M0*\.. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/inauguraldissertOOtayl AN ; :,,•,/: '■ ' ; INAUGURAL DISSERT Ati®^ ON THE SCARLATINA ANG1N0SA, AS IT PREVAILED IN THIS CITY. SUBMITTED TO THE PUBLIC EXAMINATION OF THE FACULTY OF PHYSIC, UNDER THE AUTHORITY OF THE TRUSTEES OF COLUMBIA COLLEGE IN THE STATE OF NEW-YORK: WILLIAM SAMUEL JOHNSON, LL.D. Prefident; FOR THE DEGREE OF DOCTOR OF P H Y S I C; ON THE THIRTIETH DAY OF APRIL, I793. By WILLETT TAYLOR, junior, Citizen of the State of New-Yofk. MISERIS SUCCURRERE DISCO. VIRG. N E W - Y O R K : Printed by T. and j. Swords, Printers to the Faculty of Phyfic of Columbia College, No. 27, William -Street. — x 793 — Imprimatur. •52. Gul. Hamerjley, Med. Theoret. Profeffor. SAMUEL BARD, M.D. Dean of the Faculty of Phyfic ?N COLUMBIA COLLEGE, N E W- Y O R K: THIS DISSERTATION Is refpe&fally infcribed, jfy bis obliged Friend, And humble Servant? The AUTHOR. ,C tJ /& *J « 1 *■ * _ A . - -' • » * * " » > o t INAUGURAL DISSERTATION ON T H S SCARLATINA ANGINOSA, AS IT PREVAILED IN THIS CITY. V>ONTAGIOUS difeafes, from their firft ap- pearance, have proved fo deftruclive to mankind, that any attempt to investigate their real nature, mult, be coniidered as. not only laudable, but as a duty highly incumbent on thofe who are intrufted with the lives of their fellow citizens. This difeafe has lately appeared as an epidemic in this city, and frill continues fo at the prefent time. From the variety of appearances which it has af- fumed, it has engaged the attention of Phyficians ; among ( 6 ) amotig whom there has been a difference of opinion. Some have fuppofed the fever, which accompanies this difeafe, to he of an inflammatory nature -, whilfl: others 'have, confidently aflerted that it was a real Typhus. I mail here attempt a defcription of the Scarlatina 'Anginofa^ as it appeared in this city, with that diffi- dence which becomes a young Practitioner ; not de- pending altogether upon my own judgment, but viewing it as fanctioned by men who are eminently diftinguifhed in this department of fcience. A defcription of this difeafe is not to be found in the writings of Hippocrates ; and as the exanthe- matic fevers were only confidered as varieties of febrile difeafes, we confequently meet with no ac- curate account of the fcarlet fever until the {qvqii- teenth century -, becaufe, previous to that period, medicine had never appeared in fyftematic form. Sydenham, in his writings, has defcribed a fever under this name, but without any affection of the throat : his defcription may therefore anfwer to the Scarlatina Simplex of Doctor Cullen. It ( 7 3 It is afferted, that, in the year 1689, it prevailed as an epidemic in London. Doclor Morton fpeaks of it in his Pyretologia. He thinks it differs from the meafles only in the mode of eruption. In the years 1748 and 1749, this difeafe raged at the Hague : it proved fatal to a great number of people. The fever was evidently typhus. Do6tor De Haen defcribes it as it fell under his immediate obfervation, and relates feveral cafes.— Unfortunately he praclifed blood-letting very freely, and was upon that account very unfuccefsful in his treatment of the difeafe. Sauvage defcribes a fcarlet fever, attended with idcerous fore throat, which prevailed at Montpelier in the year 1765. The difeafe was then, as it has generally been here, confined chiefly to children. Other authors have defcribed this difeafe. Wi- thering fpeaks of it as inflammatory ; Doclor Cul- kn feems to be of the fame opinion, and terms it Synocka ( 8 ) Synocba Contagiosa ; Doctor M'Bride conceives it to be fbmetimes inflammatory, at others nervous, or, in the language of exploded opinions, putrid. In the month of July, 1792, the fcarlet fever appeared in this city. It firft difcovered itfelf in fome narrow ftreets near the North-River, where the houfes were fmall, occupied by feveral" families, and badly ventilated. From the indigent circum- ftances of thofe whom it chiefly afrected, it ■ was Impoflible they could pay that attention to cleanli- nefs which was neceffary for the prefervation of their health. It was confined to this part of the city for fome time^ but at length it fpread, and became more general and raged with peculiar vio- lence in thofe parts of the city where the inhabitants were in the situation juft defcribed. It is alfo to be remarked, that as the cold weather approached, it gradually abated •> and as the cold increafed, it al- moft difappeared, HISTORY ( 9 ) HISTORY of the DISEASE. THIS difeafe generally began with anorexia, naufea, and fometimes vomiting; great laffitudc, chiilinefs, and fhivering : the patient loon complained of an head-ach; and a ftifFnefs was commonly- felt about the neck, with fome uneafinefs in the in- ternal fauces. Upon looking into the mouth, the velum pendulum palati, tonfils, and uvula appeared of a red colour : as the rednefs increased, a number of white or afh-coloured fpots made their appear- ance, which at length became as many ulcers. Deglutition was fometimes painful and difficult, the refpiration quick and laborious ; but the breath at this ftage of the difeafe was not ofTenhVe : the tongue was covered with a white fur, and the mouth and fauces loaded with mucus. Thefe fymptoms were attended with fome degree of coryza, but not fo much as to prove troublefome. The patient was now affedled with alternate chills and heats, the ikin grew hot, and the pulfe became rather hard and full. There was generally in the evening an exacer- ' bation of the fever, and the patient grew reftiefs, and fometimes delirious. B Upon ( io ) Upon the third or fourth day of the difeafe, the eruption made its appearance; the rednefs was firft perceived on the face, neck and breaft, and extended fometimes over the whole body, which became very turgid ; at other times it was not fo diffufed ; but very generally the extremities were affected, and the hands and fingers much fwelled, and pain- ful to the touch. I always found, that when the eruption on the furface of the body was in a trifling degree, the throat was much inflamed, and vice verfa. Some Practitioners in this city affert that they have {qqu. a Scarlatina Simplex, but in every cafe I have found it attended with feme degree of Cynancbe. Upon the appearance of the efHorefcence, the fever fuffered very little remiffion ; on the contrary, it frequently increafed : the duration of the eruption was uncertain \ its colour was generally changed to a brownifn appearance in three or four days : the fkin became rough, and a confiderable desquama- tion took place -, among fome it was fo great that a complete cuticular glove was taken off. The ( II ) The eruption would often vary as to its appear- ance : fometimes it would appear in fmall points ; at others, the fkin would be fmooth and equal \ and now and then fmall phlogofes phlegmonodes difco- vered themfelves, and ended in fuppuration. After the defquamation took place, the fever remitted, and a gentle fweat came on, which gave a further remimon \ the fauces looked better, the ulcerations foon healed, and the patient recovered Jiis ufual health, I have now defcribed the Scarlatina Anginofa as it appeared in its mild ftate. Several perfons who had it in its gentler}, form, fell into anfacrous fwel- lings, and had a hydrops pectoris. In confirma- tion of this afTertion, I beg leave to obferve, that from the dirTe&ions of people who have died of this difeafe, I can fay from my own experience, that there have been ferous effufions into the cavity of the bronchia, as well as into the thorax, which I apprehend may have occafioned fuifocation; of • which three or four cafes have fell under my oh- fervation. Although ( 12 ) Although the Scarlatina frequently terminated favourably, yet it often proved fatal, particularly to children. I mall now proceed to defcribe it as it appeared in its moft dangerous form. The iicknefs, which was not very great in the Scarlatina Benigna, proved very diftreffing to the patient in the Scarlatina Maligna^ which was almoft always attended with fome degree of vomiting : the parotid and maxiliary glands were confiderably fwelled, and often threatened fuirocation : the coryza, which was fcarcely perceptible in the one, was very considerably increafed in the other : the nofe, eyes and fauces difcharged an acrid matter, which excoriated the noftrils and lips ♦, palling alfo from the fauces into the cefophagus, it fpread through the whole of the alimentary canal, ccca- iioning diarrhoea. The ulcers were very numerous, they put on a livid appearance, and the breath became very offen- five. The -efrlorefcence would fometimes entirely difappear, or turn to a dark or livid colour ; the tongue was dry, and covered with a brownifh fcurfs the ( 13 ) the refpiraticn fmall, hurried, and laborious, at- tended with anxiety, and great oppreilion about the praecordia : fometimes delirium from the beginning came on, and continued through the whole courfe of the difeafe, but generally did not make its ap- pearance until the third or fourth day, and often not until a frill later period : the eyes foon loft their luftre, looked glafTy, and appeared to fink in their fockets : the patient complained of great thirft, and had a defire for acids. To thefe fymptoms fuc- ceeded involuntary difcharges of foeces and urine. The puife from the beginning was fmall, frequent, and often irregular. All thefe fymptoms increafing, the patient frequently became comatofe, and in that ftate expired. Hiccough, and fubfultus tendinum, would frequently terminate the life of the patient. Some perfons, during the continuance of this difeafe, laboured under pneumonic affections. In fome, the attack was preceded hy cholera \ but as they were accidental fymptoms, they were treated as fuch. It has generally been obferved in thefe cafes, where the flrength of the patient had been greatly ( 14 ) greatly exhaufted from exceffive evacuations, that by- far the greater number of them proved fatal. As our different modern writers have held dif- ferent opinions refpecting the nature of the fever attending Scarlatina Angtnofa y I am induced to fay fomething refpecting it. Doctor Cullen places this difeafe in the clafs of Pyrexia, order of Exanthe- mata, genus Scarlatina. He makes two fpecies. His definition is, " Quarto morbi die, facies aliquantum tumens -, " iimul in cute paffim rubor floridus, maculis am- U plis, tandem coalefcentibus, poft tres dies in fqua- " mulas furfuraceas abiens \ fuperveniente dein faepe " anafarca." Cujleni Synopfis Nofologise Methodic^, genus xxlx. The fpecies are, " i. Scarlatina (Simplex) nulla comitante Cy- " nanche. " 2. Scarlatina (Cynanchica) cum Cy nanche " ukerofa." The ( m ) The fever evidently appears to me to be fyrio- chus, or typhus ; the former I hold to be no more than a variety of the latter ; and Doctor Cullen, after placing fynochus as a genus, acknowledges that he thinks it only a variety of typhus. The variety of the fever feems to depend altogether upon the difference of conftitution, climate, and other circumftances. Thus, if a perfon is of a full, robuft habit, and of a fanguine temperament, he may be attacked with fynochus, and the fymptoms will appear to be inflammatory. On the contrary, if one of a delicate ftructure of body, or infirm make, mould be feized with this difeafe, his fever will be, more properly fpeaking, typhus, from the peculiar {tare of his body acting as a predifpofing caufe. Some authors contend, that the Scarlatina Angi- na fa is a difeafe fpecifically different from Cynanche Maligna ; but this, certainly, does not feem to be the cafe : If there is a difference, it is only m degree ; and this mull depend altogether on the circumftances of conftitution, &c. Dodor Cullen's objection to its being the fame difeafe as Cynanche Maligna*) ( 16 ) Maligna, ts not fatisfacfcorily eftablifhed \ for he fuppofes the difference to depend upon the fynn> toms being milder in Scarlatina ; but I have {tQn patients attacked with Scarlatina^ in whom 'the fymptoms were fo perfectly analogous to Cymnche Maligna^ that no line of diftinction could poffibly be drawn between them. This has been the cafe with the greater number of the perfons I have ktn. Some perfons, who were of a vigorous confuta- tion, had a flight attack of the difeafe ; but others, of a debilitated habit, v/ere generally affected with every fymptom peculiar to Cynancbe Maligna. In illuftration of what I have faid, we may remark, that the fmall-pox will affect fome people much more violently than others : Yet this difference does not depend upon a different fpecific contagion, but is merely a variety depending on confutation and other concurring circumftances. I have faid, ia£i former part of this DifTertation, that Sydenham defcrihes a Scarlatina Simplex ; and this Doctor Cullen brings as an argument in favour of its being different from Cynancbe Maligna. But I now repeat, that every cafe of Scarlatina that has come ( » ) come under my notice, has been marked with an affection of the throat. In fome, the affection was fo flight that it would have readily efcaped com- mon obfervation. Doctor Clarke, who has written very accurately on this difeafe, never met with a cafe unattended with Cynanche. He believes the two difeafes to differ only in degree. From fuch refpectable authority, added to what obfervations I have made, I muft think that they are one and the fame difeafe-, that the diftinction is an improper one, and ought to be rejected. CAUSES. THESE may be divided into remote and proximate. The remote comprehends predifpo- nent, and exciting or occafional caufes. Thefe are now to be defcribed. PREDIS. I *8 ) PREDISPONENT CAUSES. Predisposition, according to Doctor Brown, is that ftate of the body which renders a perfon fufceptible of the operation of the exciting or occa- fional caufe. This flate may be brought on, fo as to favour the aclion of the exciting caufe, by, i . The perfon' s being accuftomed to had diet, or, 2. Scanty allowance of provifions. 3. Filling the ftomach with a larger quantity of foolfcthan it can bear. 4. Fear, and other deprejfing paffions. 5. Cold long continued, or combined with moifiure. 6. Intoxication, occaftoning debility. 7. Fatigue. 8. Any vicijfitude of weather. 9. Intenfe application to ftudy, and, 10. Night watching. 1 1 . Too frequent evacuations. "12. Previous difeafes,. &c. In fhort, any thing that will have a tendency to debilitate the body gives a predifpofition. EXCITING ( m > EXCITING CAUSES. The exciting caufe of Scarlatina feems to be a fpecific contagion, arifing from a perfon labouring under the fame difeafe, or from fuch things as are impregnated with thefe effluvia -, and thefe fubftan- ces, fo imbued, are called fomites.* It is obferved, that, with refpect to contagion, we know but little ; that it appears to be of a fedative nature, and is generated by the living human body ; that if it is long retained in the fame place without being dif- fufed in the atmofphere, it acquires a great degree of virulence ; and if then applied to men's bodies, will produce a very dangerous difeafe. To confirm this opinion, we are defired to confult the writers on gaol and hofpital fevers. It defer ves to be noticed of this, as of all other contagious difeafes, that certain (rates of the atmof- phere do unqueftionably favour the propagation of tfi and the increafe and decreafe of the diforder, together with the more mild or more virulent fymptorns * Cullen's FIrft Lines of the Pra&Ice of Phyfic, vol. i, ( 20 ) fymptoms which it has aflumed, within the courfc of nine or ten months part., fince its appearance in this city, according to the changes of weather, prove, beyond all doubt, the truth of the affer- tion. is PROXIMATE CAUSE, A knowledge of the proximate caufe of difeafes efTentially necefTary to be understood by every Practitioner, as the cure immediately depends upon it. From the latitude, inactivity and proftration of ftrength, debility of the animal functions, weaknefs of the pulfe, anorexia, nauiea, vomiting, delirium, the impaired flate of the vital energy -, and laftly, from the manner in which the difeafe frequently terminates, are we not led to fuppofe debility the proximate caufe ? The different phenomena cer- tainly evince it. PROGNOSIS. ( m ) PROGNOSIS. When the ulcers in the mouth and fauces were few ; when they continued white, and did not af- fume a livid appearance ; when the tumefaction of the throat was not great, if there was but little coryza, and a foft flow pulfe, we might predict a favourable termination. Upon the appearance of the eruption, there was a remiflion of the fever ; the defquamation taking place, the fever fubfided altogether, and the ulcers healed kindly. But when the ulcers became livid, and were numerous; if the tongue was covered with a brown cruft, the breath foetid, with considerable coryza -, if the fever was typhus, with a fmall weak pulfe, and great ge- neral debility, our prognolis was unfavourable. METHOD ( |3 ) METHOD of CURE. I N the beginning of the difeafe, if the action' of the vefTels appears to be ftrong, ikin dry, counte- nance flufned, with few fymptoms of debility, we murl: endeavour to reduce the pulfe to fuch a ftand- ard as will juftify our throwing in the bark. I generally found the adminiftratton of an emetic very ferviceable. I preferred the tartar emetic, unlefs the intention was folely to remove crudities from the fbmach, when I ufed ipecacuanha. The emetic tartar may be given in fuch doles as to excite full vomiting, or to naufeate \ but as frequent vo- miting fometimes brought on too great debility, I trufted chiefly to the laft mentioned method, i. e. naufeating dofes. Warm bathing I found highly ferviceable. When the water was only tepid it often brought on a gentle diaphorefis, which greatly relieved my patients. It may be applied to the whole body, or to the extremities only. Partial bathing anfwered every purpcfe. Acids ( 2 3 ) Acids are ufeful through every ftage of this difeafe, but particularly in the beginning, on ac- count of their refrigerant quality. Laxatives, fuch as the neutral falts, were adminiftered to keep the bowels moderately open. In this ftage of the difeafe, fome Phyficians have advifed and practifed blood-letting ; but this^ like almoft every other contagious difeafe, did not well bear the lofs of blood, as it frequently increafed the fymptoms of debility very fuddenly ; for which reafon I never attempted it. If at any time this evacuation mould be indicated, the lancet ought certainly to beufed very cautioufly. In many cafes this difeafe was attended with ty- phus fever from its firft appearance -, and in fome others it foon aflumed this form. In thefe I im- mediately employed tonics and ftimulants. The tonic which I found to be the beft, was the Peru- vian bark. Although it has been rejected by fome Phyficians, it is certainly one of the beft medicines we are acquainted with. It may be exhibited in powder or infufion. Sometimes the irritability of The ( H ) the ftomach was fo great that it could not be re- tained either way : I then adrniniftered it by clyfter, previouily emptying the bowels with an injection of vinegar. Some children have derived great benefit from the ufe of the bark waiftcoat. Porter, from its containing a great deal of fixed air, muft undoubtedly be considered as an excellent tonic and upon that account ought to be ufed freely. Cold has been mentioned by fome medical men as an ufeful tonic •, they admitted it to their pa- tients. This practice I hold to be very erroneous \ and whoever will confult the writings of Doctor Brown on the fubject, will immediately perceive that it is a direct fedative, and highly improper in afthenic difeafes. Cold applications may alfo be confidered, in many cafes, as very injurious, by checking the eruption. Cafes of this kind have occurred, where it has really brought on convulfions, and ended fatally. Inftead, then, of cold, frefh air ought to be ( 25 ) be admitted in the patient's chamber, for the pur- pofe of ventilation ; and in the winter feafon, a fire may be kept in the apartment of the fick. Cleanlinefs ought to be ftricily attended to, The bed-clothes and body linen mould be fre- quently changed, all excrementitious matter remov- ed, and the apartment of the patient fprinkled with vinegar, which will remove that noxious fmell fo common in the advanced ftage of this difeafe. We come now to the different ftimuli that are advifed -, and the firft that claims our attention is wine. This is almoft always grateful to the pa- tient, and fits eafy upon his ftomach. It ought to be given pure, and the quantity muft depend upon circumftances. I firft tried it in fmall portions, gradually enlarging the dofe as the patient could bear it. Good Port wine was fometimes ufed. Some people, after continuing the ufe of wine for a few days, took a diflike to it : I then changed the ftimulus, and gave brandy, or fpirits, diluted with water » ( 26 ) In a few cafes, the patient rejected every thing that was received into the ftomach, excepting now and then milk punch, which was retained. Fo^ mentations and rubefacients, applied to the abdo- men, frequently removed this irritability, It has been faid, that the volatile alkali is of little ufe in difeafes where the patient is much weakened j but in Scarlatina I have found it very ferviceable. It ought to be given in large dofes ; combined with the fpirits of lavander compound, it proved an excellent cordial. Opium is next to be mentioned. In fmall dofes it is ftimulant. It ought to be given in folution, fuch as the tin&ura thebaica. Ten or fifteen drops mould be given every two or three hours. When the patient is in a continual ftate of watching, and has refliefs nights, in order to procure fleep we may give from forty to lixty drops. This I frequently found had the defired eifecl, and refrefhed the fick exceedingly. Through the whole courfe of the difeafe we ought to attend particularly to the patient's diet : ( 2 7 ) It mould be nutritious. Good beef- {leak Broth, or the juice of broiled meat exprefled and well fea-- foned, may be given, beginning with fmall quari* tities often repeated. The patient's bowels muft alfo be attended to : They ought to be emptied once in twenty-four hours, by a clyfter, if nece/Tary. Where the debility is very great, bark injections- ought to be thrown in. Fomentations of fpirits Jhould be applied to the extremities, and ftimulat- ing cataplafms to the feet, When the throat and fauces are much fwdled^ the linamentum volatile (compofed of olive oil and volatile alkali) may be frequently rubbed upon the parts affected. With refpecl to blifiers, I think there is fome danger in their application, as they are fometimes fucceeded by gangrene. I have fem three or four cafes where they produced mortifica- tion, and occarloned death. If they are applied, they ought to remain no longer on the throat than to ad as rubefacients. But the volatile alkali an- fwers every purpofe, The ( 28 ) The mouth and fauces mould be frequently warned with aftringent gargles, fuch as infurlon or decoction of the bark, with elixir vitriol, a folution of white vitriol, allum, rofe water, &c. The anafarcous fwellings which fometimes fuc- ceeded the Scarlatina Anginofa, I found relieved by purgatives and diuretics \ at the fame time the pa- tient may take the Peruvian bark, and ufe flich ex- ercife as his ftrength will admit of. I have now finimed the hiftory and cure of the Scarlatina Anginofa. If it is inaccurate, I hope I mail be excufed, as the want of time has prevented my paying the attention to it which I could have wifhed. However, I truft it will be found that I have attended to the moft effential circumftances of this difeafe. FINIS, tfSgJJ'*