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An Account of the Scarlet Fever and Sore Throat, or Scarlatina
Anginofa ; particularly as it appeared at Birmingham in the Year 1778. By William Withering, M. D. 8vo.
Cadell. THE HE present alarming frequency, if not the novelty, of this
disease in the western parts of England, renders it an object worthy the particular attention of all who are engaged in medical practice; and we are therefore glad to find that its nature, and the method of cure, are investigated with so much precision in the treatise now before us, which contains an account of the disease as it appeared at Birmingham, in the year 1778. Its invasion at that place happened about the middle of May; and in the beginning of June, the disorder increased in many of the towns and villages in the neighbourhood. It was preceded by some cases of the genuine ulcerated sore throat, and accompanied in its course through the summer by the hooping-cough, the measles, the smallpox, and several instances of the true quinsy. It continued with unabating force and frequency to the end of October ; though it varied in some of its symptoms as the air became more cold. In the beginning of November it was rarely met with, but towards the middle of that month, when the tem. perature of the air changed, it resumed in great measure the same appearances, which it had distinguished it in the former part of the year.
But it is necessary that we present our readers with the author's description and history of the disease. • It affected children,' says he, ' more than adults ;
but seldom occurred in the former under two years of age, or in the latter when more than fifty. In children the number of boys and girls that suffered from it was nearly equal, but in adults the number of female patients considerably exceeded that of the male; probably because the former were more employed in attendance upon the fick, and consequently more exposed to the infection.
. On the first seizure the patients feel an unusual weariness, or inaptitude to motion; a dejection of spirits, and a slight foreness or rather stiffness in the throat; with a sense of Itrajtness in the muscles of the neck and shoulders as if they were bound with cords. In a few hours chilly fits take place, generally alternating with flashing heat; but at length the heat prevails altogether. The patients now complain of light head-aches, and transitory fits of fickness. They pass a restless night, not so much fron pain, as from want of inclination to sleep.
• The next day the foreness in the throat increases, and they find a difficulty in swallowing, but the dificulty seems less oc
casioned by the pain excited in the attempt, or by the straitness of the passage, than by an inability to throw the neceffary muscles into action. A total difrelish to food takes place, and the fickness frequently arises to a vomiting. The breathing is more and often interrupted by a kind of imperfect figh. The skin feels hot and dry, but not hard; and the patients experience frequent, small, pungent pains, as if touched with the point of a needle. Towards evening the heat and restlessnefs increase; the breath is hot and burning to the lips; thirst makes them wish to drink, but the tendency to fickness, and the exertions necefiary to frequent deglutitions are so unpleasant, that they feldom care to drink much at a time. This night is paffed with ftill greater inquietude than the former. In the morning the face, neck, and breaft, appear redder than usual; in a few hours this redness becomes universal, and increases to such a degree of intensity, that the face, body, and limbs, resemble a boiled lobster in colour, and are evidently swollen. Upon preffure the redness vanilhes, but soon returns again. The skin is smooth to the touch, nor is there the least appearance of pimples or postules. The eyes and nostrils partake more or less of the general redness; and in proportion to the intensity of this colour in the eyes, the tendency to delirium prevails.
• Things continge nearly in this state for two or three days longer, when the intense scarlet gradaally abates, a brown colour succeeds, and the kin becoming rough, peels off in smal} branny scales. The tumefaction subfides at the fame time, and the patients gradually recover their ftrength and appetite.
• During the whole course of the sever, the pulse is quick, small, and uncommonly feeble. The bowels regular in their discharges. The urine small in quantity, but scarcely differing in appearance from that of a person in health. The submaxila lary glands are generally enlarged, and rather painful when pressed by the fingers.
• The tongue is red and moist, at the end and at the sides, but drier in the middle, and more or less covered with a yellowish brown mucus. The velum pendulum palari, the uvula, the tonsils, and the gullet as far as the eye can reach, partake the general redness and tumefaction. I never saw any real ulceration in the parts, but sometimes collections of thick mucus, partiCularly on the back of the esophagus, greatly resembling the fpecks or sloughs in the putrid føre throat, but these are eafily washed away by any common gargle. After the fever ceases, it is not uncommon to have abscesses form on one or both sides of the neck under the ears, but the matter easily discharges itself through the ruptured teguments, ard they heal in a few days without much croable.
• The above is a picture of the disease in its most ucual appearance; but it too frequently affumes a much more fatal form.
• In children, che delirium commences in a few hours after the forit feizure. The fefa is intensely hot; the scarlet colour ap
pears on the first or second day, and they die very early on the third.
• In others who survive this sapid termination, when the scarlet turns to brown, and you would exped their recovery, the pulse ftill remains feeble and quick, the skin becomes dry and harsh, the mouth parched, the lips chopped and black; the tongue hard, dry, and dark brown, the eyes heavy and funk; they express an averfion to all kinds of food, and extreme uneasiness upon every the least motion or disturbance. Thus they lie for several days, nothing seeming to afford them any relief. At length a clear amber-coloured matter discharges in great quantities from the nostrils, or the ears, or both, and continues so to discharge for many days. Sometimes this discharge has more the appearance of pus, mixed with mucus. Under these circumstances when the patients do recover, it is very slowly; but they generally linger for a month or six weeks from the first attack, and die at length of extreme debility.
• In adults, the rapidity of the fever, the delirium, &c. is such that they die upon the fourth or fifth day, especially if a purging fupervenes. Some survive to the eighth, or io the eleventh day ; in all these the throat is but little affected: the eyes have an uncommon red appearance, not that streaky redness which is evidently occafioned by the vessels of the cornea being injected with red blood, but an equable shining redness, resembling that which we remark in the eye of a ferret. But notwith&tanding this morbid appearance in the eye, the strongest light is not offensive. This
appearance may often be discovered, by lifting up the upper eyelid, lome hours before it shews itself in the part of the eye that is usually visible, and it is of some consequence to atiend to this circumstance, as it greatly influences the event of the case.
• Besides the full scarlet colour described above, there are frequently small circular spots of a livid colour about the breast, koces and elbo vs. The patients are extremely restless, clamourous, and desirous to drink; but after swallowing one or two mouthfuls, upon taking another, seem to forget to lwallow, and let it run out at the corners of the mouth; whilst others spurt it out with considerable force, and are very angry if urged to drink again. In these cases, the scarlet colour appears very foon after the attack, bus in an unfectled and irregular manner; large blotches of red, and others of white intermixed and often changing places. The pulse from the very beginning so quick, to feeble, and so irregular, that it is hardly posible to count it for half a minute at a sime. ---- -It is needless to add, that the greater part of those who laboured under these dreadful fymptoms died. A few recovered, and others full into a flate of debility bordering upon ideotism, from which they were rescued by time and generous living.'
Such was the disease during the bot months, but in Oober the scarlet colour of the skin became less frequent, as well as
continued a shorter time. In many patients this fymptom could not be observed; but in others, especially adults, a few small red pimples, with white pellucid heads, appeared on the more tender parts of the skin. The inside of the throat was so much tumefied, as to render deglutition difficult and painful; and in fome the disease was evidently propagated down the trachea. From the throat and noftrils were occafionally discharged large quantities of viscid mucus and purulent-like inatter, which in some was accompanied with white or afh-coloured Noughs, that had been separated from the fauces and tonfils. Under this autumnal appearance, the fever generally had a favourable termination on the fifth, eighth, or eleventh day, but was sometimes protracted to a much later period by the formation of large and painful abfceffcs.
After delivering the sentiments of various medical authors on the Scarlet Fever, Dr. Withering proceeds to specify the diagnostic symptoms of the disease; a distinction the more neceflary, as this disorder bears a resemblance to some others of the febrile kind, from which however it differs in respect to the method of cure.
The author has made fome ingenious remarks on the causes and nature of the disease, fo far as they tend to elucidate the curative indications; and he has given his opinion of the latter with great judgement, under a variety of heads, of which we Mall lay before our readers a few of the most important.
• BLOOD-Letting. Plenciz and Navier advise us to use the lancet. The former in more general practice, but the latter confines it to cases wherein the inflammatory symptoms run very high. He directs to bleed in the arm, but in case of delirium or coma, to open the jugular vein.
• Our own countryman Morton, says we should not bleed without evident reason.
• Indeed such was the state of the pulse with us during the summer months, that I never saw a case in which blood was taken away: nor would it be easy to conceive with what view the boldest, or the most ignorant practitioner would have dared to attempt it; for in those cases where the inflammation upon the surface is very great, the loss of blood can only contribute to the further depletion of the larger vessels, and thereby increale the debility and faintness which already exist in a molt alarming degree; for the small vessels accumulating the blood more in consequence of their own action, than from the pulse of the heart, would not be affected by the usual mode of blood leiting; and the extent of the inflammation is much too great to allow us to have recourse to topical bleedings.
• Sometimes where the fiery redness of the eyes and the fate of delirium ieemed to demand the application of leeches to the
temples, temples, I have seen them applied; but never with any good effect. In one instance where the constant rejection of every thing that was swallowed, even fimple water, and the pain in the ftomach during the efforts, seemed to indicate an inflammation in that organ, blood was taken away, notwithstanding the feebleness of the pulse. The blood was fizy. The bleeding was repeated; but no very evident advantage accrued to the patient. ị think therefore we may conclude that when the scarlet colour upon the kin is intense, we cannot expect to benefit either from topical or general bleedings.
• In the autumn when the scarlet colour of the skin was seldom very intense, and often did not appear at all, the tumefaction of the fauces was generally much greater, and the pulse confiderably more firm. In this case, if the patient was threatened with fuffocation, if violent head-ache, or if peripneumonic symptoms pointed out the expediency of blood-letting, it was sometimes done; but ftill with less advantage than one would have expected in almost any other situation; and fimilar symptoms in other patients were much more effectually relieved by
- VOMITING. It is very remarkable that neither Navier nor Plenciz, after having entered more particularly into the method of cure than any other writers, have never so much as mentioned the use of emetics. Vomiting feems to be the remedy of nature: it stands foremoft in her efforts to throw off the cause of the disease: it molt amply fulfils the indications arising both from a consideration of the cause and of the effects. If we want to dislodge a poison from the fauces, and the mucous membrane of the nose, and to prevent its descent to the stomacb, how shall we do it so effe ctually as by emetics? if the poison already acting upon the nervous system, destroys the equilibrium of the circu. lating powers, how can we fo readily restore that equilibrium as by emetics ? Does not the experience of every day confirm their efficacy in a variety of disorders dependant upon local congeftions?
• But not to proceed further with questions that cannot fail to be answered in the affirmative, I will venture to affert that the liberai use of emetics, is the true foundation for successful practice in the scarlet fever and sore throat.
• In the very first attack, a vomit feldom fails to remove the disease at once--if the poison has begun to exert its effects upon the nervous system, emetics stop iis further progress, and the patients quickly recover. If it bas proceeded ftill further and occasioned that amazing action in the capillaries, which exists when the scarlet colour of the skin takes place, vomiting never fails to procure a respite to the anxiety, the fainineis, ihe delirium,
• In autumn when the throat was more affected; when the tumefaction of the fauces was such that the patients could not fwallow but with the utmost difficulty: when the peripneumonic