Volume 1 — AN ACCOUNT OF THE SCARLATINA ANGINOSA, AS IT APPEARED IN PHILADELPHIA, IN THE YEARS 1783 AND 1784.

The beginning of the month of July was unusually cool; insomuch that the mercury in Fahrenheit's thermometer stood at 61° in the day time, and fires were very comfortable, especially in the evening. In the last week but one of this month, the weather suddenly became so warm, that the mercury rose to 94-1/2°, at which it remained for three days. As this heat was accompanied by no breeze from any quarter, the sense of it was extremely distressing to many people. Upwards of twenty persons died in the course of those three days, from the excess of the heat, and from drinking cold water. Three old people died suddenly within this space of time. This extreme heat was succeeded by cool weather, the mercury having fallen to 60°, and the month closed with producing a few intermitting and remitting fevers, together with several cases of inflammatory angina.

The weather in the month of August was extremely variable. The mercury, after standing for several days at 92°, suddenly fell so low, as not only to render fires necessary, but in many places to produce frost.

Every form of fever made its appearance in this month. The synocha was so acute, in several cases, as to require from three to four bleedings. The remitting fever was accompanied by an uncommon degree of nausea and faintness. Several people died, after a few days' illness, of the malignant bilious fever, or typhus gravior, of Dr. Cullen. The intermittents had nothing peculiar in them, in their symptoms or method of cure.

Towards the close of the month, the scarlatina anginosa made its appearance, chiefly among children.

The month of September was cool and dry, and the scarlatina anginosa became epidemic among adults as well as young people. In most of the patients who were affected by it, it came on with a chilliness and a sickness at the stomach, or a vomiting; which last was so invariably present, that it was with me a pathognomonic sign of the disease. The matter discharged from the stomach was always bile. The swelling of the throat was in some instances so great, as to produce a difficulty of speaking, swallowing, and breathing. In a few instances, the speech was accompanied by a squeaking voice, resembling that which attends the cynanche trachealis. The ulcers on the tonsils were deep, and covered with white, and, in some instances, with black sloughs. In several cases, there was a discharge of a thick mucus from the nose, from the beginning, but it oftener occurred in the decline of the disease, which most frequently happened on the fifth day. Sometimes the subsiding of the swelling of the throat was followed by a swelling behind the ears.

An eruption on the skin generally attended the symptoms which have been described. But this symptom appeared with considerable variety. In some people it preceded, and in others it followed the ulcers and swelling of the throat. In some, it appeared only on the outside of the throat, and on the breast; in others, it appeared chiefly on the limbs. In a few it appeared on the second or third day of the disease, and never returned afterwards. I saw two cases of eruption without a single symptom of sore throat. The face of one of those patients was swelled, as in the erisypelas. In the other, a young girl of seven years old, there was only a slight redness on the skin. She was seized with a vomiting, and died delirious in fifty-four hours. Soon after her death, a livid colour appeared on the outside of her throat.

The bowels, in this degree of the disease, were in general regular. I can recollect but few cases which were attended by a diarrhœa.

The fever which accompanied the disease was generally the typhus mitior of Doctor Cullen. In a few cases it assumed symptoms of great malignity.

The disease frequently went off with a swelling of the hands and feet. I saw one instance in a gentlewoman, in whom this swelling was absent, who complained of very acute pains in her limbs, resembling those of the rheumatism.

In two cases which terminated fatally, there were large abscesses; the one on the outside, and the other on the inside of the throat. The first of these cases was accompanied by troublesome sores on the ends of the fingers. One of these patients lived twenty-eight, and the other above thirty days, and both appeared to die from the discharge which followed the opening of their abscesses.

Between the degrees of the disease which I have described, there were many intermediate degrees of indisposition which belonged to this disease.

I saw in several cases a discharge from behind the ears, and from the nose, with a slight eruption, and no sore throat. All these patients were able to sit up, and walk about.

I saw one instance of a discharge from the inside of one of the ears in a child, who had ulcers in his throat, and the squeaking voice.

In some, a pain in the jaw, with swellings behind the ears, and a slight fever, constituted the whole of the disease.

In one case, the disease came on with a coma, and in several patients it went off with this symptom.

A few instances occurred of adults, who walked about, and even transacted business, until a few hours before they died.

The intermitting fever, which made its appearance in August, was not lost during the month of September. It continued to prevail, but with several peculiar symptoms. In many persons it was accompanied by an eruption on the skin, and a swelling of the hands and feet. In some, it was attended by a sore throat and pains behind the ears. Indeed, such was the predominance of the scarlatina anginosa, that many hundred people complained of sore throats, without any other symptom of indisposition. The slightest occasional or exciting cause, and particularly cold, seldom failed of producing the disease.

The month of October was much cooler than September, and the disease continued, but with less alarming symptoms. In several adults, who were seized with it, the hardness of the pulse indicated blood-letting. The blood, in one case, was covered with a buffy coat, but beneath its surface it was dissolved.

In the month of November, the disease assumed several inflammatory symptoms, and was attended with much less danger than formerly. I visited one patient whose symptoms were so inflammatory as to require two bleedings. During the decline of the disease, many people complained of troublesome sores on the ends of their fingers. A number of children likewise had sore throats and fevers, with eruptions on their skins, which resembled the chicken-pox. I am disposed to suspect that this eruption was the effect of a spice of the scarlatina anginosa, as several instances occurred of patients who had all the symptoms of this disease, in whom an eruption of white blisters succeeded their recovery. This form of the disease has been called by Sauvage, the scarlatina variolosa.

I saw one case of sore throat, which was succeeded not only by swellings in the abdomen and limbs, but by a catarrh, which brought on a fatal consumption.

A considerable shock of an earthquake was felt on the 29th of this month, at ten o'clock at night, in the city of Philadelphia; but no change was perceived in the disease, in consequence of it.

In December, January, and February, the weather was intensely cold. There was a thaw for a few days in January, which broke the ice of the Delaware, but it was followed by cold so excessive, as to close the river till the beginning of March. The mercury, on the 28th and 29th of February, stood below 0 in Fahrenheit's thermometer.

For a few weeks in the beginning of December, the disease disappeared in the circle of my patients, but it broke out with great violence the latter end of that month, and in the January following. Some of the worst cases that I met with (three of which proved fatal) were in those two months.

The disease disappeared in the spring, but it spread afterwards through the neighbouring states of New-Jersey, Delaware, and Maryland.

I shall now add an account of the remedies which I administered in this disease.

In every case that I was called to, I began the cure by giving a vomit joined with calomel. The vomit was either tartar emetic or ipecacuanha, according to the prejudices, habits, or constitutions of my patients. A quantity of bile was generally discharged by this medicine. Besides evacuating the contents of the stomach, it cleansed the throat in its passage downwards. To ensure this effect from the calomel, I always directed it to be given mixed with syrup or sugar and water, so as to diffuse it generally over every part of the throat. The calomel seldom failed to produce two or three stools. In several cases I was obliged, by the continuance of nausea, to repeat the emetics, and always with immediate and obvious advantage. I gave the calomel in moderate doses in every stage of the disease. To restrain its purgative effects, when necessary, I added to it a small quantity of opium.

During the whole course of the disease, where the calomel failed of opening the bowels, I gave lenient purges, when a disposition to costiveness required them.

The throat was kept clean by detergent gargles. In several instances I saw evident advantages from adding a few grains of calomel to them. In cases of great difficulty of swallowing or breathing, the patients found relief from receiving the steams of warm water mixed with a little vinegar, through a funnel into the throat.

A perspiration kept up by gentle doses of antimonials, and diluting drinks, impregnated with wine, always gave relief.

In every case which did not yield to the above remedies on the third day, I applied a blister behind each ear, or one to the neck, and, I think, always with good effects.

I met with no cases in which the bark appeared to be indicated, except the three in which the disease proved fatal. Where the sore throat was blended with the intermitting fever, the bark was given with advantage. But in common cases it was unnecessary. Subsequent observations have led me to believe, with Doctor Withering, that it is sometimes hurtful in this disease.

It proved fatal in many parts of the country, upon its first appearance; but wherever the mode of treatment here delivered was adopted, its mortality was soon checked. The calomel was used very generally in New-Jersey and New-York. In the Delaware state, a physician of character made it a practice not only to give calomel, but to anoint the outside of the throat with mercurial ointment.

ADDITIONAL OBSERVATIONS UPON THE Scarlatina Anginosa.

This disease has prevailed in Philadelphia, at different seasons, ever since the year 1783. It has blended itself occasionally with all our epidemics. Many cases have come under my notice since its first appearance, in which dropsical swellings have succeeded the fever. In some instances there appeared to be effusions of water not only in the limbs and abdomen, but in the thorax. They yielded, in every case that I attended, to purges of calomel and jalap. Where these swellings were neglected, they sometimes proved fatal.

In the winter of 1786–7, the scarlatina anginosa was blended with the cynanche parotidea, and in one instance with a typhus mitior. The last was in a young girl of nine years of age. She was seized with a vomiting of bile and an efflorescence on her breast, but discovered no other symptoms of the scarlatina anginosa till the sixteenth day of her fever, when a swelling appeared on the outside of her throat, and after her recovery, a pain and swelling in one of her knees.

In the month of July, 1787, a number of people were affected by sudden swellings of their lips and eyelids. These swellings generally came on in the night, were attended with little or no pain, and went off in two or three days. I met with only one case in which there was a different issue to these symptoms. It was in a patient in the Pennsylvania hospital, in whom a swelling in the lips ended in a suppuration, which, notwithstanding the liberal use of bark and wine, proved fatal in the course of twelve days.

In the months of June and July, 1788, a number of people were affected by sudden swellings, not only of the lips, but of the cheeks and throat. At the same time many persons were affected by an inflammation of the eyes. The swellings were attended with more pain than they were the year before, and some of them required one or two purges to remove them; but in general they went without medicine, in two or three days.

Is it proper to refer these complaints to the same cause which produces the scarlatina anginosa?

The prevalence of the scarlatina anginosa at the same time in this city; its disposition to produce swellings in different parts of the body; and the analogy of the intermitting fever, which often conceals itself under symptoms that are foreign to its usual type; all seem to render this conjecture probable. In one of the cases of an inflammation of the eye, which came under my notice, the patient was affected by a vomiting a few hours before the inflammation appeared, and complained of a sickness at his stomach for two or three days afterwards. Now a vomiting and nausea appear to be very generally symptoms of the scarlatina anginosa.

In the autumn of 1788, the scarlatina anginosa appeared with different degrees of violence in many parts of the city. In two instances it appeared with an obstinate diarrhœa; but it was in young subjects, and not in adults, as described by Doctor Withering. In both cases, the disease proved fatal; the one on the third, the other on the fifth day.

In the month of December of the same year, I saw one case in which a running from one of the ears, and a deafness came on, on the fifth day, immediately after the discharge of mucus from the nose had ceased. This case terminated favourably on the ninth day, but was succeeded, for several days afterwards, by a troublesome cough.

I shall conclude this essay by the following remarks:

1. Camphor has often been suspended in a bag from the neck, as a preservative against this disease. Repeated observations have taught me, that it possesses little or no efficacy for this purpose. I have had reason to entertain a more favourable opinion of the benefit of washing the hands and face with vinegar, and of rinsing the mouth and throat with vinegar and water every morning, as means of preventing this disease.

2. Whenever I have been called to a patient where the scarlatina appeared to be in a forming state, a vomit of ipecacuanha or tartar emetic, mixed with a few grains of calomel, has never failed of completely checking the disease, or of so far mitigating its violence, as to dispose it to a favourable issue in a few days; and if these observations should serve no other purpose than to awaken the early attention of patients and physicians to this speedy and effectual remedy, they will not have been recorded in vain.

3. When the matter which produces this disease has been received into the body, a purge has prevented its being excited into action, or rendered it mild, throughout a whole family. For this practice I am indebted to some observations on the scarlatina, published by Dr. Sims in the first volume of the Medical Memoirs.

4. During the prevalence of the inflammatory constitution of the atmosphere, between the years 1793 and 1800, this disease occurred occasionally in Philadelphia, and yielded, like the other epidemics of those years, to copious blood-letting, and other depleting remedies.