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Title: An Account of the Sore Throat Attended With Ulcers - A Disease Which Hath of Late Years Appeared in This City, - and in Several Parts of the Nation
Author: Fothergill, John
Language: English
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                                   AN
                                ACCOUNT
                                 OF THE
                              SORE THROAT

                         Attended with ULCERS;

                   A DISEASE which hath of late Years
                     appeared in THIS CITY, and the
                            PARTS ADJACENT.

                      By JOHN FOTHERGILL, _M. D._

[Illustration]

                               _LONDON_:

                   Printed for C. DAVIS, over-against
                      _Gray's-Inn Gate, Holborn_.

                              MDCCXLVIII.



                                PREFACE.


_A simple Inflammation of the Tonsils, or of other Parts about the_
Fauces, _from its frequently happening without any considerable Hazard
attending it, is commonly look'd upon as a troublesome, rather than a
dangerous Disease: And every one, how little soever conversant in the
Practice of Physic, thinks himself qualified to conduct the Patient
thro' it with Safety_.

_If a Person complains of Pain in his Throat upon swallowing, with the
Symptoms of a Fever, nothing is thought more expedient, or more
frequently order'd, than Bleeding, Purging, and such Medicines as are
daily observed to remove Inflammations in general: And in simple
Inflammations this Method is warranted to be just, by Reason and
Experience._

_But a Disease hath of late Years appeared in this City, in many of the
neighbouring Villages, and according to the best Informamation I have
been able to procure, in several other Parts of this Nation; which, tho'
it may be taken for a common Sore Throat, or a simple Inflammation of
the Tonsils, by those who are unacquainted with it, is of a very
different Nature from the common one, and requires to be treated in as
different a Method: For it has been found by Experience, that those
Measures, which seldom fail of answering the Prescriber's Expectation in
this Case, frequently produce the most unhappy Consequences in the
other, and render a Disease almost certainly fatal, which of itself is
not often so, in this Country._

_Some Instances of Mistakes in this respect have not long since fallen
under my Observation; and there is still a Possibility of the like
happening, as the same Disorder continues amongst us: It seems therefore
necessary, that some Endeavours should be used to prevent them; and that
such a Description of the Disease should be made public, as might enable
Practitioners, who have not seen or known it, to distinguish it from
that to which it bears some Resemblance; together with an Account of the
Method of treating it, which hath in general been attended with
Success._

_There are several of the Faculty, who, I readily acknowledge, have it
more in their_ _Power to give the Public Satisfaction on this Subject,
than I have, but their constant Engagements in the Duties of their
Profession, will probably hinder those who are most equal to the Task,
from executing it so speedily as public Utility requires: Wherefore, as
some Information relative to it seems immediately wanted in several
Places, the following, tho' less perfect, will perhaps in the mean time
be neither unacceptable, nor wholly useless._

_If any thing in these Sheets should appear, to those who may be better
acquainted with the Subject to be inaccurate, or premature; if some
Things of little Weight should seem too largely insisted on, whilst
others of more Consequence are neglected, this Apology will, I hope, be
admitted;_ viz. _that to have delay'd the Publication of this Essay,
till it had received those Advantages that further Observations might
have added, would have frustrated my Design; which was, to prevent, as
much as possible, the Mistakes that might happen in relation to this
Disease, by speedily communicating the Remarks, which the Instances I
had seen had afforded._

_As this Disease appears to be the same with that which raged in_ Spain,
Italy, _and the neighbouring Countries, somewhat more_ _than a Century
ago; it may not be improper, in the first place, to give some Account of
it, from such of the Authors who then wrote upon it, as have come to my
Hands, previous to a Description of the same distemper, as it now
appears in this Country._

_'Tis said, that a similar, if not the same Disease hath long been in
some of our_ American _Colonies, and the_ West-India _Islands, but as I
have met with no Accounts of it from such as were competent Judges, it
must be left to Time, and further Inquiries, to determine the Truth or
Falsity of the Report._

    _London_, Dec. 1. 1748.



                                 OF THE

                              SORE THROAT

                         Attended with ULCERS;

           As it appeared in _Spain_, _Italy_, _Sicily_, &c.


The Disease which was called by the _Spaniards_ _Garrotillo_[1], by the
_Italians_, and other Nations, _Morbus strangulatorius_, _Pestilens
Faucium Affectus_, _Epidemica Gutturis Lues_, and by divers other
Appellations[2], is said to have appeared first in _Spain_ about the
Year 1608, to have spread from thence to _Malta_, _Sicily_, _Otranto_,
_Apulia_, _Calabria_, and the _Campagnia_, in the Space of a few Years;
and to have broke out at _Naples_ in 1618, where it continued upwards of
20 Years ravaging the different Parts of that Kingdom[3].

It is not certainly known how much longer it remained in these
Countries, or to what others it was communicated at that time, its
Declension being as obscure as the Causes it sprung from. That it wholly
disappeared in these Parts, soon after the Time above-mention'd, seems
probable, from the Silence of those Physicians, who have published their
Observations made in the Places, which had so severely felt the Effects
of this Distemper.

Several Writers, as _Wierus_[4], _Forrestus_[5], _Ramazzini_[6], and
others, take notice of epidemic Affections of the Throat, in some
respects resembling the Disease here described; but a little Attention
to the Symptoms of each, will, I think, discover an essential Difference
between them. The same may be said of the Sore Throat and Scarlet Fever,
which shew'd itself at _Edinburgh_ in 1733[7].

_Tournefort_, in his Voyage to the _Levant_[8], seems to have found the
Disease we are treating of in the Islands of the _Archipelago_; at least
as far as one can judge from the imperfect Description we have of it.
His Account is as follows.

"When we were in this Island (_Milo_), there raged a terrible Distemper,
not uncommon in the _Levant_: It carries off Children in twice 24 Hours:
It is a Carbuncle or Plague-Sore in the Bottom of the Throat, attended
with a violent Fever. This Malady, which may be called the Child's
Plague, is epidemical, tho' it spares adult People. The best way to
check the Progress of it, is to vomit the Child the Moment he complains
of a sore Throat, or that he is perceived to grow heavy-headed.

This Remedy must be repeated, according as there is Occasion, in order
to evacuate a sort of _Aqua fortis_, that discharges itself on the
Throat. It is necessary to support the Circulation of the Juices, and
the Strength of the Patient, with spirituous Things; such as the
_Theriaca_, _Spir. vol. oleos. aromat._ and the like. The Solution of
_Liquid Styrax_ in Brandy is an excellent Gargarism upon this Occasion.
Tho' it is a Case that requires the greatest Dispatch, the _Levantines_
are seldom much in Haste in the Cure of any Disease."

This Account does not disagree in general with that which has been left
us of the _Morbus strangulatorius_; only he is singular in affecting it
to arise from a kind of _Aqua fortis_ discharged upon the Parts: But his
favourite Study had engrossed his Attention, and to this we must impute
both the present Mistake, and his Want of sufficient Accuracy and
Precision, when he treats upon medical Subjects.

When it first broke out in the Countries above-mention'd, it soon
engaged the Physicians of those Times, as well to observe its Nature and
Effects, with whatever might contribute to its Cure, as to vindicate
their respective Systems and Opinions, which some of them did with a
great deal of Warmth. Out of such of the Tracts that were then published
as I have had an Opportunity of perusing, and which indeed are not so
many as I could wish, the following Account has been collected. I shall
here mention the Authors to whom I am principally indebted for it.

_Johannes Andreas Sgambatus_, a Physician of _Naples_, who published a
Treatise upon this Subject in 1620[9]. He gives us a methodical and
pretty exact History of the Symptoms of this Disease, and the Method of
Cure both general and topical, together with a summary View of the
Disputes which at that time were managed with sufficient Heat and
Acrimony in relation to its Name, Cause, and Nature; about which they
were as much divided as they were about the Method of Cure; each Party
appealing to _Hippocrates_, _Galen_, _Avicenna_, _&c._ for the Support
of their Opinions concerning a Disease, which it is not certain that
those whom they appeal to ever saw.

_Johannes Baptista Cortesius_, in his _Miscellanea medica_[10] takes
notice of this Disease, and describes its principal Symptoms, in a
Letter to _Jo. Anton. Anguilloni_, Physician in chief to the _Maltese_
Gallies. He considers it indeed as a different Distemper from that which
infested _Naples_, and other Parts of _Italy_; tho', from his own
Account of it, there appears little Reason to question the Identity. He
seems to have been led into this Mistake, by considering the Disease he
treats of as contagious only in a certain limited Sense, whilst the
_Italians_ declared theirs to be pestilential and contagious without
Restriction. He allows, that the Breath of a Person affected might
convey the contagious _Effluvia_ to another near at hand; and gives an
Instance of one who got the Disease, and died of it, by trying, at his
Friend's Request, who then labour'd under this Disease, if his Breath
was affected[11]: for from this Circumstance they guessed at the Degree
of Danger attending them.

In 1636, _Ætius Cletus_, of _Signia_ in _Italy_, published his Treatise
_De Morbo strangulatorio_[12]. He mentions some Facts relating to it,
that had escaped _Sgambatus_ and _Cortesius_, which will be taken notice
of hereafter.

_Marcus Aurelius Severinus_, Professor of Anatomy and Surgery, and
Physician to the Hospital of Incurables at _Naples_, wrote a
Dissertation upon this Disease, under the Title of '_Pædanchone
Loimodes, seu de pestilente ac præfocante Pueros Abscessu_'; and annexed
it to the second Edition of his Book _De recondita Abscessuum Natura_,
which was printed

in 1643[13]. From a Person of his Capacity, and furnished with the best
Opportunities of seeing the Disease in every Stage and Condition, we
might reasonably expect such Observations as would enable one to form a
just Idea of this Distemper; but we meet with very little of this kind
in his Performance. He has indeed mention'd some Circumstances relating
to its History, not taken notice of by the other Writers I have seen,
and his Method of Cure is different from the rest; but he refers us to
others for an Account of the Symptoms, and contents himself with
reciting and commenting upon _Aretæus_'s Description of the _Ulcera
Syriaca_, which he takes for granted to be the same with the Disease he
treats upon; yet does not put it in our Power to compare them, by giving
a candid Relation of the Symptoms.

One might justly expect some curious Observations upon this Disease,
from a Person so well qualified for it as _Thomas Bartholine_: He was in
_Italy_ whilst it raged there, and it might be supposed, would be
attentive to the minutest Circumstance relating to it, and be
inquisitive enough to know what Men of Character had said upon it. But
the Treatise which he wrote upon this Disease, and publish'd in
1646[14], contains so little to the Purpose, that it is difficult to
conceive for what End it was wrote, unless to compliment his Master
_Severinus_, which he does very liberally.

ACCORDING to the Accounts which have been left us by these Authors, it
appears, that the Disease which they describe was most particularly
fatal to Children; tho' Adults, if they were much conversant about the
Sick, were very often seized with it; yet more of these recover'd in
proportion than of Children; and it was observed, that more Boys got
well through the Disease than Girls; some thought, that such of this Sex
as had black Eyes suffer'd more from it than others.

As it was sometimes observ'd to carry off whole Families together, and
to spread to those Places first, where the Communication with the
Country affected by it was most frequent; and also that Children sent
away in order to avoid it, escaped whilst they remained there, but had
it on their Return, if the Disease was not extinguished; it was almost
universally allow'd to be contagious[15].

Those who were Seized with it, first complained of a Pain in the Throat,
with a Stiffness of the Neck, an Uneasiness upon Motion, and a
Difficulty in Swallowing their usual Nourishment. On Inspection, the
_Uvula_, the Tonsils, _Pharynx_, and the whole _Fauces_, appeared of a
remarkably florid red Colour, like that attending an _Erysipelas_: This
Colour was not uniformly intense, but Some Parts Seemed to be of a
deeper Dye than others. The Parts above-mention'd were swell'd more or
less, tho' seldom so much as to affect Respiration, as in a common
_Angina_; but the Sick could not Swallow without Pain. An acute Fever
came on at the same time, which in Some was accompanied with small
Pimples and Eruptions like Flea-bites. Several had Vomitings, according
to an Observation of _Severinus_[16].

On the same Day, or the Day following, such Parts of the _Fauces_ as at
first seem'd to be of a deeper Colour than the rest, turn'd white; this
did not proceed from any Crust or Matter superinduced upon the Parts,
but from a gangrenous Colliquation, the Substance itself being
mortified.

The Voice was hoarse and obscure; not as in a common Cold, but as it is
in those People who have venereal Ulcers in the Throat: So that, from
this Circumstance alone, some were able to guess at the Disease.

The Neck and Throat soon after began to swell externally; the Tumour was
of a soft œdematous kind, and increased in Magnitude as the Disease
advanced. All the Symptoms were commonly aggravated during the Night. If
the Patients had any Interval of Quiet, it was commonly in the
Day-time[17]. About the fourth Day this Tumour was generally grown very
large, and the white Places in the _Fauces_ began to turn black; the
Breath grew extremely offensive; Respiration, hitherto not much
affected, now became difficult, and the Patient expired in a very short
time.

Tho' this was the common Progress of the Disease, where it terminated
unhappily, yet it often varied from this Type, and was attended with
very different Symptoms. Some had a Difficulty of breathing almost from
the first; some had a violent Cough; some were comatous; others had a
Delirium; some died in a lethargic Stupor; others bled to Death at the
Nose; whilst others again had none of these Symptoms, but were carried
off suddenly by an instantaneous Suffocation. The _Oesophagus_ in some
was sphacelated to the Stomach; the _Aspera Arteria_, in others, to the
Lungs: As these could only breathe in an erect Position; so those could
swallow nothing when the Parts were so affected. The Nostrils discharged
a fetid pituitous Ichor, sometimes mixed with Blood; and sometimes Blood
alone, without Mixture. This bleeding at the Nose seem'd at first, in
one Case, to give Relief; but the Patient soon after died[18].

These were the Symptoms in general, and they judged of the Event by the
Mildness of their Progress, or the contrary: Tho' it was agreed, that
nothing could be more fallacious than this Disease; and that the most
Experienced were often deceived in their Prognostic.

If the Redness above described, which appeared at the first being
seized, was succeeded by an Ulceration, without any of that Whiteness
(which for the future I shall call Sloughs), if the Swelling about the
Neck and Throat was not large, if the Patient discharged by the Mouth
considerable Quantities of thin pituitous Matter, if the Breath was not
fetid, and the Patient had no Disgust to his Food, if the Eyes retain'd
their proper Lustre, all was judged to be secure.

On the other hand, if this Lustre was in any degree faded[19], if the
external œdematous Tumour was very large, if the Breath stunk, if the
_Fauces_ were livid or black, with a Coma, or Delirium, if with these
the Patient had an Aversion to his Nourishment, and his Breathing became
difficult or laborious, the Danger was judged to be extreme.

It was not observed that the Disease had any stated Crisis; or that the
Signs of Recovery, or Death, appeared on any certain Day. Some died on
the first, others on the second, third, and on every Day, to the
seventh. Those who survived the fourteenth, were thought to be out of
Danger, at least from the Disease itself[20]; tho' some dropp'd off
unexpectedly, after a much longer Reprieve[21].

The Consequences of this Disease were often felt a long time after it
had ceased: An excessive Languor and Weakness continued for many Months;
and the Voice or Deglutition was frequently affected, so as to be
perceivable in some almost a Year after[22].

It was however observed, that notwithstanding the Disease most
frequently was accompanied with Symptoms of pestilential Malignity, yet
it sometimes appeared with a much more favourable Aspect; its Progress
not being so quick, nor its Symptoms so violent and dangerous, as hath
here been described to be the Case in general[23]. At its first breaking
out in any Place it was commonly the most severe; it then spared no Age
or Sex, but swept off Adults together with Infants: By degrees it became
less violent, and at length either wholly disappeared, or was of so
little Consequence as to be disregarded.

We are directed, by most of the Authors I have seen, to begin the Cure
of this Distemper with Evacuations; the chief whereof are Bleeding and
Purging; tho' which of the two ought to precede was not a little
disputed. Purging was in general preferr'd; and they commonly made use
of Manna, Rhubarb, Senna, and Agaric, for this Purpose. _Cortesius_
directs six Ounces of Manna to be given to Adults in a Decoction of
Tamarinds. Bleeding, tho' commonly directed at the first, hath been used
more sparingly in this, than most other acute Cases[24]. _Severinus_,
who was by no means a timid Operator, directs from four to eight Ounces
to be taken away; which, considering the common Practice in those
Countries, is a very small Quantity[25], But it may not be improper here
to give a short Sketch of this Author's Practice, as he differs in
several Respects from most others.

He orders an antimonial Vomit to be given at the first Attack, and a
cooling gently astringent Gargle to be used Night and Day. He then
directs a Clyster, takes away some Blood from the Jugular, and gives
from _xv_ to _xxi_ Grains of Bezoar Mineral twice a Day; or oftener, as
Occasion requires, with thin diluting Liquors, in order to raise and
promote a moderate Sweat. He gives five or six Grains of the same
Medicine to Children at the Breast, and commends it highly. He scarifies
the discolour'd Parts in the _Fauces_, in order to let out the corrosive
_Virus_; a Practice, which, though it was countenanced by some of the
_Spaniards_, was disliked and condemned by the most eminent _Italians_.
He, as well as _Zacutus Lusitanus_[26], used the _Arsenicum album_ in
Gargles in very small Quantities, but with how much Advantage to the
Patient is nowhere so fully proved, as to induce one to follow their
Example.

Cupping, with Scarification, was universally approved, and commonly
practised. Leeches were also applied, by way of Revulsion, to different
Parts.

Considerable Benefit was expected from Ligatures made on the
Extremities, and from chafing the Limbs with the Hand or a Cloth; also
from Cupping without Scarification; apprehending that a Revulsion from
the Parts affected was by this means procured; and that some Portion of
the morbific Matter, was carried off by the Pores of the Skin.

Some of the _Spanish_ Physicians recommended Vesicatories of
_Cantharides_ to be laid on each Side the Neck: The _Italians_ seem not
to have been fond of them; and urge it as a Reason against their Use,
that the Progress of the Disease was too quick to be relieved by any
Discharge they could make.

The internal Medicines they used were such as they deemed Alexipharmics.
_Armenian_ Bole, Bezoar both animal and mineral, Pearls, and, according
to the Philosophy of those Times, the precious Stones. The _Theriaca_
was excepted against for Children, as _Galen_ had condemned its Use in
such young Subjects. But after they had lessened, as they thought, the
Plethora by Bleeding, and the Cacochemy, as they stiled it, by a
Cathartic; as they found, from Experience, that no Concoction of Humours
was to be waited for in this Case[27], without laying much Stress upon
Internals, they seem chiefly to have applied themselves to Topics;
considering the Disease as local, and a peculiar morbid Affection of the
_Fauces_.

In this Part of their Directions they have been more particular; and
some of them, in order to point out their Applications with more
Propriety, have divided the Course of this Disease into four different
Periods[28].

The first is the State of Inflammation. In this Repellents were thought
necessary; such as Vinegar in Barley-water, Syrup of Roses, Mulberries,
and Purslain.

The second, is that wherein the white Sloughs begin to appear, which is
a Step towards a gangrenous Colliquation. In this State they order'd
mild Abstergents, of which Honey of Roses was esteemed the chief.

In the third, the _Fauces_ begin to look black, and a real Mortification
is come on, sometimes penetrating to a considerable Depth, with great
Putrefaction. Here the mild Abstergents were deem'd ineffectual, and
Caustics were recommended; such as Alum with Honey, Alum-Water, Oil of
Sulphur, and Oil of Vitriol. These were used both to check the
Putrefaction, and to destroy the mortified Flesh.

Sometimes the Oil of Vitriol was dextrously applied to the Part affected
by an arm'd Probe; but it was oftener mix'd with Syrup of Roses, and in
Children pour'd into the Mouth. Bole dissolv'd in Treacle-Water, and the
Juice of Wood-Sorrel, was used by some for the like Purposes.

In the fourth Stage the Putrefaction is supposed to be extinguished, the
mortified Parts cast off, and an Ulcer only remains. In this Case, the
Fume of white Amber thrown on live Coals, and received into the Mouth,
as a _Suffitus_, was advised; also the _Vinum Myrrhites_, a Decoction of
Guaiacum, Roses, Balaustines, Pomegranate-Peels by way of Gargle;
Medicines that were supposed to dry with some Degree of Astringency.

Such was the general Appearance of this Disease at its first being taken
notice of in _Europe_; and such, as far as I can collect, the Methods
that were pursued in treating it, by the most eminent Practitioners at
that time.

The Disease which is described in the following Pages, seems to be the
same with this _Angina maligna_, or strangulatory Affection of the
_Fauces_, and seems only to differ from it in Degree; in which, as it is
much more favourable and mild with us in general, than it was with them,
we have greatly the Advantage.



                                 OF THE
                              SORE THROAT
                         Attended with ULCERS;


                   As it hath appeared in THIS CITY,
                          and PARTS adjacent.


About twelve Years ago, two Children, in a Family of Distinction, and
some others in the same Part of the Town, being carried off suddenly,
and their principal Complaints having been of a Soreness in their
Throats, it occasion'd a Suspicion, that the _Morbus strangulatorius_
was broke out amongst us: But as very few Cases occurred after these, or
pass'd unobserv'd, the Disease and the Remembrance of it seemed to
vanish together.

It began however to shew itself again about 4 or 5 Years ago, but not
very frequently: And tho' some of the Faculty met with it now-and-then,
it remained unknown to Practitioners in general, till within these two
or three Years: Since which Time its Appearance has been more frequent,
both in Town, and the Villages adjacent.

In the Winter of 1746, so many Children died, and so suddenly, at
_Bromley_ near _Bow_ in _Middlesex_, of a Disease that seem'd to yield
to no Remedies or Applications, that the Inhabitants began to be alarmed
with Apprehensions that the Plague was broke out amongst them; some
losing all, and others the greater Part of their Children, after a few
Days Indisposition. Some others of the neighbouring Places were affected
at the same time, tho' in a less Degree, with the same Disease; which,
from all the Accounts I have met with, from those who attended the Sick,
was the Disease here treated of.——It still continues in this City, and
sometimes shews itself in the Villages about it, though at present with
so mild an Aspect, as seldom to prove fatal; unless the Subject is very
unfavourable, or the Disease hath been neglected, or improperly treated
at the Beginning; which Circumstances, tho' of Moment in all Cases, yet
are very much so in this, as a wrong Step at the first, may put it out
of the Power of Art to afford Relief.

It is observed here, as well as in those Countries where the _Angina
maligna_ was first taken notice of, that Children and young People are
more exposed to it than Adults: A greater Number of Girls have it than
Boys; more Women than Men; and the infirm of either Sex suffer more from
it than the healthy and vigorous.

If it breaks out in a Family, all the Children are commonly affected
with it, if the healthy are not kept apart from the sick; and such
Adults as are frequently with them, and receive their Breath near at
hand, often undergo the same Disease.

It generally comes on with a Chilness or Shivering like that of an
Ague-Fit: This is soon follow'd by great Heat; and these interchangeably
succeed each other during some Hours, till at length the Heat becomes
constant and intense. The Patient complains at the same time of an acute
Pain in the Head, of Heat and Soreness in the Throat, commonly of great
Sickness, with Vomiting, Purging, or both. The Face soon after looks red
and swell'd, the Eyes inflam'd and watry; with Restlessness, Anxiety,
and Faintness.

This Disease frequently seizes the Patient in the fore Part of the Day:
As Night approaches, the Heat and Restlesness increase, till towards
Morning; when after a short disturbed Slumber (the only Repose they
often have during several Nights), a Sweat breaks out; which mitigates
the Heat and Restlessnes, and gives the Disease sometimes the Appearance
of an Intermittent.

If the Mouth and Throat be examin'd soon after the first Attack, the
_Uvula_ and _Tonsils_ appear swell'd; and these Parts, together with the
_Velum Pendulum Palati_, the Cheeks on each Side near the Entrance into
the _Fauces_, and as much of them and the _Pharynx_ behind as can be
seen, appear of a florid red Colour. This Colour is commonly most
observable on the posterior Edge of the Palate, in the Angles above the
Tonsils, and upon the Tonsils themselves. Instead of this Redness, a
broad Spot or Patch of an irregular Figure, and of a pale white Colour,
is sometimes to be seen, surrounded with a florid Red; which Whiteness
commonly appears like that of the Gums immediately after having been
pressed with the Finger, or as if Matter ready to be discharged was
contained underneath.

Generally on the second Day of the Disease, the Face, Neck, Breast, and
Hands to the Fingers Ends, are become of a deep erysipelatous Colour,
with a sensible Tumefaction; the Fingers are frequently tinged in so
remarkable a manner, that, from seeing them only, It has not been
difficult to guess at the Disease.

A great Number of small Pimples, of a Colour distinguishably more
intense than that which surrounds them, appear on the Arms, and other
Parts. They are larger, and more prominent in those Subjects, and in
those Parts of the same Subject, where the Redness is least intense;
which is generally on the Arms, the Breast, and lower Extremities.

As the Skin acquires this Colour, the Sickness commonly goes off, the
Vomiting and Purging cease of themselves, and rarely continue after the
first Day.

The Appearance in the _Fauces_ continues to be the same; except that the
white Places become of a more opake White; and it is now discoverable,
that what at first might have been taken for the superficial Covering of
a suppurated Tumor, is really a Slough, concealing an Ulcer of the same
Dimensions.

All the Parts of the _Fauces_ above-mention'd are liable to these
Ulcerations; but they generally are first discernible in the Angles
above the Tonsils, or on the Tonsils themselves; though they are often
to be seen in the Arch form'd by the _Uvula_, and one of the Tonsils;
also on the _Pharynx_ behind, on the Inside of the Cheeks, and the Bale
of the Tongue, which they cover in the manner of a thick Fur. Instead of
these Sloughs, where the Disorder is mild, a superficial Ulcer of an
irregular Figure appears in one or more of these Parts, scarce to be
distinguish'd from the sound, but by the Inequality of Surface they
occasion.

Towards Night, the Heat and Restlessness increase, and a _Delirium_
frequently comes on. This Symptom, which appears in some even on the
first Night, seems to differ considerably from the like Affection in
other Diseases. They commonly answer the Questions put to them properly,
but with an unusual Quickness; they talk to themselves incoherently when
left alone, and frequently betray the first Tendency to this Disorder,
by affecting too great a Composure: This for the most part happens to
those who sleep but little; for some are comatous and stupid, and take
little notice of any thing that passes.

In this manner they continue during two, three, or more Days; they
commonly grow hot and restless towards Evening: which Symptoms increase
as Night comes on; a Sweat more or less profuse breaks out towards
Morning; and from this time they are easier during some Hours; a
Faintness only continuing, of which they frequently complain more than
of the rest of their Sufferings.

The Disease seems to have no stated Period which can properly be called
its Ἀκμὴ or Height. Some grow easier from the first Day of the Attack;
but, in general, the Symptoms of Recovery appear on the third, fourth,
or fifth Day, and proceed in the following manner:

First, the Redness of the Skin disappears; the Heat grows less; the
Pulse, which was hitherto very quick, becomes slower; the external
Swellings of the Neck subside; the Sloughs in the _Fauces_ cast off; the
Ulcerations fill up; the Patient sleeps without Confusion, is composed
when awake, and his Appetite begins to return towards more solid
Nourishment, than has hitherto been allow'd him.

The parotid Glands on each Side, and the Parts about them, are commonly
swell'd, and painful to the Touch; and if the Disease is violent, the
Neck and Throat are surrounded with a large œdematous Tumor; which, by
straitening the _Fauces_, increases the Danger.

The Pulse, during the whole Course of this Disease, is generally very
quick; frequently 120 Strokes or more in a Minute: In some it is hard
and small; in others soft and full; but without that Strength and
Firmness which usually accompany equal Quickness and Heat in genuine
inflammatory Disorders.

If a Vein is open'd soon after the Distemper is come on, the Blood
generally appears of a fresh florid Red; the _Crassamentum_ is rather of
a lax gelatinous Texture, than dense or compact; the _Serum_ yellow, and
in a large Proportion.

The Urine is at first crude, and of a pale Whey-Colour: As the Disease
advances, it turns yellower, as if Bile was diluted in it and soon after
the Patient shews any Marks of Recovery, it commonly grows turbid, and
deposits a farinaceous Sediment.

They seldom have any Stools, if the Symptoms are favourable, from the
Time when the Purging, which generally attends the Accession, ceases.
This Discharge is frequently bilious, and without any Pain: Tho' these
Circumstances differ in different Habits.

They complain less of Thirst in this than in other acute Diseases. The
Tongue is generally moist, and not often furr'd: In some nevertheless it
is cover'd with a thick white Coat or Fur, and those who are so
affected, often complain of Soreness about the Root of the Tongue.

The _Uvula_ and _Tonsils_, tho' they are sometimes so much swell'd, as
to leave but a very narrow Entrance into the Gullet, and this Entrance
frequently surrounded with Ulcers or Sloughs; yet the Patients often
swallow with much less Difficulty and Pain than might be expected under
such Circumstances.

They frequently complain, soon after they are taken ill, of an offensive
putrid Smell, affecting their Throats and Nostrils, which oft occasions
Sickness before any Ulcerations appear.

In those who have this Disease in a severe manner, the Inside of the
Nostrils, as high up as can be seen, frequently appears of a deep red,
or almost livid Colour: After a Day or two, a thin corrosive _Sanies_,
or with it a white putrid Matter of a thicker Consistence, flows from
them, which is so acrid, as to excoriate the Part it lies upon any
considerable time. This is most observable in Children, or in young and
very tender Subjects, whose Lips likewise are frequently of the Colour
above-mention'd, and cover'd on the Inside with Vesicles containing a
thin _Ichor_, which excoriates the Angles of their Mouths, and the
Cheeks where it touches them.

It is probable, that Part of the same acrid Matter passes with the
Nourishment into the Stomach; especially in Children; and it is perhaps
owing to this Cause in part, that they suffer much more from this
Distemper than Adults; this corrosive Fluid without Doubt producing the
same Effects on the Stomach and Bowels, as it does when applied to the
much less sensible Skin of the Face; _i. e._ it excoriates the Parts it
touches; which in fact seems to be the Case: For, if they get over the
Disease, a Purging sometimes succeeds it, attended with the Symptoms of
Ulcerations in the Bowels, and after enduring great Pain and Misery,
perhaps some Weeks, they at length die emaciated: And I have been
inform'd, that some Children have had the Parts about the _Anus_ also
excoriated; the _Sanies_ retaining its Virulency thro' the whole Tract
of the Intestines.

The Sick sometimes bleed at the Nose towards the Beginning of the
Disease; and the _Menses_ very often appear in those of the Female Sex,
who are of Age to have them, soon after they are seized, notwithstanding
the regular Period is at a considerable Distance: If they are taken ill
about the usual Season, the Discharge is commonly large and expensive.
Some young Persons, who never had the least Appearance of them, have had
this Evacuation during their Illness.

In strong and full Habits, these Evacuations are seldom attended with
much Benefit, or manifest ill Effects, unless they are very copious; for
in this Case they occasion great Faintness, and an Increase of the other
Symptoms, in proportion to the Excess. In tender weak Subjects, they are
often prejudicial.

It has happen'd in this Disease, that Hæmorrhages from the Nose and
Mouth have suddenly carried off the Patient. I have heard of the like
Accident from Bleeding at the Ear: But these fatal Discharges most
commonly happen after the Patient has been ill several Days; and it
seems more probable, that they proceed from the Separation of some
Slough from the Branch of an Artery, rather than from a Fulness of the
Vessels, or an Effort of Nature to relieve herself by a salutary Crisis.

Bleeding in this Disease has in general been observed to be prejudicial:
Some indeed admit of it without any sensible Inconvenience; but a
Repetition of it, even where the Disease is mild and favourable, seldom
fails to aggravate the Symptoms; and in some Cases it appears to have
occasion'd very dangerous Consequences. The Heat, Restlessness, and
Delirium, which this Evacuation commonly prevents or mitigates in other
Cases, in this are increased by it; nor does the Swelling of the
Tonsils, _Fauces_, &c. seem to receive the least Benefit from it: On the
contrary, tho' the Fullness of these Parts decreases, yet the Sloughs
thicken, the external Tumor grows large, and the Spitting commonly
diminishes.

Nor has Purging been observed to be more beneficial: Gentle Cathartics
have brought on very dangerous Symptoms. Upon procuring a few Stools
with Manna, the Redness of the Skin has disappeared, and the Flux to the
Throat has been surprisingly increased: If it happens that the Discharge
by Stool continues, the Swelling of the Neck commonly grows larger, the
_Fauces_ become flaccid, dry, and livid; and the Patient in a few Hours
after this expires: So that Purgatives seem to have no better Effects in
diminishing the Tumor, and abating the supposed Inflammation, than
Bleeding.

Nitrous cooling Medicines frequently produce the like Effects; they
increase that Faintness which accompanies this Disease, and either
dispose the Patient to copious sinking Sweats, or to Stools.

Upon the whole, it appears, that all Evacuations which tend to lessen
the natural Strength of the Constitution, are in this Disease injurious;
and that those Persons in common are in the greatest Danger, if attacked
with it, who have been previously indisposed or have had their Strength
impair'd by Grief, or any other Accident. Of which it may not perhaps be
improper to relate an Instance or two in this Place, as it will also
tend to explain the usual Progress of the Symptoms in the worst Cases we
meet with.

A young Gentlewoman about 26 Years of Age, of a pale lax Habit, but of
an active chearful Disposition, had enjoy'd a pretty good Share of
Health in common, till a Year or two before her last Illness; about that
time she unhappily made use of some external and empirical Application
to remove a Redness attended with Pimples, which now-and-then broke out
in her Face. She was soon relieved from this Complaint by the Medicine
she used; but was quickly after seized with Sickness, Vomiting, Loss of
Appetite, and either obstinate Costiveness, or a troublesome Diarrhœa;
the _Menses_ were pale, and in small Quantities, and her Health in
general greatly impaired.

She had scarce recover'd from this weak State, when the Loss of a near
Relation brought her almost into the same Circumstances; from which she
was slowly recruiting, when she married. Her Sickness, Vomiting, and
Loss of Appetite, soon return'd; which she conceal'd as much as
possible.

Under these Disadvantages, she was seized with this Distemper, a Day or
two after she had visited an Acquaintance labouring under the same
Disorder: It came on with a Coldness and Trembling like that of an
Ague-Fit, great Faintness, and an acute Pain in her Head, with a
Vomiting more violent than she was usually affected with, and a Purging.
Towards Evening she grew very hot and restless, complained of a Soreness
in her Throat, and the Discharges abated. Her Face, Neck, and Hands were
intensely red; she frequently sigh'd, and from her Aspect and Gestures
there was Reason to suspect a Delirium approaching. She slept little
that Night; and next Morning her Pulse, which before was very quick and
small, seemed to be somewhat more full, but not sensibly slower; and she
complained of Faintness and Anxiety. The Parts about the _Fauces_ were
much relax'd, and very red, in some Places almost livid, with a kind of
glossy Dryness upon them. She continued in this Manner without any
remarkable Increase of Symptoms till Night, when the Looseness return'd,
and in a very short time exhausted her Strength to a great Degree: The
Redness upon the Skin disappeared, the Extremities grew cold, her Eyes
became dim, her Pulse scarce perceptible, she breath'd with Difficulty,
and expired in the Morning, on the third Day of the Disease.

Another young Woman, who frequently visited, and sometimes assisted a
Relation, who had this Disease, was attack'd with it in the usual
manner. She was about 17, of a pale and somewhat bloated lax Habit,
naturally inactive, averse to Exercise, and was thought to have indulged
some painful Solicitude, to the Prejudice of her Health, and making way
for an obstinate _Chlorosis_.

Under these Circumstances she was seized with the usual Complaints, but
in a violent manner. The Purging continued till the Day following; when
it yielded for the present to Opiates, but constantly return'd when
their Effects were over. The other Symptoms, such as Heat, Restlessness,
Anxiety, and Faintness, increased with the Purging; the Pulse was small,
quick, and hard; a Difficulty of breathing came on, the small Remains of
Lustre in the Eye perish'd, and she died early on the fourth Day of the
Distemper.

No Marks of any Sloughs in the Throat appeared in either of these Cases;
but the Redness became daily more intense, and approached nearer to
Lividness, whilst the _Fauces_ could be inspected; which, from the great
Difficulty they had in breathing, was impracticable several Hours before
the Patients expired.

Warm aromatic Cordials, and anodyne Astringents, were administred
assiduously, with suitable Nourishment, and Vesicatories applied
successively to the Neck on each Side, the Shoulders and Arms, but
without Effect.

If the Purging therefore continues long after the first Exacerbation of
the Disease, it may be look'd upon as a dangerous Symptom; for though it
be sometimes restrain'd for the present by Opiates or Astringents, yet
it commonly returns with more Vehemence, when their Efficacy ceases, and
in a short time exhausts the small Degree of Strength remaining.

In this Case they generally spit very little; the _Fauces_ appear dry,
glossy, and livid; the external Tumor grows large; they void their
Excrements without perceiving it, and fall into profuse Sweats;
Respiration becomes difficult and laborious; the extreme Parts grow
cold, and Death in a few Hours closes the Scene; and in no Disease that
I have seen is the Eye so early deprived of its Lustre as in this; for
it is sometimes opake and glassy several Hours before Death; and, as
_Ætius Cletus_ hath observed, is a fatal Presage of its Approach.

A copious Flux of pituitous Matter to the Glands, and other Parts about
the _Fauces_, seem'd to be the Cause of sudden Death, in a Girl about 12
Years old. She was seized in the common Way, with Shivering, Headach,
Sickness, Vomiting, and Purging. The Discharges abated in a few Hours,
and were succeeded by great Heat, Redness of the Skin, and a sore
Throat; the _Uvula_, Tonsils, and, contiguous Parts were red, and so
swell'd in eight or ten Hours, as to touch each other, and seem d to
close the Entrance into the _Pharynx_. She breath'd without much
Difficulty, swallow'd with less Pain than could be imagin'd, and spit up
large Quantities of Phlegm. About six in the Evening she was seized with
a Difficulty of breathing, as if strangled: Those about her rais'd her
up, thinking she was in a Fit; she recover'd herself a little, but
expired upon being again laid down in Bed; in somewhat less than 24
Hours from the first Attack. A large Quantity of viscid Phlegm, with
which, after she was dead, her Mouth appear to be fill'd, together with
the tumefied _Uvula_, Tonsils, and _Velum Palati_, had perhaps jointly
closed the _Rima Glottidis_, and put a Stop to Respiration.

By a Fall in her Infancy she was reduced to the Necessity of using
Crutches. She was big-bon'd, had a good Appetite, and for want of that
Exercise, which Persons at her Age commonly enjoy, seem'd to be
plethoric. These Circumstances perhaps might contribute to this speedy
and unhappy Event.

Accidents of the like kind seem not to have been uncommon while this
Disease continued in _Italy_, according to a Remark of _Cortesius_[29].

From the preceding Account of the Sore Throat attended with Ulcers, it
will, I believe, appear, that this Disease is widely different from a
common Sore Throat, or simple Inflammation of any of the Parts about the
_Fauces_; both as to the Subject commonly affected by it, the Manner of
its Attack, the Progress of the Symptoms, and its Conclusion: For the
sore Throat with Ulcers generally attacks Children; and of these Girls
more frequently than Boys, as hath been observ'd: If Adults are seized
with it, they are commonly such as have been very much conversant with
the Sick, or else are weak and infirm: And it seems to affect those
Adults in the severest manner, who have been previously indisposed, or
whose Strength has been reduced by unseasonable or immoderate
Evacuations.

On the contrary, the common _Angina_, or an Inflammation of the Tonsils,
most frequently attacks the healthy, the vigorous, and robust; the weak,
the delicate, and infirm, are less exposed to it, at least suffer less
from it, than the former.

As both Diseases are attended with a Fever, and as most Fevers come on
with Shivering or Chilness, this Symptom may at least appear equivocal:
But if Sickness, or Vomiting, or Purging, or an acute Head-ach, towards
the back Parts or Top especially, or if all these, come on in the Space
of a very few Hours, which they generally do, where the Disease is
vehement, it may justly be esteem'd of the malignant or putrefactive
kind: But if an erysipelatous Redness discovers itself in the _Fauces_,
or if any Ulcerations or white Sloughs appear in them, the Disease is
evident.

In some Cases, the Symptoms have been so obscure, that it was difficult
to determine to which Class they properly belonged: But in these
Circumstances the Disorder was so favourable, that, supposing it not to
be of the ulcerated kind, no other Inconvenience seemed likely to ensue
from treating it as such, than a Suppuration; which is often an Event
rather to be chosen than avoided.

The Redness of the Skin in the Face, Neck, Breast, and Hands, is another
obvious and distinguishing Characteristic, which in Children and young
People especially, seldom fails to accompany this Disorder.

In the common sore Throat, a local Inflammation is the Disease: All the
Symptoms are derived from this Source: An acute throbbing Pain, greatly
increased upon swallowing even Liquids, is the principal Grievance. In
the other, the whole Habit suffers, as if by a _Stimulus_ of a peculiar
Nature and although the Throat is always more or less affected, yet it
is sometimes the least Part of the Patient's Complaint; and Instances
have occurr'd to me of considerable Sloughs being formed, before any
Soreness or Pain in the _Fauces_ hath been mention'd.

Again, this Disease is accompanied with a greater Tendency to a
Delirium, than either a common _Angina_, or almost any other Disease we
are acquainted with. To have this Symptom appear in the Disease we are
treating of on the first Night, is not uncommon; and on the second,
frequent. A Girl about eight Years of Age, whom I attended, was scarce
known to be indisposed, till she alarmed the Family, by appearing to be
light-headed. She had made no Complaint of her Throat, nor was this Part
thought to be affected, till, upon Examination, I found it so; being led
to suspect it by the Colour of her Hands, and the Delirium. She got well
through the Disease, tho' its Progress, at first, appear'd to be very
swift.

A common Sore Throat, if the Patient recovers, either goes off by
Resolution, or suppurates, or becomes hard and scirrhous.

In that attended with Ulcers, none of these Circumstances happen; for it
terminates in a superficial Ulceration of some of the Parts about the
_Fauces_, with little Appearance of any Sloughs, if the Disease is very
mild; and with large and deep ones, of a white, cineritious, livid, or
black Colour, if it is more violent.

It will not perhaps be difficult, from this comparative View of the
Disease, to distinguish it from a common Sore Throat, or an inflammatory
Affection of those Parts: But there is another no less certain
Criterion, tho' too often a fatal one, which is, the constant Increase
of Symptoms upon Bleeding, Purging, and the liberal Use of cooling
antiphlogistic Medicines; an Instance whereof I think evidently appeared
in the following Case.

A Youth of about 14 Years old, of a brisk lively Disposition, who had
enjoyed a good Share of Health, saving that, for a few Years past, a
cutaneous Disease, akin to a Leprosy, had sometimes appeared on his Head
and Arms, was seized one Morning with a general Uneasiness, and a
Disposition to vomit; he was put to Bed, and a severe Shivering ensued;
his Sickness increased, he vomited up every thing, had several purging
Stools that Day, and complained much of his Head, with some Soreness in
his Throat. He was order'd to be blooded, and had an Emetic given him:
This operated but little; he grew hot and restless, a deep Redness
spread itself over his Face, Hands, and Arms, with a plentiful Eruption
of small Pimples, which induced those about him to apprehend it was a
Scarlet Fever.

The next Day, which was the second of the Disease, his Throat continuing
sore, and the feverish Symptoms increasing, a Purge of Manna was given
him, which operated gently; and at Night his Head and Throat being more
uneasy, his Heat still continuing, with a Tendency to Delirium; a
Blister was applied.

On the third, the Symptoms not abating, he lost about ten Ounces of
Blood. He had taken a cooling nitrous Powder every four Hours; this was
now changed for one more cordial. At Night he grew delirious, his Fever
increased, and he had some loose Stools, which were rather encouraged
than restrain'd, as it was hoped they might relieve him. Blisters were
applied to his Head and Arms.

On the fourth in the Morning I was sent for: I found him delirious, with
convulsive Twitchings; his Hands in constant Motion, gathering the
Bed-cloaths; his Pulse quick and weak; his Tongue parched. With some
Difficulty I looked into the _Fauces_; they seemed to be pale in some
Places, intensely red or livid in others, with a glossy Brightness: His
Excrements came away involuntarily; his Eyes were languid, and somewhat
opake; he breath'd with Difficulty, and died in a few Hours after.

In some of the first Cases I met with, the Quickness of the Pulse, the
Degree of Heat, the apparent inflammatory Redness of the Eyes and Face,
and Pain in the Head, some times urged me to order Bleeding, especially
if there were any Marks of a _Plethora_; but in these Cases it did not
appear to have any advantageous Effects: So that, notwithstanding the
Urgency of the Symptoms above-mention'd, it seems proper in general to
omit this Evacuation.

Cupping with Scarification has been applied to the Shoulders and Back of
the Head, in order to remove an acute Pain of this Part, which is often
complain'd of, but, as far as I have been able to observe, without much
Benefit.

It is necessary that the Patient should keep in Bed as much as may be,
tho' the Disease should seem to be slight: It has happen'd, for want of
Care in this Respect, that a Purging has come on, the Redness of the
Skin disappeared, and a Disorder, which with Confinement alone would
probably have gone off in twice 24 Hours, has been render'd tedious and
difficult.

If we are called in at the first, while the Sickness or Vomiting
continues, it will be of Use to promote this Discharge, by giving an
Infusion of Green Tea, Chamomile-Flowers, Carduus, or a few Grains of
_Ipecacuanha_. In some Instances, where the Attack has been severe, and
this Method practised, the Disorder has gone off with more Ease than was
at first apprehended.

If these Symptoms don't abate with the Operation of the Emetic, small
Draughts of Mint-Tea, with a sixth Part of red Port added to it, may be
given frequently; together with some grateful and warm aromatic, cordial
Medicine, every four or six Hours. The _Pulvis Contrayervæ simp._—_comp.
Confect. cardiac._—_Raleigh. Spec. arom. Vinum croceum_; _Aq. Menth.
spirit. Aq. Alex. spirit. cum Aceto_; with others of the like Nature,
may be used for this Purpose.

In this Disease it is at all times necessary to attend very carefully to
the Diarrhœa. For the most part it ceases with the Vomiting, in less
than twelve Hours from the first Attack: If it continues longer than
this Period, it is necessary to check it, otherwise it occasions great
Faintness, sinks the Strength, and in the End produces very dangerous
Consequences. The aromatic Cordials above-mention'd, if they are given
plentifully, commonly take off this Symptom, as well as the Vomiting;
but if they prove ineffectual, Recourse must be had to Astringents and
Anodynes, in proportion to the Exigence of the Case; such as the
_Confectio Fracastorii_, or _Elect. e Scordio cum Opio_, dissolved in
small Cinnamon-water, and given _post singulas sedes_.

It is common for the Redness, so often mention'd, to appear upon the
Skin, as these Discharges abate: It has happen'd that this Colour has
gone off sometimes, and the Patient has been brought into imminent
Danger, upon giving a mild Cathartic: Which Circumstances, as they point
out a close Connexion between them, indicate the Use of a warm Regimen,
notwithstanding the Heat and other Symptoms might seem to forbid it.

A Girl about 9 Years old, of a slender Make, but healthy and active, was
seized with this Disorder. The Sickness and Vomiting went off, and the
Redness of the Skin appeared soon after: The Apothecary who attended
her, judging it an inflammatory Case, as she complained of her Throat,
bled her, gave her a cooling Purge the next Day, and afterwards some
nitrous Draughts. A plentiful Efflorescence which cover'd the Face,
Neck, and Arms, suddenly disappeared; a Diarrhœa came on, she grew
restless, faint, and insensible. In this Condition I first saw her on
the third Day of the Disease; she frequently sigh'd, her Pulse was
quick, small and hard, without any remarkable Colour upon her Skin; and
the Swelling on each Side the Neck large: It was not possible to examine
the _Fauces_, as she lay in a comatous helpless Condition, her Stools
and Urine coming away insensibly. A warm cordial Mixture was frequently
given her, upon which the Diarrhœa soon abated; and the next Day the
Efflorescence again appeared upon her Face and Arms. From this time she
continued to recover, tho' slowly, and was for some time attended with a
Cough and hectic Heats.

Another Symptom which requires our Attention in the Cure of this
Disease, is an excessive Faintness: Of this they generally complain soon
after they are taken ill, and continue to do so, if sensible, till the
Distemper begins to abate: The Urgency of this Symptom seems to indicate
the Degree of Danger: It is more or less violent, as the Disease is mild
or malignant; and an Abatement of it may be look'd upon as a sure
Presage of Recovery.

Warm aromatic and gently stimulating Medicines, such as have, been
already mention'd, as the most effectual to suppress the Vomiting, and
check the Looseness attending this Disease, have likewise been found
useful in removing the present Complaint: And tho' the Degree of Heat,
and Quickness of the Pulse, would be enough to dissuade a Person who has
not seen the Disease, from giving them in so liberal a manner as
Necessity requires; yet we are not to be governed so much by these
Symptoms, as by the Faintness, Depression of the Pulse, and Increase of
Putrescency in the _Fauces_. One Drachm of the _Confectio Raleighana_
has been given to a Youth not quite 15 Years of Age, every four Hours,
which was soon follow'd by a sensible Amendment, and the Decrease of the
Patient's Restlessness, Faintness, and Heat.

Some of the _Italian_ Physicians forbad the Use of Wine in the Cure of
this Disease, and the Warmth of that Climate might perhaps make this
Caution necessary; but as it is a generous Cordial, and at the same time
antiseptic, it seems to be in no respect improper here; and, besides in
Whey, I have allow'd it to be given, in small Quantities, mixed with
Mint, Baum, or Sage-Tea, Barley-Water, Gruel, Panada, Sago, and
suchlike; and alone, where the Faintness has been excessive; the Age,
the former Way of Life, and the Symptoms, affording the necessary Rules
as to Quantity and Kind. Chicken-Water, or thin Broth, may also be
allow'd; which is frequently very acceptable to the Patient. And I don't
remember to have observed so general and early an Inclination after
solid Food, in any acute Disease, as in this: For at a time when one
would imagine, both from the Condition of the _Fauces_, and the Degree
of Heat, that Liquids would be the most acceptable, it is not uncommon
to find Children, who have this Disease, extremely desirous of Chicken,
and chearfully complying with Directions, in hopes of being gratified in
this respect.

Blisters are likewise of Use to relieve the Faintness. At first I was in
Doubt, lest the Flies, by their Acrimony, should increase the putrescent
Disposition, and consequently aggravate the Disorder they were intended
to remove: but no such Effect having appeared from their Use, I have
order'd them to be applied, and I think with Advantage, both to the
usual Parts, and to the Neck on each Side from below the Ear almost to
the Clavicle, as Occasion required.

The Ulcers in the Throat demand our early and constant Attention, as a
considerable Loss of Substance cannot here be suffer'd without immediate
Danger to Life itself, or the most pernicious Consequences to the future
Action of the Parts, if the Patient survives.

Where the Disease is of the mildest kind, a superficial Ulceration only
is observable; which may easily escape the Notice of a Person
unacquainted with it. A thin, pale, white Slough seems to accompany the
next Degree: A thick, opake, or ash-colour'd one is a further Advance:
And if the Parts have a livid or black Aspect, the Case is still worse.
These Sloughs are not formed of any foreign Matter covering the Parts
affected as a Crust or Coat, but are real Mortifications of the
Substance; since when they come off spontaneously, or are separated by
Force, they leave an Ulcer of a greater or less Depth, as the Sloughs
were superficial or penetrating.

When the Tendency to Putrefaction is stopp'd, these Sloughs in most
Cases come off spontaneously; or their Separation may be promoted by
suitable Remedies and Applications: But it seems by no means adviseable
to attempt it by Scarification, scraping them off with the Fingers or
Instruments, as _Severinus_ proposes; since the Experiment has been
tried, but with such unhappy Consequences[30], as are sufficient to
discourage one from persisting in this Method.

In a Case where I was concerned, previous to my being called in, a
Surgeon had endeavour'd to separate the Sloughs by the Assistance of his
Probe: He succeeded in his Attempt without much Difficulty; but was
surprised to see the same Parts cover'd the next Day with thick, dark,
ash-colour'd Sloughs, penetrating deep into the Substance, with an
Increase of every Symptom.

It is true, the Sloughs have been sometimes scarified, from an
Apprehension, that Matter was lodg'd underneath them, without any
manifest Inconvenience; but as there are Instances of fatal
Mortifications having ensued, it seems most prudent to decline the
Practice.

From under these Sloughs, and from every Part of the Ulcers which they
cover, a thin corrosive _Ichor_ is discharged, so acrid as to excoriate
the external Parts upon which it is suffer'd to remain. This is
sometimes observable in Adults, when the Parts above the _Fauces_ are
affected; the _Ichor_ in these Cases flows thro' the Nostrils, and
frequently raises Pimples on the Skin of the upper Lip; but it is most
obvious in Children, who often have this Part, the Corners of the Mouth,
the Cheek of that Side on which they most commonly lie, blister'd or
excoriated.

It is probable, as hath been already hinted, that Part of the same
virulent Matter, passing down the _Oesophagus_ into the Stomach and
Intestines, acts upon them as it does upon the Skin, when applied to it
externally; it frets and corrodes the Parts it touches, and produces
that Sickness, Vomiting, Purging, and Faintness, which sometimes
accompany this Disease in different Parts of its Progress.

In Children, and very young Subjects, the Symptoms arising from this
Cause are yet more dangerous: The natural Softness and Laxity of the
Parts liable to be affected, disposes them to suffer by it much more
than Adults: At the same time they are commonly alike incapable of
promoting the Discharge of this Matter themselves, and of admitting
Assistance from others, being generally, if the Distemper is acute,
either comatous and stupid, or delirious and untractable. If Gargles are
injected, they either prevent them from reaching the Seat of the
Disorder, by their Tongues, or they swallow them, and the putrid Taint
of the Ulcers, together; the Mischief spreads beyond the Power of Art to
restrain it; violent Purgings ensue, or fatal Hæmorrhages from the
penetrating Gangrene. And to this, perhaps, it may in part be owing,
that Children suffer so much more from this kind of Sore Throat, than
Adults.

That this corrosive Matter produces these Effects, is farther confirm'd,
by observing, that those whose Throats are severely affected, if they
have a plentiful Discharge from the _Fauces_, are seldom attended with
Sickness, Vomiting, or excessive Faintness; though, after longer Sleeps
than ordinary, or a Neglect of encouraging this Evacuation, they have
complain'd of Sickness, and have had Reachings come on: Likewise, that
in such Cases, where little or no Discharge of this kind appears, the
Symptoms are commonly the most dangerous.

From hence it is obvious that great Advantages may be expected from the
constant Use of gently stimulating aromatic Gargles; as they promote the
Discharge of the pituitous Matter flowing to the _Fauces_, and,
doubtless, with it, of some Part of the corrosive Fluid above-mention'd:
To which if we add Antiseptics and Detergents, in order to check the
Progress of the Mortification, and cleanse the sordid Ulcers it
produces, every Indication is provided for.

Where the Disease is mild, the Symptoms favourable, the Sloughs
superficial, or scarce perceptible, it may be sufficient to order a
Gargle of Sage-Tea with a few Rose-Leaves added in the Infusion; three
or four Spoonfuls of Vinegar may be mixed with half a Pint of the Tea,
and as much Honey put to it, as will leave it agreeably acid.

But where the Symptoms are urgent, the Tendency, to Putrefaction great,
the Sloughs large and thick, and the Breath offensive, Recourse must be
had to more efficacious Remedies: A Composition like the following,
varied only as the Patient's Age and the Circumstances of the Disease
required, has in general been attended with very good Effects. The
Proportion here given may be used for Adults, and the more active Parts
lessen'd for younger Subjects.

    ℞ [prescription] _Decoct. Pectoral. ℥ [ounce] xij. cui inter
    coquendum add. Rad. Contrayerv. contus. ℥ [ounce] ss. Liquori
    colato admisce Acet. Vin. Alb. ℥ [ounce] ij. Tinct. Myr. ℥
    [ounce] i. Mel. opt. ʒ [dram] vi. f. Gargarisma._

As the Parts about the Gullet are frequently so much affected, as to
render it painful or impracticable for the Sick themselves to make use
of the Gargle so freely as they ought, it is commonly order'd, that a
few Spoonfuls of this Liquor, made somewhat warm, should be very often
injected into the _Fauces_ with a small Syringe; and especially before
the Patient swallows any thing, in order to wash off as much as possible
the putrid _Sordes_ adhering to the Ulcers, and prevent it from passing
into the Stomach and Bowels. In young Subjects this Method is the more
necessary, as they don't always know how to manage a Gargle to any
Purpose, did the Soreness of the Parts permit them to do it.

If the Sloughs are large, and cast off slowly, they may be touched with
_Mel Ægyptiacum_, by means of an armed Probe; or it the Condition of the
_Fauces_ is such, that this cannot conveniently be done, a Spoonful of
the following Mixture may be injected, and retain'd in the Throat, as
long as the Patient can endure it; the Parts may then be washed two or
three times with the Gargle alone.

    ℞ [prescription] _Gargarism. præscript. ℥ [ounce] ij. Mel Ægypt.
    ʒ [dram] j. m._

By the constant and regular Use of these Applications, if the Patient is
kept warm, and the Method of treating him in other Respects is observed,
agreeable to what has been mention'd above, it seldom happens but that
the febrile Symptoms disappear, the Sloughs come off, and the Ulcers are
disposed to heal in a few Days; unless it be where Mismanagement at
first, Malignity of the Infection, or an unfavourable Constitution, have
one or all contributed to increase the Disease, and to render its
Consequences more lasting and mischievous.

What Effects improper Treatment produces in this Case has already been
observed. With regard to the Matter of Contagion, or Nature of that
Cause which so suddenly brings on such a Train of Symptoms as hath been
described, little can be said with any Degree of Certainty: Thus much,
however, seems to be true in Fact, that in some Cases the Disease
appears to be of so mild a Nature, and so benign, as to require but
little Assistance from Art: Persons even recover from it under the
Disadvantages of unskilful and injurious Management; whilst in others,
the Progress of the Symptoms is so rapid, and the Tendency to Corruption
so strong, that nothing seems able to oppose it. Just as it happens in
the Small-Pox; the benign and distinct sort bears ill Treatment without
Injury; in the malignant flux Kind, the utmost Art and Experience are
too often insufficient to conduct the Distemper to a happy Issue.
Whether this Diversity in the Sore Throat we are speaking of, is owing
to a Difference of Constitutions, or of Seasons, to the different
Quality or Quantity of the Contagion, or the Manner of receiving it; or
whether there are in Reality distinct Species of it; may perhaps
hereafter be more certainly determined.

With respect to Constitution, it may be further observed, that in soft,
lax, leucophlegmatic Habits, and languid inactive Dispositions, every
thing else being equal, the Disease seems to proceed more slowly, to go
off more irregularly, and to leave behind it more lasting Effects. In
some Persons of the Temperament described, tho' the Fever has grown
less, and all the Symptoms abated in four or five Days, yet the Sloughs
in the Throat have continued almost a Week longer; whilst in the
opposite Constitution, tho' the Disease has been much more acute, yet
the Symptoms have no sooner abated, than the Sloughs have cast off, and
the Ulcers healed of their own Accord.

A copious Hæmorrhage from the Nose, Mouth, or Ears, the last especially,
coming on after the Disease has continued three or four Days, or longer,
is a dangerous _Phænomenon_: For at this time of the Distemper, it most
probably proceeds from the Branch of an Artery destroy'd by the
Mortification, and laid open by the Separation of the Slough. If the
Vessel is therefore large, the Bleeding may prove fatal to the Patient
in a very short time; or if he escapes for the present, the Loss of a
considerable Quantity of Blood at this time of the Disease, will
occasion various ill Consequences.

It is therefore absolutely necessary to endeavour to stop this Discharge
with all the Expedition possible. If the Patient is costive, it will be
of Use to procure Relief in this respect, by Clysters or Suppositories
as soon as can be done: To apply Vinegar, by the means of Tents or
otherwise, as near to the Orifice of the Vessel as we can: To convey the
Steam of it into the _Fauces_ and Nostrils plentifully: To keep the
Patient in a sitting Posture, or his Head raised as high as may be, and
his upper Parts moderately cool: If these Methods don't immediately take
Effect, Recourse must be had to the most efficacious Remedies, amongst
which we may rank the _Bark_ and _Opium_.

It is not uncommon for hectic Heats, Night Sweats, Want of Appetite, and
Dejection of Spirits to attend those a considerable time, who have had
the Disease in a severe manner. Asses Milk commonly relieves them, or a
Decoction of the _Bark_, and _Elix. Vitriol_ if the Case is more
obstinate.

                  *       *       *       *       *

Having thus related, as concisely as I could, the most material
Circumstances that have occurr'd to me in respect to the Symptoms,
Progress, and Event of this Distemper, the _Juvantia_, _Lædentia_, and
the Accidents chiefly to be regarded in its Cure; in such a manner as I
hope will enable those who have not seen or known it, to distinguish it
from a common Sore Throat and to treat it with some Degree of Propriety
and Success, I shall conclude with observing;

1. That the Sore Throat attended with Ulcers seems to be accompanied
with a strong Disposition to Putrefaction, which affects the Habit in
general, but the _Fauces_, and the Parts contiguous in particular. And
it seems not unreasonable to suppose,

2. That the Cause of this Disposition or Tendency is a putrid _Virus_,
or _Miasma sui generis_, introduced into the Habit by Contagion,
principally by means of the Breath of the Person, from whom it is
received.

3. That this _Virus_, or contagious Matter, produces Effects more or
less pernicious, according to the Quantity and Nature of the Infection,
and as the Subject is disposed to receive or suffer by it.

4. That putrefactive and malignant Diseases, in common, admit of the
most sensible and secure Relief, from Discharges of the peccant Matter,
either upon the Skin in general, or on particular Parts of the Body.

5. That the Redness, and cutaneous Efflorescence in the present Case may
be consider'd as an Eruption of the like Nature; and therefore to be
promoted by such Methods as have proved successful in similar Diseases.

6. That a cordial, alexipharmac, warm Regimen has been found by
Experience to be of the most Use in such Cases; and that Bleeding,
Purging, Antiphlogistics, liberally employed, either retard, or wholly
prevent these Discharges.

Therefore, as to expel the morbific Matter (3) seems to be the Design of
Nature; to promote this Design by the Measures that are approved by
Experience in analogous Disorders, is the Duty of the Physician.

It may likewise be remarked, that, though this Disease has now been
amongst us several Years, and has consequently survived the different
Seasons, and all the Variety of Weather to which we are exposed, yet it
seems to shew itself most frequently in Autumn and the Beginning of
Winter; at least I have met with many more Cases from _September_ to
_December_, inclusive, than in all the other Months together; having not
yet seen any who had it in the Spring, and very few in the Summer.

It may likewise be remark'd, that the Summers of 1747 and 1748 were dry,
with some Days in each uncommonly hot, for this Climate; the Mercury in
_Fahrenheit_'s Thermometer rising in the Shade, and within-door, one Day
to 78, and during several to 75 and 6. The Autumns of the same Years as
unusually temperate and warm; the Wind continuing longer in the
Southerly Points than has often been known at this Season.


                                _FINIS._

-----



                               FOOTNOTES:


Footnote 1:

  Ab Hispanis _Garrotillo_ appellatur, ut eadem patiantur Angina
  laborantes, quæ facinorosi homines, cum injecto circa collum sune
  strangulantur. Epist. _R. Moreau_ ad _Th. Barth_. Epist. Med. Cent. i.
  _p._ 336.

Footnote 2:

  Affectus suffocatorius, Carbunculus anginosus, Phlegmone anginosa,
  Angina pestilentialis, Epidemica Gutturis Lues, Morbus Gulæ, Morbus
  Puerorum, Pestilens ac præfocans pueros abscessus, Tonsillae
  pestilentes, Ἀγχόνη λοιμώδης, Aphthæ malignæ, Passio angìnosa, Laqueus
  Gutturis, _&c._ _Vide Cortes. Miscel. Med._ _p._ 696. _Severin. Epist.
  Ren. Moreau ad Th. Barthol. de Laryngotomia._

Footnote 3:

  _Severin._ de recondita Abscessuum natur. _p._ 446.

Footnote 4:

  _Joh. Wieri_ Observat. lib. i. de Angina pestilenti Epidemica, Oper.
  _p._ 910.

Footnote 5:

  _Pet. Forrest._ Observat. lib. vi. de Febribus publice grassantibus,
  p. m. 150.

Footnote 6:

  _Bern. Ramazzini_ Constitutiones Epidem. Oper. _p._ 195, & seq.

Footnote 7:

  Medical Essays, vol. iii. p. 26.

Footnote 8:

  _Tournefort's_ Voyage to the _Levant_, vol. i. p. 133.

Footnote 9:

  De pestilente faucium affectu Neapoli sæviente, opusculum, auctore
  _Jo. Andrea Sgambato_, phylosopho ac medico Neapolitano, et academico
  otioso. Neapoli excudebat Tarquinius Longus, 1620, in _4to._

Footnote 10:

  _Joannis Baptistæ Cortesii_, medici ac philosophi, in Messanensi
  academia praxim ordinariam e prima sede interpretantis, Miscellaneorum
  Medicinalium Decades Denæ. _Messanæ_ 1625. in fol.

Footnote 11:

  Divi Francisci Custos, vir doctrina et moribus insignis, hac lue
  obsessus, tonsillas solummodo et gargareonem inflammatione læsa
  habebat, et continuo querebatur se percipere in ore fætorem quendam;
  et ut hac de re certior redderetur, ad se vocavit baccalaureum quendam
  sibi amicissimum, qui maximo affectu assistebat, rogavitque ut vellet
  olfacere, percipereque naribus, an verum esset talem fætorem emittere,
  an ab ejus imaginatione prodiret: olfecit baccalaureus me (scil.
  _Cortesio_) præsente, et multis aliis, at statim non multis elapsis
  horis decubuit sola faucium et glandularum inflammatione vexatus,
  absque aliqua manifesta corruptione partium, omnibusque præsidiis ex
  arte factis, quarto die suffocatus periit; et tamen Custodem non
  tetigerat, sed solo olfactu aerem ab ore prodeuntem naribus traxerat:
  quare ab hujusmodi exemplo veni in sententiam hunc morbum non esse
  absque aliqua contagione. _Cort. Miscel._ _p. 698._

Footnote 12:

  De morbo strangulatorio, opus Ætii Cleti Signini, doctoris medici et
  philosophi. _Romæ_ 1636. _8vo._

Footnote 13:

  De recondita abscessuum natura, libri 8. Marci Aurelii Severini
  Tharsiensis, philosophi et medici, regio in gymnasio Neapolitano
  anatomes et chirurgiæ professoris. Editio secunda, _Francofurti ad
  Mænum_ 1643. And again printed with _Bartholine_'s _Exercitationes_,
  as a Commentary upon it, with _Villani_'s _Therapeuta Neapolitanus seu
  Veni mecum Consultor_. Neapoli 1653.

Footnote 14:

  _Thomæ Bartholini_ de Angina Puerorum Campaniæ Siciliæque epidemica
  exercitationes. _Lut. Parisior._ 1646.

Footnote 15:

  Quod ad contagium attinet, hoc turn communi omnium consensu atque
  experimento evincitur, tum etiam comprobatur ratione. _Severin._ p.
  442.

Footnote 16:

  Ibid.

Footnote 17:

  Idem ibid.

Footnote 18:

  Idem, _p. 440_.

Footnote 19:

  Hoc unum salutis est indicium vel interitus: dum oculorum nitor
  adservatur, salutis spes semper adest; quo tempore hic deperiit, in
  propinquo mors est. _Ætii Cleti_ Op.

Footnote 20:

  _Ætii Cleti_ Op. de Morbo Strangulatorio.

Footnote 21:

  Quinimo post xxx dies, et xl. jam prærepti morbi furoribus, præter
  omnium opinionem ex improviso sunt extincti. Adeo scil. latitans et
  recondita veneni vis est. _Severin_, p. 440.

Footnote 22:

  _Æt. Clet._

Footnote 23:

  _Severin._ p.

Footnote 24:

  In hoc sacro igne non mittendus est sanguis in ea quantitate ac in
  angina exquisita.—Placuit quibusdam in hoc morbo fecare venas sub
  lingua; alii admoverunt hirudines collo: mihi nulla istarum
  evacuationum unquam probari potuit. Nam cum tumor superveniens ex
  sanguine non oritur, frustra adhibentur ea auxilia quæ ad sanguinem ex
  parte affecta evacuandum excogitata fuerunt. _Sgambat._ de Pest.
  Faucium Affect.

Footnote 25:

  _Severin._ ubi supra. _Cort._ Miscel. _p. 697_.

Footnote 26:

  _Zacut. Lusitan._ de praxi medic. admiranda _lib_ i. observ. 99. where
  he mentions this Disease, and relates an unhappy Instance of its
  Effects in the following Terms.

  In his partibus (scil. faucibus) ex humoris virulenti affluxu
  gignuntur carbunculosæ inflammationes, quæ pestis diræ, aut veneni
  promptissimi instar, contagio quodam, pueros et adultos corripiunt; et
  sævis maleficentissimisque stipatæ symptomatis citissimam necem
  inferre solent. Malum in Hispania non multis abhinc annis frequens,
  vulgus medicorum Hispano sermone _Garrotillo_ nuncupat; de cujus
  essentia, periculo, brevitate, et complicatione ustivi et ulcerosi
  tumoris, ac deleteria corruptione, laconice dicam. Hoc fuit pressus
  biennis infans, sanguineus et obesus. Primo die ex catarrhosa
  defluxione in suffocationem pene incurrit, difficulter respirabat, et
  lac deglutiebat, et febri acuta affectus, nec plorare poterat. In
  parte gutturis dextra externa glandulosus apparuit tumor cum dolore
  multo. Secundo die intra fauces ulcus visum est ad nigrum vergens,
  quod putrilago et mollities multa comitabantur; at ab ore fætor
  horribilis prodibat, magnum certe corruptionis completæ indicium.
  Tertio die nullis adjutus auxiliis strangulatus, est extinctus.

Footnote 27:

  _Cortes._ Miscel. _p. 703_.

Footnote 28:

  _Sgambat._ de Affectu Faucium pestilente.

Footnote 29:

  —Ad prædictarum partium (Uvulae, Tonsillarum) inflammationem
  subsequebatur interdum materia quædam pituitosa a capite tam repente
  et inopinato descendens, ut miseri ægrotantes subito suffocarentur.
  _Cortes. Miscell._ p. 697.

Footnote 30:

  Si quis tamen vel digitis, vel aliquo instrumento levi ipsam (materiam
  aliam) auferre tentâsset, quamvis operatio hæc fieret absque dolore,
  ea tamen ablata brevissimo tempore peribant ægrotantes; quod præ
  cæteris in _Petro Soprano_ genero meo observatum est, cui cum
  hujusmodi mortificatio apparuisset in suprema superficie dictarum
  glandularum faucium, et palati, ita ut videretur esse maximo
  respirationi et deglutitioni impedimento, chirurgus existimans posse
  facillimo negotio a subjectis partibus eam separari solis digitis,
  levissime quidem eam abstulit; quæ ablata, tantum abest ut juverit
  deglutitionem aut respirationem, ut utraque potius actio læsa magis
  fuerit, unde brevissimo tempore miser, meo cum maximo dolore, mortem
  oppetiit; id quod etiam in aliis quamplurimis pueris sæpius observavi,
  et præfertim in ejusdem _Petri_ filiolo nepoti ex filia, quinque
  annorum, mihi carissima, qui post paucos dies eodem modo, quo pater,
  vitam cum morte mutavit. _Cortes. Miscel. Med_, p. 697.



------------------------------------------------------------------------



                          Transcriber's Notes.

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