

    The drink  fhould be agreeable and antifeptic :  water
 with plenty of wine, and acidulated with the  mineral
 acids j  and by way of change, good pure cyder :  and they
 fhould be  moderately cool, if more agreeable to the pa-
 tient.

D* The general indications of cure in the  typhoid fpecies,
 are,                   :

 .'  j ft. After evacuating  the ftomach, as directed in the
typhus  fpecies:  to moderate the redaction  of  the fyftem.
by proper remedies.

   .fid* To  reftore  tone to the  fyftem.

   In every cafe, or  (|>eries of this difeafe, we are not to
loofe fight  of the tendency which it has to terminate in pu-
trefaction ; we muft therefore in fulfilling-our  firft indica.
tion, proceed with cautiori and ceconomyv 
•C   32  3
    Bleeding is a remedy, the moft powerful of any we ar<2
  acquainted with, in diminifhing the action of the fyftem;
  but from what has been faid it muft be evident,  that it is
  not adapted to the difpofition of  this difeafe; I cannot
  therefore approve of it in any cafe, unlefs there would be
  danger from its omiflion, of an inflammation of the brain,
  lungs, or other vital organs ;  or unlefs the arterial action
  appeared greater than  the animal oeconomy was  able  to
  withftand; in which cafes, ajudicious phyfician may  ven-
  ture to take a few ounces y but fhould be very careful  how
  he repeats the operation.

    My reafons  for  objecting to this evacuation  are. ifl>
  Becaufe the increafed  action for which it is prefcribed, is
  but  temporary  and accidental.  2d.  It reduces the fyftem
  too  fuddenly, and confequently, does not allow fufficient
  time for the contagion  to become infenfibleto it:—It is a
3/Jaw  of the  nervous fyftem ; " that by a continued applica-
  tion, it becomes infenfibleto an  impreffion (22);" when
  this  takes place withrefpedtto the contagion, its fpecific
  mobihty is deftroyed; which is the reafon why that of the
  fmall-pox,  meazles, fcarlet-fever, &c. cannot produce the
  fame difeafe twice in the fame perfon; but fliould debili-
  ty be induced, while the Contagion is acting with its full
  force, the  patient will be'iri danger of finking under the
  difeafe; 4th. I do not believe the blood to be the feat of the
  difeafe ; although  it is affected in the fame manner as the
  reft of the body. 5th. Even in cafes which Teem to require
  the  evacuation, it feldom  or never  relieves;  it  muft
  therefore  in thefe cafes in    fe the difeafe.

    The remedies then, which areTto be employed to an-
  swer this indication are ;  cold, neutral  falts, vegetable
  acids, furamer fruits, and cool drinks.

    Cool air in this fpecies of the difeafe may  undoubtedly
  be applied with the greateft fafety and  advantage;  fome 
                       t  .33 , 3
 Ate fearful of its fuppreffing the eruption,. but I  am confi.
 dent there is no foundation for this.

    Neutral falts are very great fedatives : nitre hath been
 known to lower the pulfe immediately after it was admi-
 niftered (23); it may be given often, and'in pretty large
* dofes, unlefs it fhould increafe the fymptoms, and  the addi-
 tion of a fmall quantity of tart- emet.  in  fome cafes may
 not be amifs ; but the cathartic neutrals as Glaub. Epfom.
 Rochelle, &c are to be ufed  with great care, as their ef-
 fects might be  dangerous,'and this intention may  better
 be anfwered by a little  manna,  fenna,  tamarinds,  ripe
 fruits, &c                  a.

    Vegetable acids and fummer fruits are  very agreeable
  and refrefhing ; they may be ufed with advantage  as re-
 frigerating antifeptics.

    The  drinks fhould not be in the leaft ftimuiating," but
 -fiich as lemon or lime juice and water, apple-water, br
 fimple fpring-water;  and as for  the temperature,  let lis
 be guided in a great meafure by the defire of our patients.

    In  this fpecies of the difeafe  I confider Dr. Ogden's
 Specific, upon the principle that I admitted it might be ufe-
 iful in the other, as highly improper, except as  a local re-
 medy to the ulcerated parte.

    •Blifters have little to do here, they may however be ap-
 plied to the throat when confiderably fwelled and inflam-
 ed ; but are of no ufe as general remedies, and will be found
 in almoft every cafe to i,.   .afe the difeafe; and perhaps a
 linament compofed of vol. alk.  oil and camphor might be
 fubftituted for them" even as  local remedies, with as much
 advantage, aha without the pain and uneaflnefs unavoida-
 bly attending their ufe • But common eataplafms as  local
 applications, cannQt anfwer any  good purpofe, as  they
 grow ftiffan d uneafy to the patient, particularly in warm
   (23) iY&V.Kuhr.'s manafcrint lectures on the practice of phyftc 
E   34  3
weather ; and in general, I believe will be found  to  dq
more harm than good.

  Thefe are the remedies  to diminifh the preternatural
arterial action,  which fometimes  occurs in the beginning
of the difeafe ; but for its radical cure, we muft frequently
havi^tourfe to  our fecond  indication, which is to rcftore
tfcmert;© the  fyftem ;  to do this, we rre not  to wait for a
fweat, or remiflion of the fever ;  but as foon as the fymp-,
toms will  admit,  njuft lay  afide the refrigerating, and
fly  immediately to the tonicj antifeptic,  and ftimuiating
plan; neither ai«e  we to  be  dilatory  and  wait  till  the
ftrength of  the patient is exhr-ufted ;  but beg'n as early as
jolfible; always remembering  that we had  better be too
foon than too late  (24) ; in the former cai'e, the effect will
be of very little confeque nee, and but  temporal; as we
may always defift  if we find it neceffary : but in the latter,
it h too often eternal, as all the bark and wine in Ameri-
ca would be ineffectual inreftoring the excitement crtone
after the excitability  Was1 defttoyed.

  After ha. mg found this indication to be proper ;  the
bark, wine, and remedies mentioned for cure cf the ty-
phus fpecies of the difeafe, muft  be  given, with a liberal
hand, and in nearly double quantities ; as we here have

  (24) Note. " Tha{ inflammation of the throat, v.l ich ends
" in what they call a putrid fore throat,  is fingukrly infduous :
** Doring the firft days, it differs little in its appearance from'
" the llhenic  fore throat. The pcrural fymptoms arealfo f mi-
" lar; the pulfe fcarce exceeds the jneafure  of the (thenic
" pulfe in its 1'requ'ency and other characte'rifti. s ; but for fome
" time the whole difeafe appears witii gentjeneis and tranquifi-
m< ty excepting that a conftant rejecting  bv fpiuing of  a tough
*s mucous matter is  trouhleiome. '  At lafl when read is not
" niade  againfi it by means  of the moft "powerful diifufible fti-
'*'muli, a period arrives,.when alijbe fjrppioms are precipta-
" ted into a  bad ftate,  wven the pulfe becomes very quick and
*f remarkably fmall when the ftrength  over the whole fyftem
" finks ;  aad now  it  is not a moderate portion of diffuiible
" ftimulus, not before  adminiftered, that will (lop the much
"lamented death of the  greateft  ornament* of human  na-
" ture."           Brown's elements of medicine, ccxiii.
  * .AU^qiijnr to. akdy v:.'n. die?U;  '^iiaa^ii_gi£L_^— 
C  35   ]
 direct debility fuperadding itfelf to indirect fo encounr
 ter.

   But we muft expedk to  find  many cafes of this dif-
 eadfir,  where neither  bark  or wine  can be given with
 fafety, andjivhere the oppofite plan will do harm i! this is
 a difficult cafe ; but the beft thing I can recommend,'is to
 do nothing,  unlefs it  is to keep the patient cool;  theas:
 pure;  adminifter  a  little  of the fpecific, if nothing for-
 bids ; and wait for a change of  the fymptoms, fo as to
 determine what will be  the proper plan of cure.
                      '•'■■'  -rf OJ
  I have hitherto  faid nothing of gaggles ; they are very
 important remedies,   and fhoukl never be neglected, but
 ufed 3,s often as poffible in both  fpecies of the difeafe':
 they cleanfe  the  fauces ;  and difpofe the floughs to caft
 off,  and the ulcers to heal  ;  th ey fliould be more particu-
 1 rly ufed before the patient eats, drinks, or takes his me-
 dicines.   Thofe children who are  not  capable of uiino-
 gargles, fhould have them injected with  a fyringe; and
 the  perfons   who attend, fhould  frequently  wafh their
 mouths with  a linen rag,  made wet With diluted fpirit of
 fait.

 ,. In the very beginning qf the complaint, aftringent gar-
 gles are very proper ; fuch  as a  decoction  of bark, folu-
 tion of white  vitriol,  allum,  &c.  after the parts  are ul-
 cerated, we may ufe fome of  the following according to
 the  ftate of the ulcers;  viz. lime or lemon, juice and wa-
 ter; brandy,   with a little loaffugar  ;  tncture of bark ;
 expreifed juice of  black  currants either alone or combi-
 ned with ardent fpirits or  brandy ;  tincture of myrrh ;
 msl  egyptiacum :  and. there are a variety of others, but
 the fpirit of fait, combined with  honey  or tinct- of rofes,
 is recommended by Dr. Fordyce,  as  luperior to any  he
 ever tried,    .rrtoq o;

 When the Ulcers appear  of a gangrenous, or malignant
nature ; fixed air^ as,Wiing ro.verfully antifeptici/^j)?. 
                       t  3&  1
fhould be conveyed to the parts by means of a tube ; and
 the humid vapour of vinegar fliould be drawn into the
 mouth by the fick, as often as convenient.

   Before I conclude this differtation ;  I fhall briefly fjpint
out the caufes of  the fatality,  or rather of the want of
 fuccefs in curing this difeafe :  thefe are,

   ift. The admiffion of bleeding.
   2d. Trufting  to  inert medicines,, fuch as diaphoretic
antimony ;  pv\y. contray. comp. crocus mettallorum ;
vinum croceum, &c.  &c.
 3d.  Prefcribing nitre, to remove the heat  and  deliri*
um in the typhus fpecies of  the difeafe, when it always
increafes both.
   4th. Giving tart. emet. to produce a fweat in the fame
fituation.
   5th. Giving heating, ftimuiating fubftances to deter-
mine to the  furface,'  when inftead of this, they determine
to the brain or other vital organs.
 '  6th. Confining the patients to  their bed.
   7*h. The indiicriminate ufe of blifters.
  8th. Waiting till the third, fourth or fifth day, for a re-
miffion of the  fever, or till the patient is dying,  to ad..
minifter  the bark;  and during this time, trufting to the
inert and dangerous medicines mentioned."
   9th. Giving it in  the trifling form of deco&ion, infe-
fion, or tincture  in fo rapid, and dangerous a difeafe ;  or
omitting it entirely if difagreeable to the patient.
   10th.  Giving ardent fpirits, brandy, or tke phyfician*
favourite of his own palate, inftead of good old Madeira
wine.                       ^
   nth.  Trufting to calomel  to the exclufion of other
remedies, implicitly believing m its fpecific virtues.
   12th.  Giving  it  with  this*idea in  fuch  dofes, as to
purge the patient to death.
P  I   N  Z  £. 
 
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