OBSERVATIONS On a particular Kind of SCARLET FEVER, That lately prevailed in and about ST. ALBAN's. In a LETTER to Dr. MEAD.
By NATHANAEL COTTON, M.D.
LONDON, Printed for R. MANBY and H.S. Cox, on
Ludgate-Hill.
MDCCXLIX.
OBSERVATIONS,
&c.
SIR,
St.
Alban
's
Feb. 12, 1748-9.
I Take the liberty to send you a few observations on a particular kind of Scarlet Fever, that hath lately obtained in this place, and some towns adjacent. The only circumstances, which can entitle this sheet to the trouble of your perusal, are the novelty of the subject, and a careful representation of facts. Nor shall I obtrude upon you any vague conjectures, or precarious hypotheses, relating to the causes of this disease; much less take up your valuable moments in the pursuit of useless, unmeaning quotations from other authors.
About the latter end of
Sept.
1748. a Scarlet Fever began to appear in this town. At first children only were seized with it; but afterwards it attacked adults. The manner of seizure was not always one and the same. There was some diversity herein; as likewise in the symptoms, and stages of the disease. Its period also was sometimes various in various patients. And as there was a difference in the time, so likewise there was in the manner of its terminating.
In general, the first symptoms were sickness, vomiting and purging. But these symptoms seemed pretty much confined to children. A sore throat either attended these discharges of the intestinal tube, or immediately followed. The Tonsils, Parotids, and maxillary glands hastily swelled to a considerable degree. In some, the Tonsils only were inflamed and swelled; in some a swelling of the Parotids accompanied the inflammatory tumours of the Tonsils; in some, all the glands abovementioned tumefied at the same time. Upon looking into the mouth, there were frequently seen, especially after the disease was a little advanced,
ulcuscula,
scattered up and down the
fauces,
which were pretty broad upon, and about the Tonsils, superficial, (at least all, that I saw, were superficial) and covered with a whitish slough. The eyes appeared watry, and the countenance, particularly the eye-lids were puffed up, as in the Measles. In many, the neck, arms, and hands were puffed up, and swelled likewise. And it is not improbable, that the trunk of the body was also swelled, if we could as easily have discerned such a general enlargement, as we could the enlargement of a particular member. In some, a cough also accompanied the preceding symptoms. But there was a great difference as to the cough: for in some, it was slight, and rather abated, as the disease advanced; while in others, it encreased, and grew severer each day than the preceding.
The scarlet Efflorescence differed as to degree, and time of its appearance. In some it appeared immediately on the attack of the disease; and That, not always gradually, as many eruptive disorders do; but in some it was sudden, universal, and of an intense red; as intensely red sometimes upon its first appearance, as when the disease was further advanced. In some, there intervened one or more days between the first sickening, and the scarlet efflorescence; and in some, this efflorescence was partial, and gradual in its advances. The legs and thighs were spotted up and down with spots of various dimensions, some as large, or larger than a six-pence, while the trunk of the body was covered with such an infinite number of them, and so closely set together, that no interstices appearing, the body was in some persons as red almost, as if it had been dipped in blood. In others again the scarlet efflorescence was trifling as to the degree of colour; and so very slightly was the skin tinged, that the disease was known, more from the collateral symptoms, than from the efflorescence. Yet the sameness of some symptoms, happening in a family to one or two, where the rest had the disease compleat, abundantly satisfied me as to the genius of the distemper.
From this diversity of symptoms, I have found some practitioners inclined to think, that this disease could not with propriety be called a scarlet fever. But I imagine, that such disputes are about words only. For altho' there is a considerable difference between the present scarlet fever, and that milder one, which
Sydenham
describes; yet if an increased number of symptoms, and a more exasperated degree thereof, would authorise a physician to alter the name of the difease, I fear, that confusion would be the consequence of such a liberty. For the same reasons, the small Pox might suffer a change in its name; because there is not so great, or a greater difference between a former, and the present Scarlet Fever, than there is between small pox and small pox; more especially if the comparison be made between the mildest degree of the
distinct,
and the most violent degree of the
confluent
sort. But if a man consults
Morton,
as well as
Sydenham,
he will find, that the
febris scarlatina
of the former differs greatly from the
febris scarlatina
of the latter, as to the appearance, degree, and period of the disease. For however mildly
Sydenham
represents this distemper,
Morton
scruples not emphatically to term it a plague; and his reasons are the severity of some of the symptoms. In his eleventh case, towards the close, speaking of a patient, he hath these words,
a peste, inquam, evasit.
And afterwards he goes on thus,
quantum tonsillas, uvulam, fauces, nares, et quamdiu intumuisse vidi! quam turgida nonnunquam labia! et quam sordida scabie obducta et exulcerata ab eadem causa animadverti!
I might observe, that this scarlet eshorescence not only differed as to degree in different persons, but in one and the same person, there was often this diversity. The efflorescence on the face, neck, and breast was even with the superficies of the skin (
rysipelas
-like) at least so far as the eye could discover; while in other parts, the eruptions were more prominent, and carried the exact appearance of a
Rash,
(with this difference only, that they were very red) and the cuticle felt with all the asperity of
Fishskin,
that spectacle cases and the like are frequently made of.
I now proceed to the Fever, which in most was high, that is to say, intense thirst, and the sensation of a burning heat upon the skin, were the prevailing complaints of the greater part of those, who laboured under the disease. But even with all this extraordinary heat and increased celerity of the blood's motion, the tongue was commonly moist, furred but slightly, and here and there a person not very thirsty. Some underwent extreme anxiety and inquietude; some were delirious for four, or more days together, without one lucid interval or slumber, incessantly talking incoherently. Others were comatous, and when awaked to drink, immediately relapsed to sleep again. Only a few complained of head-achs; and even some of those, who were afterwards most delirious, did not complain of previous pain in the head. Several were sleepless whole days and nights successively, without any delirium. Almost all complained of great dejection of spirits, and sudden loss of strength, which leads me to speak of the pulse.
The Pulse in general was very quick, and very small; which circumstance, in conjunction with lowness of spirits, and impaired strength, contributed a good deal to embarrass the method of cure. For however the inflammatory disposition of the blood might seemingly call for Bleeding, the untoward symptoms abovementioned seemed either to forbid this discharge, or to permit it in such small quantities, that little service could reasonably be expected from it. And in fact I found that bleeding, tho' recourse was had to it at the beginning, was very little beneficial towards the cure of the fever, tho' often serviceable to the inflamed throat. But of bleeding more hereafter. Let me here add, that there were a few, whose pulse was quick, and not weak; and in this case, I ordered plentiful bleeding, and even repeated it, if the difficulty of deglutition was considerable. I remember two patients particularly, the one about eleven years of age, the other about eighteen, each of whom I blooded the second and third day of the disease. The first bleeding was followed with little, or no benefit to either of them. The next day, finding their tonsils still greatly swelled and inflamed, and apprehending danger of suffocating in a few hours, I directed a further quantity of blood to be taken away, which presently abated these complaints. Their blood was sizey each time of bleeding. But tho' in these, and a few more persons, the blood was sizey, yet in others it was not so, notwithstanding they were bled after the disease was pretty far advanced: for it is well known, that even in the small pox, and many other inflammatory diseases, the blood, when taken away at the beginning, is frequently not sizey, tho' found to be so, upon bleeding some days afterwards. Nor can I recollect, that any ill effect followed upon bleeding, where I directed it. Tho' there frequently occurred cases, where the smallness of the pulse, and lowness of the spirits deterred me from it. But then these circumstances were so obvious and glaring, that they could not escape an inattentive practitioner.
The urine was seldom high coloured, not even the urine of adults; it was generally the complexion of water saturated with a paler clay. And when the fever abated, the urine, as usually, separated, and deposited a thick clay-coloured sediment. In some indeed, who were remarkably delirious, the urine was limpid and pale, as is common under such circumstances; but, as the patient mended, the urine had a better colour and consistence, and threw down a plentiful sediment.
There was some diversity in the terminating of this disease, both as to the time and manner. When it was not very violent, it terminated, in some measure, on the fourth or fifth day; that is, the disease at that period had arrived to its height, and was on the decline. In few or none did the fever leave the patient so totally, but it recurred once, twice, or more, the evenings following; and grew so mild at each return, as to be little more, than barely noticed: at which time too, all the glandulous swellings commonly vanished. But in some, altho' the fever evidently remitted of its severity on the fourth, or fifth day, its returns were of more hours duration, and higher in degree; and a large share of inquietude continued, even to the eighth, or ninth day. In one person particularly, the delirium continued after the fever was off, the skin cool, the efflorescence dying away, and the pulse slow and regular. In another, when the fever was past its height, the Parotids began to swell for the first time, and continued to enlarge for three days successively; when suddenly they subsided, in a night's time, one half of their increased magnitude. In two persons, after the fever was quite removed, and the appetite for food returned, the tumor of the Parotids still continued, which daily encreased in their bulk, and gradually grew harder, till a fortnight or three weeks afterwards, the right Parotid of the one, and the left Parotid of the other suppurated largely.
The distemper left a great many very low spirited, complaining of an ill taste in their mouth, with loss of strength, and a slowly recovering appetite. The cuticle of almost all peeled off, as in other scarlet fevers; and many complained for a long time, that their bodies were as sore within, as without. Such a sensibility indeed they suffered, as rendered them quite unhappy.
In some the nervous system was shattered to such a degree, that the dejection of spirits, which had accompanied the disease thro' all its stages, still continued, when the distemper was over; and the patient dreaded the approach of the evening with an unusual kind of horror, assuring me, that the shadows which were consequent upon the lighting up of candles, affected their minds with extravagant terrors and perturbations. And I well remember, that in a child near three years old, this circumstance was so very remarkable, that upon the candles entering the room, and the shadows arising thereupon, the boy appeared with a ghastly stare; and cried with a vehemence not to be pacified, on discovering the moving shades on the walls of the chamber.
I now proceed to the cure, the method whereof was different in different patients. When the disease began with sickness and purging, as it generally did, I commonly ordered a salt of wormwood mixture, with the testaceous powders in it; upon which the vomiting and diarrhoea usually stopped, and truly I hardly remember, that they ever returned again. Then if the inflammation and swelling of the tonsils, and parts adjacent required, and the pulse permitted, I directed bleeding, and repeated it as the symptoms indicated. If this method did not take speedy effect, I ordered a vesicatory between the shoulders; and for internals, I commonly prescribed draughts of
sperma ceti
and
nitre,
with plentiful dilution, by means of barley-gruel, white wine whey, and other liquors. Sometimes too I ordered
linctuses,
gratefully acidulated with spirit of vitriol, or in lieu of linctuses, black currant jelly; in order to keep the parts soft and flexible, and to remove or abate that aridity, which is an attendant of inflamed parts, especially such as are exposed to the air; and the tonsils may be justly regarded in this view, because the nostrils being generally stopped, the patient was obliged to inspire thro' his mouth.
And by this method alone the distemper, when not violent, went thro' its stages with success. But if
subsultus tendinum, deliria,
and other threatening symptoms appeared, I immediately applied
blisters
likewise to the arms. And if symptoms were not obviated hereby, but the pulse also began to sink, I directed a vesicatory to the head, and exchanged the
nitre
for warmer medicines, such as the
pulvis bezoardicus, contrayervae comp,
and
confectio cardiaca.
If the ulcers on the tonsils and
fauces
were fouler than common, detersive and astringent gargarisms were found to be of service, by contributing much to bring away the sloughs, and facilitate deglutition.
If the fever ran high, and the body was very costive, I ordered an emollient clyster. But the observations made on bleeding held true likewise here. For the usual weakness of the patient, and depression of spirits, seemed to hint, that these intestinal discharges were the less necessary; and the scarlet efflorescence seemed likewise to forbid a too great laxity being brought upon the intestines.
And now I shall conclude, by throwing together a few general observations, which could not conveniently be classed under the foregoing articles.
Opiates had no beneficial influences to remove watchfulness. This perhaps is not to be wondered at, during the febrile ebullition; tho'
Sydenham
recommends paregorics under the worst symptoms, that he hath mentioned of this disease. But in three persons or more, where the fever was in great part, or altogether off, I gave opiates aromatized; to one, that I might calm the delirium; and to others, that I might procure sleep after many nights watching. But all to no purpose.
I bled one patient, whose pulse was tolerably strong, to remove the delirium and loquacity, that still continued, after the fever was seemingly gone. But no benefit arising in a few hours after bleeding, I ordered blisters to the arms, administered more cordial medicines than before; and that night the patient slept several hours without waking, and afterwards mended apace.
The blood had no size upon it, the serum was a bright citron, and bore a due proportion to the
crassamentum,
as in health.
In others, under pretty much the same circumstances, as the foregoing, but where the pulse was not so strong indeed, I omitted bleeding, and prescribed vesicatories, and generous medicines, but no sleep ensued hereupon.
I was called to a child of four years old, the second day of the disease. He appeared quite bereaved of sense, almost suffocated, and at the point of death. Immediately I ordered him to be blooded to six ounces, speedily after which he revived, and came to himself. The child was naturally subject to enlarged Tonsils. But this symptom of strangling hastily came on, I think, within the space of half an hour, or thereabouts. On the fourth day, at two in the afternoon, it returned again with greater severity, if possible, than before; tho' several blisters that had been applied, discharged most copiously. The Tonsils were swelled to that degree, as threatened every minute to preclude all admission of air. Whereupon a Surgeon was called in, who attempted to relieve the child, by making incisions on these glands. And so far the operation answered the end, that the boy who appeared before in danger every moment of being suffocated, lived 'till about seven in the evening. The operation was followed by a pretty deal of blood, and a little purulent matter, which was very offensive to the smell.
There were two things remarkable in blistering; the one was, that oftentimes no good effect accrued hereby to the fever, tho' the pulse by these means was generally raised, and the difficulty of deglutition somewhat abated. The spirits too were improved by these applications. And indeed in a disease so seemingly threatening, perhaps it would be imprudent to omit these applications. For altho' the fever did not yield to them, so as to shorten its stages; yet it is probable, that symptoms were hereby prevented from rising to a more dangerous height. And in general it was true, that few were delirious, whose complaints of the throat obliged them to the early application of blisters. However this observation did not always hold good; for there were a few, who had blisters timely applied, and nevertheless, a subsequent delirium not prevented.
Another remark worth noticing, was the great length of time, that the blisters continued to discharge. In some, for eight or ten days successively, and in some, much longer.
In general, few sweated plentifully, till towards the conclusion of the cure;
i. e.
till the fever was past its height. The younger the patients, the earlier, and the more they sweated, and so
vice versâ.
The appearance of the efflorescence seemed to command but little regard, as to the method of cure. For I have seen some persons raving, with the eruption fully out, and intensely red; and I have seen others equally delirious, with the eruption sparing and pale. So that latterly I did not much consult the appearance of the efflorence, but I ordered bleeding &c. as other circumstances indicated.
It is a general law in eruptive disorders, that the more liberally the eruption comes out, the securer is the patient rendered thereby. And yet so little did this rule hold true here, that in two patients, who died, the efflorescence was universal, and florid to the last. And in one of them, that
anxietas circa praecordia,
which is usually most urgent in other eruptive fevers, before the eruption breaks out, was in this case as exquisite, when the efflorescence had attained its highest colour, as before the efflorescence made its appearance.
Under the article of cure, I should have observed, that the universal soreness within, which multitudes complained of, was alleviated much by solutions of
sperma ceti,
light oleaginous mixtures, broths,
&c.
and when the cough continued, bleeding and asses milk removed this complaint.
But the most troublesome symptom, which occurred after the fever was removed, was that great dread upon the spirits mentioned before, which occasioned the unhappy patient to fear the approach of the evening. Here no
nervous
medicines, as they are called, seemed to take any immediate effect. But air and a restorative diet gradually restored the person to better spirits.
From the whole, that I have advanced upon this disease, I think it appears, that general rules of cure were precarious and uncertain; and that particular rules were not ascertainable, on account of the various appearances, and symptoms of the disease, and the various constitutions of various patients. And this perhaps furnishes a hint, why mankind are so often disappointed in the perusal of medicinal writers. We are apt to expect too much from them; indeed more, than it is possible for the art to supply. When authors write generally upon these subjects, they seldom write very usefully; and when they write particularly, we grow weary of their prolixity. And perhaps, after the pains of turning over a variety of volumes, we still find, that the particular case we wanted, is either not mentioned at all, or too partially and superficially, to serve our purposes.
So that it is in Medicine, as in Navigation. Rules may be laid down, and Charts exhibited; but when a man hath made himself master of all these, he will often find himself among shelves and quicksands; and must at last have recourse to his own natural sagacity, to extricate himself out of these difficulties.
When obscurities arise, and emergencies press, every practitioner knows, how poor and insufficient all
systematic
authors are; and how tedious, and oftentimes unavailing the best
observators.
The necessity therefore, and superiority of a physician's own judgment, in many cases, to the writings of others, Your practice and Your success most abundantly testify. I am, with the greatest respect,
SIR, Your very obedient Humble Servant,
N. COTTON.
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