OBSERVATIONS, &c.

I Take the liberty to ſend you a few obſerva⯑tions 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 repreſen⯑tation 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, unmean⯑ing quotations from other authors.

About the latter end of Sept. 1748. a Scarlet Fe⯑ver began to appear in this town. At firſt chil⯑dren only were ſeized with it; but afterwards it at⯑tacked adults. The manner of ſeizure was not al⯑ways one and the ſame. There was ſome diverſity [4]herein; as likewiſe in the ſymptoms, and ſtages of the diſeaſe. Its period alſo was ſometimes va⯑rious in various patients. And as there was a dif⯑ference in the time, ſo likewiſe there was in the manner of its terminating.

In general, the firſt ſymptoms were ſickneſs, vo⯑miting 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 conſidera⯑ble degree. In ſome, the Tonſils only were inflam⯑ed and ſwelled; in ſome a ſwelling of the Parotids accompanied the inflammatory tumours of the Ton⯑ſils; in ſome, all the glands abovementioned tume⯑fied at the ſame time. Upon looking into the mouth, there were frequently ſeen, eſpecially after the diſeaſe was a little advanced, ulcuſcula, ſcatter⯑ed up and down the fauces, which were pretty broad upon, and about the Tonſils, ſuperficial, (at leaſt all, that I ſaw, were ſuperficial) and cover⯑ed with a whitiſh ſlough. The eyes appeared wa⯑try, and the countenance, particularly the eye-lids [5]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 en⯑largement, as we could the enlargement of a par⯑ticular member. In ſome, a cough alſo accom⯑panied 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 advanc⯑ed; 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 diſ⯑orders 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 efflo⯑reſcence; and in ſome, this effloreſcence was par⯑tial, and gradual in its advances. The legs and thighs [6]were ſpotted up and down with ſpots of various di⯑menſions, 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 toge⯑ther, 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, abun⯑dantly ſatisfied me as to the genius of the diſtem⯑per.

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 be⯑tween the preſent ſcarlet fever, and that milder one, which Sydenham deſcribes; yet if an increaſed num⯑ber of ſymptoms, and a more exaſperated degree [7]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, eva⯑ſit. And afterwards he goes on thus, quantum tonſil⯑las, 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 diſco⯑ver; 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 Fiſh⯑ſkin, 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 ſen⯑ſation 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, [9]or more days together, without one lucid inter⯑val 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 de⯑lirium. 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, contri⯑buted 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 ei⯑ther 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 bleed⯑ing, tho' recourſe was had to it at the beginning, was very little beneficial towards the cure of the fe⯑ver, [10]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 plen⯑tiful 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 blood⯑ed 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 ton⯑ſils ſtill greatly ſwelled and inflamed, and appre⯑hending danger of ſuffocating in a few hours, I di⯑rected 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, notwithſtand⯑ing they were bled after the diſeaſe was pretty far ad⯑vanced: 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 fre⯑quently not ſizey, tho' found to be ſo, upon bleeding ſome days afterwards. Nor can I recollect, that any [11]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 de⯑cline. In few or none did the fever leave the pati⯑ent [12]ſo totally, but it recurred once, twice, or more, the evenings following; and grew ſo mild at each re⯑turn, as to be little more, than barely noticed: at which time too, all the glandulous ſwellings common⯑ly vaniſhed. But in ſome, altho' the fever evident⯑ly 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 continu⯑ed, 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 ſubſid⯑ed, in a night's time, one half of their increaſed mag⯑nitude. In two perſons, after the fever was quite re⯑moved, and the appetite for food returned, the tu⯑mor of the Parotids ſtill continued, which daily en⯑creaſed 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 fe⯑vers; 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 extrava⯑gant terrors and perturbations. And I well remem⯑ber, that in a child near three years old, this cir⯑cumſtance 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 [14]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 vo⯑miting and diarrhoea uſually ſtopped, and truly I hardly remember, that they ever returned again. Then if the inflammation and ſwelling of the ton⯑ſils, and parts adjacent required, and the pulſe per⯑mitted, 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 dilu⯑tion, by means of barley-gruel, white wine whey, and other liquors. Sometimes too I ordered linctuſ⯑es, 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 [15]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 cardi⯑aca.

If the ulcers on the tonſils and fauces were foul⯑er than common, deterſive and aſtringent gargariſms were found to be of ſervice, by contributing much to bring away the ſloughs, and facilitate degluti⯑tion.

If the fever ran high, and the body was very coſtive, I ordered an emollient clyſter. But the obſervati⯑ons made on bleeding held true likewiſe here. For [16]the uſual weakneſs of the patient, and depreſſion of ſpirits, ſeemed to hint, that theſe inteſtinal diſcharg⯑es 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 conveni⯑ently 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 recom⯑mends paregorics under the worſt ſymptoms, that he hath mentioned of this diſeaſe. But in three per⯑ſons 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. [17]But no benefit ariſing in a few hours after bleeding, I ordered bliſters to the arms, adminiſtered more cor⯑dial medicines than before; and that night the pati⯑ent ſlept ſeveral hours without waking, and after⯑wards 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 circum⯑ſtances, as the foregoing, but where the pulſe was not ſo ſtrong indeed, I omitted bleeding, and pre⯑ſcribed veſicatories, and generous medicines, but no ſleep enſued hereupon.

I was called to a child of four years old, the ſe⯑cond 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 ha⯑ſtily came on, I think, within the ſpace of half an [18]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 de⯑gree, as threatened every minute to preclude all ad⯑miſſion of air. Whereupon a Surgeon was called in, who attempted to relieve the child, by making in⯑ciſions 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 degluti⯑tion ſomewhat abated. The ſpirits too were improv⯑ed by theſe applications. And indeed in a diſeaſe ſo ſeemingly threatening, perhaps it would be impru⯑dent to omit theſe applications. For altho' the fever [19]did not yield to them, ſo as to ſhorten its ſtages; yet it is probable, that ſymptoms were hereby pre⯑vented 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 obſervati⯑on 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 erup⯑tion [20]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 bleed⯑ing &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 efflo⯑reſcence 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 oc⯑curred after the fever was removed, was that great dread upon the ſpirits mentioned before, which oc⯑caſioned 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 diſ⯑eaſe, 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 varie⯑ty [22]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 abun⯑dantly teſtify. I am, with the greateſt reſpect,