Anginofa; particularly as it appeared at Birmingham in the Year 1778. By William Withering, M. D. 800. Cadell. THE Is. 6d. HE prefent 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 precifion in the treatife now before us, which contains an account of the difeafe as it appeared at Birmingham, in the year 1778. Its invafion at that place happened about the middle of May; and in the beginning of June, the diforder increased in many of the towns and villages in the neighbourhood. It was preceded by fome cafes of the genuine ulcerated fore throat, and accompanied in its courfe through the fummer by the hooping-cough, the measles, the fallpox, and feveral inftances of the true quinfy. It continued with unabating force and frequency to the end of October; though it varied in fome of its fymptoms 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 temperature of the air changed, it refumed in great measure the fame appearances, which it had diftinguished it in the former part of the year. But it is neceffary that we present our readers with the author's defcription and history of the disease. It affected children,' fays he, more than adults; but feldom 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 fuffered from it was nearly equal, but in adults the number of female patients confiderably exceeded that of the male; probably because the former were more employed in attendance upon the fick, and confequently more exposed to the infection. 'On the first feizure the patients feel an unufual wearinefs, or inaptitude to motion; a dejection of fpirits, and a flight foreness or rather stiffness in the throat; with a fenfe of ftraitnefs in the mufcles of the neck and fhoulders as if they were bound with cords. In a few hours chilly fits take place, generally alternating with flushing heat; but at length the heat prevails altogether. The patients now complain of flight head-aches, and tranfitory fits of fickness. They pafs a reftless night, not fo much from pain, as from want of inclination to fleep. The next day the forenefs in the throat increases, and they find a difficulty in fwallowing, but the difficulty feems lefs oc E 2 cafioned cafioned by the pain excited in the attempt, or by the ftraitness of the paffage, than by an inability to throw the neceffary muscles into action. A total difrelifh to food takes place, and the ficknefs frequently arifes to a vomiting. The breathing is fhort and often interrupted by a kind of imperfect figh. The skin feels hot and dry, but not hard; and the patients experience frequent, fmall, pungent pains, as if touched with the point of a needle. Towards evening the heat and reftleffnefs increafe; the breath is hot and burning to the lips; thirft makes them wish to drink, but the tendency to fickness, and the exertions neceffary to frequent deglutitions are fo unpleafant, 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 ufual; in a few hours this redness becomes univerfal, and increafes to fuch a degree of intenfity, that the face, body, and limbs, refemble a boiled lobster in colour, and are evidently fwollen. Upon preffure the redness vanishes, but foon returns again. The skin is fmooth to the touch, nor is there the leaft appearance of pimples or puftules. The eyes and noftrils partake more or lefs of the general redness; and in proportion to the intensity of this colour in the eyes, the tendency to delirium prevails. Things continue nearly in this ftate for two or three days. longer, when the intenfe fcarlet gradually abates, a brown colour fucceeds, and the skin becoming rough, peels off in small branny fcales. The tumefaction fubfides at the fame time, and the patients gradually recover their ftrength and appetite. During the whole courfe of the fever, the pulfe is quick, fmall, and uncommonly feeble. The bowels regular in their difcharges. The urine fmall in quantity, but fcarcely differing in appearance from that of a perfon in health. The fubmaxillary glands are generally enlarged, and rather painful when preffed by the fingers. The tongue is red and moift, at the end and at the fides, but drier in the middle, and more or less covered with a yellowish brown mucus. The velum pendulum palati, the uvula, the tonfils, and the gullet as far as the eye can reach, partake the general redness and tumefaction. I never faw any real ulceration in these parts, but fometimes collections of thick mucus, particularly on the back of the cefophagus, greatly refembling the fpecks or floughs in the putrid føre throat, but thefe are easily washed away by any common gargle.-After the fever ceafes, it is not uncommon to have abfceffes form on one or both fides of the neck under the ears, but the matter eafily discharges itself through the ruptured teguments, and they heal in a few days without much trouble. The above is a picture of the difeafe in its moft ufual appearance; but it too frequently affumes a much more fatal form. In children, the delirium commences in a few hours after the first feizure. The flesh is intenfely hot; the fcarlet colour appears 1 pears on the firft or fecond day, and they die very early on the third. In others who furvive this rapid termination, when the scarlet turns to brown, and you would expect their recovery, the pulfe' fill 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 exprefs an averfion to all kinds of food, and extreme uneafinefs upon every the least motion or disturbance. Thus they lie for feveral days, nothing feeming to afford them any relief. At length a clear amber-coloured matter discharges in great quantities from the noftrils, or the ears, or both, and continues fo to discharge for many days. Sometimes this difcharge has more the appearance of pus, mixed with mucus. Under thefe circumftances when the patients do recover, it is very flowly; but they generally linger for a month or fix weeks from the first attack, and die at length of extreme debility. In adults, the rapidity of the fever, the delirium, &c. is fuch that they die upon the fourth or fifth day, especially if a purging fupervenes. Some furvive to the eighth, or to the eleventh day;, in all thefe the throat is but little affected: the eyes have an uncommon red appearance, not that freaky redness which is evidently occafioned by the veffels of the cornea being injected with red blood, but an equable fhining redness, refembling that which we remark in the eye of a ferret. But notwithstanding this morbid appearance in the eye, the ftrongeft light is not offenfive. This appearance may often be discovered, by lifting up the upper eyelid, fome hours before it fhews itself in the part of the eye that is ufually visible, and it is of fome confequence to attend to this circumftance, as it greatly influences the event of the cafe. • Befides the full scarlet colour described above, there are frequently fmall circular spots of a livid colour about the breast, knees and elbows. The patients are extremely reftiefs, clamourous, and defirous to drink; but after fwallowing one or two mouthfuls, upon taking another, feem to forget to fwallow, and let it run out at the corners of the mouth; whilst others fpurt it out with confiderable force, and are very angry if urged to drink again. In these cafes, the fcarlet colour appears very foon after the attack, but in an unfettled and irregular manner; large blotches of red, and others of white intermixed and often changing places. The pulfe from the very beginning fo quick, fo feeble, and fo irregular, that it is hardly poffible to count it for half a minute at a time. -It is needlefs to add, that the greater part of thofe who laboured under thefe dreadful fymptoms died. A few recovered, and others fell into a state of debility bordering upon ideotifm, from which they were refcued by time and generous living.' Such was the disease during the hot months, but in 03ober the fcarlet colour of the fkin became lefs frequent, as well as continued a fhorter time. In many patients this fymptom could not be obferved; but in others, especially adults, a few fmall red pimples, with white pellucid heads, appeared on the more tender parts of the skin. The infide of the throat was fo much tumefied, as to render deglutition difficult and painful; and in fome the difeafe was evidently propagated down the trachea. From the throat and noftrils were occafionally discharged large quantities of vifcid mucus and purulent-like inatter, which in fome was accompanied with white or afh-coloured floughs, 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 abfceffes. After delivering the fentiments of various medical authors on the Scarlet Fever, Dr. Withering proceeds to specify the diagnostic symptoms of the difeafe; a diftinction the more neceffary, as this diforder bears a resemblance to fome 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, so 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 fhall lay before our readers a few of the most important. BLOOD-LETTING. Plenciz and Navier advife us to use the lancet. The former in more general practice, but the latter confines it to cafes wherein the inflammatory symptoms run very high. He directs to bleed in the arm, but in cafe of delirium or coma, to open the jugular vein. Our own countryman Morton, fays we fhould not bleed without evident reason. • Indeed fuch was the ftate of the pulfe with us during the fummer months, that I never faw a cafe in which blood was taken away: nor would it be eafy to conceive with what view the boldeft, or the most ignorant practitioner would have dared to attempt it; for in thofe cafes where the inflammation upon the furface is very great, the lofs of blood can only contribute to the further depletion of the larger veffels, and thereby increase the debility and faintnefs which already exift in a moft alarming degree; for the small veffels accumulating the blood more in confequence of their own action, than from the pulfe of the heart, would not be affected by the ufual mode of blood letting; and the extent of the inflammation is much too great to allow us to have recourfe to topical bleedings. • Sometimes where the fiery redness of the eyes and the flate of delirium feemed to demand the application of leeches to the temples, temples, I have seen them applied; but never with any good effect. In one inftance where the conftant rejection of every thing that was fwallowed, even fimple water, and the pain in the ftomach during the efforts, feemed to indicate an inflammation in that organ, blood was taken away, notwithstanding the feeblenefs of the pulfe. The blood was fizy. The bleeding was repeated; but no very evident advantage accrued to the patient. think therefore we may conclude that when the fcarlet colour upon the skin is intenfe, we cannot expect to benefit either from topical or general bleedings. In the autumn when the fcarlet colour of the skin was feldom very intenfe, and often did not appear at all, the tumefaction of the fauces was generally much greater, and the pulfe confiderably more firm. In this cafe, if the patient was threatened with fuffocation, if violent head-ache, or if peripneumonic fymptoms pointed out the expediency of blood-letting, it was fometimes done; but ftill with lefs advantage than one would have expected in almost any other fituation; 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 fo much as mentioned the ufe of emetics.-Vomiting feems to be the remedy of nature: it ftands foremost in her efforts to throw off the cause of the difeafe: it most amply fulfils the indications arifing both from a confideration of the caufe and of the effects. If we want to diflodge a poifon from the fauces, and the mucous membrane of the nofe, and to prevent its defcent to the ftomach, how shall we do it fo effectually as by emetics? if the poifon already acting upon the nervous fyftem, deftroys the equilibrium of the circulating 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 diforders 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 liberal ufe of emetics, is the true foundation for fuccefsful practice in the fcarlet fever and fore throat. In the very first attack, a vomit feldom fails to remove the difeafe at once-if the poifon has begun to exert its effects upon the nervous fyftem, emetics ftop its further progrefs, and the patients quickly recover. If it has proceeded ftill further and occafioned that amazing action in the capillaries, which exifts when the fcarlet colour of the fkin takes place, vomiting never fails to procure a refpite to the anxiety, the faintneis, the de lirium. In autumn when the throat was more affected; when the tumefaction of the fauces was fuch that the patients could not fwallow but with the utmost difficulty: when the peripneumonic E 4 fymp |