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. LONDON: Printed for C. Davis, over-against Gray's- Inn Gate, Holborn. M DCC XL VIII. [i] PREFACE. A SIMPLE Inflammation of the Ton- sils, or of other Parts about the Fau- ces, 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 expe- dient, or more frequently order'd, than Bleed- ing, 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 Informa- a tion ii PREFACE. mation 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 Me- thod: 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 un- happy 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 Obser- vation; and there is still a Possibility of the like happening, as the same Disorder conti- nues amongst us: It seems therefore neces- sary, that some Endeavours should be used to prevent them; and that such a Descrip- tion 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; toge- ther with an Account of the Method of treat- ing 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 PREFACE. iii Power to give the Public Satisfaction on this Subject, than I have; but their constant Engagements in the Duties of their Pro- fession, will probably hinder those who are most equal to the Task, from executing it so speedily as public Utility requires: Where- fore, 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 de- lay'd the Publication of this Essay, till it had received those Advantages that fur- ther 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 af- forded. As this Disease appears to be the same with that which raged in Spain, Italy, and the neighbouring Countries, somewhat more than iv PREFACE. than a Century ago; it may not be impro- per, 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 Ame- rican 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 Re- port. London, Dec. 1. 1748. ON [1] OF THE SORE THROAT Attended with ULCERS; As it appeared in Spain, Italy, Sicily, &c. THE Disease which is called by the Spaniards Garrotillo (a), by the Ita- lians, and other Nations, Morbus stran- gulatorius, Pestilens Faucium Affectus, Epi- demica Gutturis Lues, and by divers other Appellations (b), is said to have appeared first (a) Ab Hispanis Garrotillo appellatur, ut eadem pa- tiantur Angina laborantes, quæ facinorosi homines. cum injecto circa collum sune strangulantur. Epist. R. Mo- reau ad Th. Barth. Epist. Med. Cent. i. p. 336. (b) Affectus suffocatorius, Carbunculus anginosus, Phlegmone anginosa, Angina pestilentialis, Epidemica Gutturis Lues, Morbus Guæ, Morbus Puerorum, Pes- tilens ac præfocans pueros abscessus, Tonsillæ pestilentes, ’AvX'ovn ........ Aphthæ malignæ. Passio anginosa, La- queus Gutturis, &c. Vide Cortes. Miscel. Med. p. 696. Severin. & Epist. Ren. Moreau ad Th. Barthol. de Laryn- gotomia. A [2] first in Spain about the Year 1610, 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 (c). 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-men- tion’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 Distem- per. Several Writers, as Wierus (d), Forrestus (e), Ramazzini (f), 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, (c) Severin. de recondita Abscessuum natur. p. 446. (d) Job. Wieri Observat. lib. vi. de Angina pestilenti Epidemica, Oper. p. 910. (e) Pet. Forrest. Observat. lib. vi. de Febribus publice grassantibus, p. m. 150. (f) Bern. Ramazzini Constitutiones Epidem. Oper. p. 195, & seq. [3] will, I think, discover an essential Difference between them. The same I think may be said of the Sore Throat and Scarlet Fever, which shewed itself at Edinburgh in 1733 (g). Tournefort, in his Voyage to the Levant (h), seems to have met with this Disease in the Islands of the Archipelago; at least so 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 un- “common in the Levant: It carries off Chil- “dren in twice 24 Hours: It is a Carbuncle "or Plague-Sore in the Bottom of the Throat, “attended with a violent Fever. This Ma- "lady, which may be called the Child’s "Plague, is epidemical, tho’ it spares adult “People. The best way to check the Pro- “gresss of it, is to vomit the Child the Mo- "ment 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 (g) Medical Essays, vol. iii. p. 26. (h) Tournesort's Voyage to the Levant, vol. I. p. 133. A2 [4] “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 “Gaigarism 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 Mor- bus strangulatorius; only he is singular in as- serting 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 Accuracy and Precision too frequently, when he treats upon medical Sub- jects. When it first broke out in the Countries above-mentioned, it soon engaged the Phy- sicians of those Times, as well to observe its Nature, Effects, and whatever might con- tribute to its Cure, as to vindicate their re- spective Systems and Opinions; and out of such of the Tracts then published as I have had an Opportunity of perusing, the follow- ing Account of it, as it appeared at that time, has been collected. Ludovicus [5] Ludovicus Mercatus, Physician to Philip II. and III. Kings of Spain, among his Con- sultations, published in Tome V. of his Works (a), has one upon this Disease (b): He men- tions it as a Calamity which had but newly appeared, and at that time affected several Provinces and Cities of that Kingdom: He has related only one Case; but, in comment- ing upon it, according to the Method of writing on Diseases then in Use, he takes notice of several Circumstances relative to it, and makes some Observations respecting the Cure, which, tho’ they seem to have been neglected by many who succeeded him, Ex- perience hath since shewn to be just; some of these will be pointed out in their proper Places: And, considering that he wrote very soon after the Distemper broke out, the Ap- probation prefixed to this Part of his Work being dated in 1612, they are a Proof of his Attention and Sagacity. Johannes Andreas Sgambatus, a Physician of Naples, published a Treatise upon this Subject (a) D. Ludovici Mercati, Medici a cubiculo Philippi III. Hispaniarum-—Regis, &c. Oper. Tom. 5. Francof. 1614. (b) De Faucium et Gutturis anginosis et lethalibus Ulceribus. Consultatio xxiv. p. 137. [6] Subject in 1620 (i). He gives us a metho- dical and pretty exact History of the Sym- ptoms, and Method of Cure both general and topical, together with a summary View of the Disputes, which at that time were ma- naged 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 Miscel- lanea medica (k), takes notice of this Disease, and describes its principal Symptoms, in a Let- ter to Jo. Anton. Anguilloni, Physician in chief to the Maltese Gallies. He considers it indeed as a different Distemper from that which in- fested Naples, and other Parts of Italy; tho’, from his own Account of it, there appears little Reason (i) De pestilente faucium affectu Neapoli sæviente, opusculum, auctore Jo. Andrea Sgamhato, philosopho ac medico Neapolitano, et academico otioso. Neapoli ex- cudebat Tarquinius Longus, 1620, in 4to. (k) Joannis Baptistœ Cortesii, medici ac philosophi, in Meslanensi academia praxim ordinariam e prima sede in- terpretantis, Miscellaneorum Medicinalium Decades De- næ. Messanœ 1625, in fol. [7] Reason to question its being the same. He seems to have been led into this Mistake, by considering the Disease he treats of, as conta- gious only in a certain limited Sense, whilst the Italians, as some of the Spaniards had also done, declared theirs to be pestilential and contagious without Restriction. He al- lows, that the Breath of a Person affected might convey the contagious Effluvia to an- other 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 (l): for from this Circumstance they guessed at the Degree of Danger attending them. In (l) Divi Francisci Custos, vir doctrina et moribus in- signis, hac lue obsessus, tonasillas solummodo et gargareo- nem inflammatione Iæfa 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 effet talem fætorem emittere, an ab ejus imaginatione prodiret: olfecit baccalaureus me (scil. Cortesio) præsente, et mul- tis aliis, at statim non multis elapsis horis decubuit sola faucium et glandularum inflammatione vexatus, absque aliqua manifesta corruptione partium, omnibusque præ- sidiis ex arte factis, quarto die suffocatus periit; et tamen Custodem non tetigerat, sed solo olfactu aerem ab ore prodeuntem naribus traxerat: quare ab hujusmodi ex- emplo veni in sententiam hunc morbum non esse absque aliqua contagions. Cort. Miscel. p. 698. [8] In 1636, Ætius Cletus, of Signia in Italy, published his Treatise De Morbo strangula- torio (m). He mentions some Facts relating to it, that had escaped Sgambatus and Corte- sius, 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 Pœdanchone Loimodes, seu de pestilente ac prœfocante Pueros Abscessu; and annexed it to the second Edition of his Book De recon- dita Abscessuum Natura, which was printed in 1643 (n). From a Person of his Capacity, and furnished with the best Opportunities of seeing the Disease in every Stage and Condi- tion, we might reasonably have expected such Observations as would enable one to form a just Idea of this Distemper; but we meet with little of this kind in his Performance. He has indeed mention’d some Circumstances re- lating (m) De morbo strangulatorio, opus Ætii Cleti Signini, doctoris medici et philosophi. Romœ 1636. 8vo. (n) 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 Mœnum 1643. And again printed with Bartholine’s Exercitationes, as a Commentary upon it, with Villani's Therapeuta Neapolitanus, seu Veni mecum Consulter. Neapoli 1653. [9] lating 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 comment- ing upon Aretœus's Description of the Ulcera Syriaca, which he takes for granted to be the same with the Disease which at that time infested Naples. One might justly expect some curious Ob- servations 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 Trea- tise which he wrote upon this Disease, and publish’d in 1646 (a), 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 li- berally (b). ACCORDING (a) Thomæ Bartholini de Angina Puerorum Cam- paniæ Siciliæque epidemica exercitationes, Lut. Parisior. 1646. (b) Zacutus Lusitanus also mentions this Disease, and relates an unhappy Instance of its Effects in the following Terms. In B [10] ACCORDING to the Accounts which have been left us by these Authors, it appears, that the Disease which they describe was ex- tremely malignant, and 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 Chil- dren; 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 In his partibus (scil. faucibus) ex humoris virulenti affluxu gignuntur carbunculosæ inflammationes, quæ pes- tis diræ, aut veneni promptissimi instar, contagio quodam, pueros et adultos corripiunt; et fævis maleficentissimisque ftipatæ symptomatis citissimam necem inferre solent. Malum in Hispania non multis abhinc annis frequens, vulgus medicorurn Hispano sermone Garrotillo nuncupat; de cujus essentia, periculo, brevitàte, et complicatione ustivi et ulcerosi tumoris, ac deleteria corruptione, laco- nice dicam. Hoc suit pressus biennis insans, sanguineus et obesus. Primo die ex catarrhosa defluxione in suffoca- tionem pene incurrit, difficulter respirabat, et lac deglu- tiebat, et sebri 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, mag- num certe corruptionis completæ indicium. Tertio die nullis adjutus auxiliis strangulatus est extinctus. De praxi medic. admiranda, lib. i. observ. 90. [11] As it was sometimes observ’d to carry off whole Families together, and to spread to those Places first, between which and the Countries affected by it the Communication was most frequent; and also that Children, sent away from the Towns where it raged, in order to avoid it, escaped whilst they were kept at a Distance, but had it on their Return, if the Disease was not extinguished; it was almost universally allow’d to be conta- gious (o). Those who were seized with it, first com- plained of a Pain or Soreness in the Throat, with a Stiffness of the Neck, an Uneasiness on moving it, as if a Cord was twisted about it, a Difficulty in swallowing, and frequently in breathing also, with a disagreeable fetid Smell and Taste. On Inspection, the Uvula, the Tonsils, Pharynx, and the whole Fauces, ap- peared of a remarkably florid red Colour, like that attending an Erysipelas: This Co- lour 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’ not always so much as to affect Respiration, as in a common Angina. If (o) Quod ad contagium attinet, hoc communi omnium consensu atque experimento evincitur. Severin. p. 442. B2 [12] If the Attack was violent, they had an extreme Difficulty in breathing, and also in swallowing; with a kind of compressive Pain and Straightness of the Breast and Back, a Red- ness of the whole Face and Neck, great Heat of all the Parts affected, Depravation of the Voice, an unquenchable Thirst, and the Patient seemingly in Danger of being choaked (q). In some, the Swelling and Ulcers of the Fauces were apparent upon looking into the Mouth; in others, nothing could be seen, but a most offensive putrid Smell was perceivable. A Fever came on with the other Symptoms, and was frequently ac- companied with small Pimples and Eruptions like Flea-bites. In very bad Cases, this Fe- ver, which Mercatus calls a most malignant one (r), did not always discover its Violence or Malignity at first; but it was not the less formidable on this Account (s). On (q) -- difficultas respirandi, et non raro deglu- titiendi, cum pectoris et dorsi dolore ac veluti compres- sione suffocante, simul cum pestilenti odore, et vehementi harum omnium partium ardore, et rubore totius oris et colli, cum vocis et loquelæ vitio, ac linguæ extractione, et siti incompescibili. Mercat. Consult. p. 136. (r) Maxima ob malignissimam febrem, quam plerum- que sibi adjunctam habet, &c. Consult. p. 136. (s)-—nec multum, sidere oportet, si febris mox non appa- reat aut succrescat, nam fæpe citius suffocat affectio, quam causa succendatur; ac non raro malignitas humoris cor- rumpit spiritus et mortem accelerat, sine eo quod febris succendatur. Mercat. Consult. p. 137. [13] 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, ash-colour'd, or black; this was not occasioned by any Crust or Matter superin- duced upon the Parts, but proceeded from a gangrenous Colliquation of them, the Sub- stance itself being mortified. The Voice was hoarse and obscure; not as in a common Cold, but as it is in those Peo- ple who have venereal Ulcers in the Throat: So that, from this Circumstance alone, some were able to guess at the Disease (t). The Neck and Throat soon after began to swell externally; the Tumour was of a soft œdematous kind, and increased in Magni- tude as the Disease advanced. All the Sym- ptoms were aggravated during the Night. If the Patients had any Interval of Quiet, it was commonly in the Day-time (u). About the fourth Day this Tumour was generally grown very large, and the white Places in the Fauces began to turn black; a putrid corro- sive Sanies was discharged by the Mouth and Nostrils (w); the Breath grew extremely offen- sive; (t) Severin. p. 442. (u) Sgambat. (w) Quibus etiam accedit sublimis respiratio et alta ac spirituum revulsio, cum maxima pinnarum nasi disten- tione,--saniei per os et nares excretio, variis ulcerum coloribus et intensissimo fætore nauseam plerumque mo- 4 vente [14] sive; Respiration, if hitherto not much af- fected, 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 an extreme 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 instan- taneous 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 dis- charged a fetid Ichor, sometimes mixed with Blood; and sometimes Blood alone, with- out Mixture. This Bleeding at the Nose seem'd at first, in one Case, to give Relief; but the Patient soon after died (x). Mercatus relates vente cum sordida excretione. In aliquibus vero extra, prope cervicem, et infra mentum glandule apparent, pes- tiferi morbi naturam redolentes, et universa cervix, et collum intumescunt, et fauces cum rubore saturato, instar laqueo suffocatorum. Merc. Consult. p. 136. (x) Severin. p. 440. [15] relates an Instance of a Child that had the Disease, in which the Acrimony of the Hu- mour discharged from the Ulcers was so great as to inflame the Nurse’s Breast, and brought on a Mortification. He also tells us, that the Father of the Child whose Case is described above, having frequently put his Finger in the Child’s Mouth, to draw out the viscid Phlegm, had his Finger inflamed, and was seized with the same Distemper (y). 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 sallacious than this Disease; and that the most Expe- rienced were often deceived in their Pro- gnostic. If the Redness of the Fauces above de- scribed, 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 Swell- ing about the Neck and Throat was not large, (y)---erat quidem dira humoris conditio adeo pernici- osa, efficax et contagiosa, quod digitum patris indicem, quo extrahebat eum succum ob ore filii, mordicaret, et in ruborem moveret cum dolore: tandem mox pater conque- rebatur de difficultate respirandi et deglutiendi cum dolore et tumore faucium, ac saturato colore, et glandulis extra apparentibus juxta mentum. Ex quibus secundo die ha- litum prave olentem expirabat; ita ut jure optimo possis colligere, contagio filii patrem fuisse affectum. Mercat. Cons. p. 139. [16] 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 (z), if the external œdema- tous Tumour was very large, if the Breath stunk, if the Fauces were livid or black, with a Coma or Delirium, if with these the Pa- tient had and Aversion to his Nourishment, and his Breathing became difficult of labo- rious, the Danger was judged to be ex- treme. It was not observed that the Disease had any stated Crisis; or that the Signs of Reco- very, or Death, appeared on any certain Day. Some died on the first, others on the second, third, and on every Day, to the seventh; tho' the greatest Part died before the fourth (a). Those who survived the fourteenth, were thought to be out of Danger, at least from the Disease itself (b); though some dropp'd off unexpectedly, (z) Hoc unum falutis est indicium vel interitus: dum oculorum nitor adservatur, aalutis apes semper adest; quo tempore hic deperiit, in propinquo mors est. Ætii Cleti Op. (a)---indies magis ac magis hæc accidentia crescunt, donec brevissimo tempore laborantium majorem partem perimat idque non raro intra quartum diem. Merc. p. 137. (b) Ætii Cleti Op. de Morbo Strangulatorio. [17] unexpectedly, after a much longer Re- prieve (a). The Consequences of this Disease were of- ten felt a long time after it had ceased: An excessive Languor and Weakness continued for many Months; and the Voice or Deglu- tition was frequently affected, so as to be per- ceivable in some almost a Year after (b). It was however observed, that notwith- standing the Disease most frequently was ac- companied with Symptoms of pestilential Ma- lignity, yet it sometimes appeared with a much more favourable Aspect; its Progress not being so quick, nor its Symptoms so vi- olent and dangerous, as hath here been de- scribed to be the Case in general (c). 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 In- fants (d): By degrees it became less violent, and at length either wholly disappeared, or was of so little Consequence as to be disregarded. We (a) 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. (b) Æt. Clet. (c) Severin. p. (d)--ut pestis more in citissimam mortem pueros et adultos deducat. Merc. Consult. p. 135. C [18] We are directed, by most of the Authors I have seen, to begin the Cure of this Dis- temper, whenever we are called in Time, with Evacuations; the chief whereof are Bleeding and Purging: Which of the two ought to precede was not a little disputed; but it was on all hands agreed, that unless these Remedies were very early applied, as they were principally useful by way of Revul- sion, they were not only of no Advantage to the Patient, but highly injurious (e). An Obser- vation of this kind, we are told (f), induced several Physicians to omit Bleeding entirely; and it was, probably, the Reason why those who were Friends to Venesection directed it more sparingly in this, than in most other acute (e)---disputare cœpimus de sanguine extrahendo: siquidem non defuerunt medici, qui id renuerent: cæterum unanimi consulentium consensu, primo die sanguinem misimus, cruribus scarificatis, et mox octava noctis hora brachiis, aut si ultra duos annos fuerit natus, ex vena brachii: in hoc malo plurimum vereri oportet, vires plu- rimum dejicere. Mercat. Brevissime secandam esse venam in hoc confitentur omnes. P. Mich. de Heredia de Morb. acut. p. 101. (f) Circa quod præsidium (venæsectionem) in pueris ex- equendum, consulo ne differatur, quia ejus occasio solum est, antequam fluxio in partibus contenta ad putredinem commigret. Nam tunc temporis, si sanguinem fuderis, summopere lædes, quæ causa suit quod multi medicorum, viso hoc damno renuerint sanguinem mittere. Mercat. Consult. p. 138. [19] acute Diseases (g). Severinus, who was by no means a timid Operator, orders from four to eight Ounces to be taken away; which, considering the common Practice in those Countries, is a very small Quantity (h). Some not only gave the Precedence to Purging, but imagin'd it alone was suffi- cient; alledging, as a Reason for it, that some Children had recover’d, where this Evacuation only had been employed; whilst Bleeding had been injurious, by lessening the Strength (i). Purging was however commonly allow'd the second Place, by those who were Advocates for Bleeding, but (g) In hoc sacro igne non mittendus est sanguis in ea quantitate ac in angina exquisita. — Placuit quibusdam in hoc morbo secare venas sub lingua; alii admoverunt hiru- dines collo: mihi nulla istarum evacuationum unquam probari potuit. Nam cum tumor superveniens ex san- guine non oritur, frustra adhibentur ea auxilia quæ ad sanguinem ex parte affecta evacuandum excogitata fue- runt. Sgambat. de Pest. Faucium Affect. Esse vero efficiendas parcas missiones in quantitate, dum revellere intendimus, docuit antiquitas.-—Quod præ- ceptum magis observandum in morbo præsenti, in quo nimis timemus virium jacturam. Copiosa enim sanguinis missio, præterquam quod minus proprie revellit, dejicit vires. P. M. de Heredia, ubi supra. (h) Severin. ubi supra. (i) - hoc solo præsidio aliquando visum fuit, pueris ad integram sanitatem recuperandam sussicere, sicut aliis sanguine detracto, vires plurimum fuisse dejectas. Merc. Cons. p. 138. C2 [20] but under the like Restrictions (k). They generally made use of Manna, Rhubarb, Sen- na, Tamarinds, Syrup of Roses, and the like, for this Purpose. But it was always incul- cated, that, in directing these Evacuations, the Patients Strength was especially to be regarded; since whatever diminished this, in the End was undoubtedly prejudicial (l). Severinus 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 Mi- neral twice a Day, or oftener, as Occasion requires, with thin diluting Liquors, in or- der to raise and promote a moderate Sweat. He gives five or six Grains of the same Me- dicine to Children at the Breast, and com- mends 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 recommended by the Spaniards (m), was (k] Quod evacuandum morbus exposcit, evacuetur bre- vissime. Idem, p. 102. (l) - in morbis malignis breviter destruentibus vires, et poscentibus simul robur animalis virtutis ad sui sana- tionem, multum evacuare non licet. Heredia, p. 102. (m)Si vero malum non mitescat, sed gravius affligat partem, quod constabit ex lucido aut nigro colore, vel ex nimia mollitudine - cum intolerabili fætore, scarifi- cabitur [21] was disliked by some of the most eminent Italians (n). Cupping, with Scarification, was univer- sally approved, and commonly practiced. Leeches were also applied, by way of Re- vulsion, to different Parts. Considerable Benefit was expected from Ligatures made on the Extremities, and from chasing the Limbs with the Hand, or a Cloth; also from Cupping without Scarification; ap- prehending 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 recom- mended Vesicatories of Cantharides, and other acrid caustic Substances, to be laid on each Side the Neck; but they had not the same Opinion of their Usefulness, when ap- plied to the Back or Shoulders: Heredia ex- presly tells us, that he had seldom found any Benefit from them (o): Neither do the Ita- lian Physicians seem to have been fond of them; the Progress of the Disease was, in their Opinion, too swift to admit of any Relief cabitur profunde, prout partis natura tulerit. Heredia, p. 105. (n) Cort. Miscel. p. 697. (o) Multi etiam vesicatoria consulunt spatulis applicata. ——Quod auxilium parum prodesse semper vidi. Here- dia, p. 108. [22] Relief from either Caustics or Vesicatories (p), both which had been made use of in Spain (q). To moderate the continual and malignant Fever, which accompanied this Disease from the first, and which was thought by some to be only symptomatical, and had therefore the last Place in their Consideration (r), they had recourse to such internal Medicines as were deem'd cordial and alexipharmic. Ar- menian Bole, Bezoar both animal and mine- ral, and according the Philosophy of those Times, the precious Stones, were reckoned of this Class. Of vegetable Products, the Juices of Citrons, Lemons, Oranges, Pome- granates, and Sorrel; Vinegar, the Juice and Decoctions of Borage, Bugloss, Carduus Be- nedictus; Endive, Scabious, Scorzonera, Scor- dium, with many others of the like Nature, were recommended. But a Decoction of the Contrayerva Root was in the highest Esteem, both for its great Use as an Alexipharmic in ge- neral in this Disease, and its particular Efficacy, when applied as a Gargle to the Throat; of which Mercatus, from his own repeated Ob- servations, gives a very ample Testimony (s). But (p) Sgambat. (q) Heredia, ubi supra. (r) Febris etiam continua statim in initio apparet, symptomica quidem. Idem, p. 97. (s) Hoc unum observantissimum habeo, nimirum omnes oris et gutturis collutiones efficere supra decoctum ejus [23] But as they found from Experience, that no regular Crisis or Concoction of the Hu- mours was to be waited for; that no Eva- cuations, except by way of Revulsion, after the Access, were of Use (t), they began to consider the Disease as local, a peculiar (u) morbid Affection of the Fauces, and applied themselves chiefly to Topics, without laying much Stress on Internals. In this Part of their Directions they have therefore been more explicit; and some of them, in order to point out their Applica- tions with more Propriety, have divided the Course of this Disease into four different Pe- riods (x). The first they called the State of Inflam- mation. In this mild Repellents were thought necessary; such as Vinegar in Barley-Water, Juice of Pomegranate, Syrup of Roses, Mul- berries, Purslain, or a Decoction of Barley, red Roses, Liquorice, and Plantain; to two Pounds of which were added Acet. Ros. zjss. Syr. Diamor. ejus celeberrimi medicamenti, quod medici Hispani Con- trayerva nuncupant, maxime si mucosa et viscida pituita abundaverit. Mercat. Consult. p. 138. (t) Experimento monstratur, quamcunque evacua- tionem per alvum, aut sudorem inutilem esse et nocivam, quia cum non profit, necessario debilitat. Hered. p. 100. (u) Cortes. Miscel. p. 703. (x) Sgambat. de Affectu Faucium pestilente. [24] Diamor. 3j. M (y). If it was required yet more repellent, a small Quantity of Alum was added. The second Stage is that wherein the white Sloughs begin to appear, which is a Step to- wards a gangrenous Colliquation. In this they order'd mild Abstergents and Antiputres- cents; such as a Decoction of Lupins, Beans, Vetches, with Honey of Roses (z). The third is, when the Ulcers appear foul and sordid, and begin to look black, a real Mortification being come on, sometimes pene- trating to a considerable Depth, with great Pu- trefaction. More powerful Astringents and Exsiccants were requisite in this Case; such as Powder of Myrrh, and a little Alum mixed with Honey, or Honey of Roses, Bole dis- solv'd in Treacle-Water, a Solution of Un- guent. Ægyptiacum in Barley-Water was also much in Use (a), Alum, Sulphur, Cop- peras, Verdigrise, Oil of Vitriol, Oil of Sul- phur, Spirit of Salt alone, or mix'd, or di- luted in different Liquors, were much em- ploy'd. In this Case, sometimes the acid Spirits (y) Heredia, p. 105. (z) Idem ibid. (a) Celebris utilissimaque est unguenti Ægyptiaci lotu- ra: sumuntur quidem 3ij. et infunduntur in 3ij. aquæ hor- dei, plantaginis, vel seri lactis: post infusionem percolatur per linteum, et colatura tangitur ulcus. Idem ibid. [25] Spirits were dexterously applied to the Parts af- fected by means of an arm'd Probe; but they were oftener diluted with Syrup or Honey of Roses, and in Children pour'd into the Mouth. Tho' many had recourse to these power- ful Remedies, and even to Arsenic itself, yet the most Experienced were justly afraid, that the Use of such caustic and acrimonious Ap- plications was often attended with pernicious Consequences, both to Children and Adults; and they are therefore, with great Reason, condemned by Mercatus (b). Nevertheless some went so far as to ad- vise the actual Cautery, if the potential ones did not succeed, and give Directions for the Time and Manner of their Application; (c) but as this Operation will be liable to all the Objections made to the former, to have men- tion'd it will, I imagine, be thought sufficient. Tho’ the Author last quoted advises us to scarify the black or livid Crusts or Sloughs, yet he gives us a Caution not to tear them off, or forcibly separate them, as the Conse- quences (b) Ego quidem arbitror, plures pueros interfecisse usum horum medicamentorum, quæ caustica sunt, quam affectionem ipsam. Merc. Consult. p. 139. —compertum habuimus in hoc viro, et aliis laboranti- bus, hæc caustica inflammationi et ulceri summopere esse nocua: suppurantia corruptioni. Id. p. 40. (c) Heredia, p. 106. D [26] quences would be an Increase of Pain, and Inflammation; whence the Ulcers would spread, and at the same time eat deeper (d). 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 sup- posed to dry with some Degree of Astrin- gency. Such was the Appearance of this Disease at its first being taken notice of in Europe; and such, as far as I can collect, the Me- thods of Cure pursued by the Authors above- mention'd. The Disease which is described in the following Pages, appears to be the same with the Angina maligna, or strangulatory Af- fection of the Fauces of these Writers, and seems only to differ from that in Degree; in which, as it is much more favourable and mild with us in general, than it was in the Countries where they practiced, we have greatly the Advantage. OF (c) Idem p. 109. [27] OF THE SORE THROAT Attended with ULCERS; As it has appeared in THIS CITY, and PARTS adjacent. ACCORDING to the Information I have received from several eminent Persons of the Faculty, it was in the Year 1739, that a Disease was first taken notice of, which was thought to be the Morbus stran- gulatorius, already described, and which dif- fered in no essential Circumstance, as far as I can learn, from the Distemper which is the Subject of this Treatise. The sudden Death of two Children in a Family of Distinction, and of some others near the same Part of the Town, whose Complaints had chiefly been of a sore Throat, seem to have occasion’d this Suspi- cion: But as very few Cases of the like Na- ture occurr'd after these, or, if they happen’d, pass’d unobserv’d, little mention was made of it during several Years. D2 It [28] It began however to shew itself again in 1742, but not in so general a Way as to render it the Subject of much public Dis- course; for tho’ such of the Faculty, as were in the most extensive Practice, met with it now-and-then, in the City especially, it re- mained unknown to the greatest Part of Practitioners, till within these two or three Years, in which Time its Appearance hath been more frequent, both in Town, and the Villages adjacent. In the Winter of 1746, so many Chil- dren died, and so suddenly, at Bromley near Bow in Middlesex, of a Disease that seem’d to yield to no Remedies or Appli- cations, that the Inhabitants were greatly alarmed by it; 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 with the like Disease; which, from all the Accounts I have met with, from those who attended the Sick, was that here treated of. I am informed likewise that it raged at Greenwich about the same time (a). --It (a) The Reader may be pleased to take notice, that the Facts contained in the following Narrative, where the contrary is not expressly mention’d, have all come under the Author’s Observation, who has endeavour’d to relate manner [29] --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 Be- ginning; which Circumstances, tho’ of some Importance in all Cases, yet are of the ut- most in this; as a wrong Step at the first may put it out of the Power of Art to af- ford Relief. Tho’ 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 Au- tumn and the Beginning of Winter; at least I have met with many more Cases from Sep- tember to December inclusive, than in all the other Months together. It may likewise be remark’d, that the Summers of 1747 and 1748 were dry, with some Days in each uncommonly hot, for this what he has seen, and only what he has seen, in such a man- ner as he thought would best contribute to public Advan- tage. It may also be necessary to observe, that the Disease is described, as it appeared in 1747 and 1748, that if the Symptoms should hereafter vary in any Circumstance, the Diversity may be attributed to the Nature of the Distemper, and not imputed to Design or Inattention. [30] this Climate; the Mercury in Fahrenheit's Thermometer rising in the Shade, and with- in-doors, one Day to 78, and during several to 75 and 6. The Autumns of the same Years were as unusually temperate and warm; the Wind continuing longer in the South- erly Points than has often been known at this Season. In this Country, as well as in those where the Angina maligna was first taken notice of, 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 are more liable to have the Dis- ease, and to suffer from it, than the healthy and vigorous. I have seen very few grown People of this Class who had it, and not one who died of it. If it breaks out in a Family, all the Chil- dren 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 such a Giddiness of the Head, as often precedes Fainting, and 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 [31] becomes constant and intense. The Patient then complains of an acute Pain in the Head, of Heat and Soreness, rather than Pain, in the Throat, Stiffness of the Neck, com- monly of great Sickness, with Vomiting, Purging, or both (b). The Face soon after looks red and swell'd, the Eyes inflam'd and watery, as in the Measles; with Restlessness, Anxiety, and Faintness. This Disease frequently seizes the Patient in the fore Part of the Day: As Night ap- proaches, the Heat and Restlessness increase, till towards Morning; when, after a short disturbed Slumber (the only Repose they of- ten have during several Nights), a Sweat breaks out; which mitigates the Heat and Restlessness, 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, to- gether (b) The Vomiting and Purging were but seldom ob- served to accompany this Disease, at its first Appearance amongst us, as I have been inform’d by some Physicians of Eminence, who saw it early; but it is generally agreed, that these Symptoms almost constantly attended, in the manner here described, during the Years 1747 and 1748, the Time in which these Observations were collected: And I have found, that within these three Months, the abovemention’d Symptoms have not so regularly appeared as before. [32] gether 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 com- monly 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, sur- rounded with a florid Red; which White- ness 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 Dis- ease, the Face, Neck, Breast, and Hands to the Fingers Ends, are become of a deep ery- sipelatous Colour, with a sensible Tumefac- tion; 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 Red- ness is least intense; which is generally on 3 the [33] the Arms, the Breast, and lower Extremi ties (a). As the Skin acquires this Colour, the Sick- ness commonly goes off, the Vomiting and Purging cease of themselves, and rarely con- tinue 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 Dimen- sions. All the Parts of the Fauces above-men- tion'd are liable to these Ulcerations; but they generally are first discernible in the An- gles above the Tonsils, or on the Tonsils themselves; though they are often to be seen in the Arch form'd by the Uvula, and on of the Tonsils; also on the Pha- rynx behind, on the Inside of the Cheeks, and the Base of the Tongue, which they cover (a) The Redness and Eruption have not accompanied this Disease so regularly, during the latter Part of this Winter, as they did in the preceding Seasons: In some Cases they did not appear at all; in others not till the third or fourth Day; and, as I have heard, in some not till the fifth, and even later. E [34] cover in the manner of a thick Fur. In- stead 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 distinguished from the sound, but by the Inequality of Surface they occasion. The parotid Glands (b) on each Side com- monly swell, grow hard, and are painful to the Touch; if the Disease is violent, the Neck and Throat are surrounded with a large œdematous Tumor, sometimes extending it- self to the Breast; which, by straitening the Fauces, increases the Danger. 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 con- siderably from the like Affection in other Diseases. They commonly answer the Que- stions put to them properly, but with an un- usual Quickness; they talk to themselves in- coherently when left alone, and frequently betray the first Tendency to this Disorder, by (b) Heredia takes notice of the same Symptom, and assigns a very probable Reason for it. -—In Angina ma- ligna non tument externa, quia in illas ex externis trans- lata materia suerit, sed quia ita adimplentur interna, ut materiam fluentem non capiant, et sic ad externa dilabi- tur. Heredia, p. 99. [35] 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 and the Delirium 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 Suf- ferings. The Disease seems to have no stated Period which can properly be called its ’Azµn' 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 fol- lowing manner: First, the Redness of the Skin disappears; the Heat grows less; the Pulse, which was hitherto very quick, becomes slower; the ex- ternal Swellings of the Neck subside (c); the Sloughs (c) At least, of all the Parts about the Neck, except the Parotids themselves; which sometimes continue swell’d and hard a long time after the other Symptoms abate, and at length suppurate. E2 [36] Sloughs in the Fauces cast off; the Ulcera- tions fill up; the Patient sleeps without Con- fusion, is composed when awake, and his Appetite begins to return towards more so- lid Nourishment, than has hitherto been al- low'd him. The Pulse, during the whole Course of this Disease, is generally very quick; fre- quently 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 inflamma- tory Disorders. If a Vein is open’d soon after the Distem- per 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 (d). 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 Sym- ptoms are favourable, from the Time when the (d) But it is often sizy when the Disease has conti- nued two or three Days; and in some Instances which lately occurr’d, it was so, soon after the first Attack. [37] the Purging, which generally attends the Ac- cession, ceases. This Discharge is frequently bilious, and without any Pain: Tho' these Evacuations differ in different Habits. They complain of Thirst commonly less 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 some- times so much swell'd, as to leave but a very narrow Entrance into the Gullet, and this En- trance frequently surrounded with Ulcers or Sloughs; yet the Patients often swallow with less Difficulty and Pain than might be expected under such Circumstances (e). 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 (e) I have seen a few Cases, where these Glands were so enlarged, as to force back thro' the Nostrils a consider- able Part of the Nourishment they took. 2 [38] 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 Con- sistence, flows from them, which is so acrid, as to excoriate the Part it lies upon any con- siderable time. This is most observable in Children, or in young and very tender Sub- jects, 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 Dis- temper 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: I have been informed, that some Children have had the Parts about the [39] the Anus excoriated (f); the Sanies retain- ing its Virulence 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 Di- stance: If they are taken ill about the usual Season, the Discharge is commonly greater than it ought to be. Some young Persons, who never had the least Appearance of them, have had this Evacuation during their Illness. In strong and full Habits, these Evacua- tions are seldom attended with much Bene- fit, 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 preju- dicial. It has happen’d in this Disease, that Hæ- morrhages from the Nose and Mouth have suddenly carried off the Patient. I have heard of the like Accident from Bleeding at the (f) Some Adults, who have had the Disease in a vi- olent Degree, have suffer’d very much from the same Cause: Emollient mucilaginous Liquids taken plentifully, and also applied externally, by way of Fomentation, to the Part affected, frequently give speedy Relief. [40] the Ear: But these fatal Discharges most com- monly 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 Fullness of the Vessels, or an Effort of Nature to relieve herself by a salutary Crisis (g). Bleeding in this Disease has in general been observed to be prejudicial: Some in- deed admit of it at the first Attack, 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 produced very fatal Consequences. The Heat, Restlessness, Delirium, and Diffi- culty of breathing, which this Evacuation commonly prevents or mitigates in other Cases, in this are increased by it; nor does the (g) This I find was also Heredia's Opinion, who considers a Discharge of Blood either from the Mouth or Nose, as a Sign of the utmost Danger.--Malignam significationem præbet segnis sanguis stillans e naribus; ex corrosione quippe vasorum, et putrilagine emanat, innuitque certissimam mor- tem, quia putredo interne cohiberi non potest;--ideo periculosissimus censetur sanguinis fluxus ex naribus aut ore. Quidam cum hoc signo nullum vidisse liberatum docent: nos vero unicum solum ægrotum summa dili- gentia a tanto periculo vindicavimus. Heredia, p. 100. Tho' of three whom I attended, and who had this Sym- ptom, two recover’d; the third died of a Bleeding at the Nose, before any Assistance could be procured. [41] 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, and change to a livid or black Colour, the external Tu- mor grows large, and the Spitting com- monly diminishes (h). Nor has Purging been observed to be more beneficial: Gentle Cathartics have brought on very dangerous Symptoms. Upon procuring a few Stools with Manna, especially when the Disease has continued two or three Days, the Redness of the Skin has disappeared, and the Flux to the Throat has been surprisingly increased: If it happens that this 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 Purga- tives seem to have no better Effects in dimi- nishing the Tumor, and abating the supposed Inflammation, than Bleeding. Nitrous (h) The Heat indeed and Quickness of the Pulse seem at first to be affected by this Evacuation, but they commonly return after a fallacious Respite with greater Violence; the Patient is seized with a Difficulty of breathing, falls into cold Sweats, a Stupor, and dies suddenly. F [42] Nitrous cooling Medicines frequently pro- duce the like Effects; they increase that Faint- ness which accompanies this Disease, and either dispose the Patient to copious sinking Sweats, or to Stools. Upon the Whole, it appears, that all Eva- cuations which tend to lessen the natural Strength of the Constitution, are in this Dis- ease injurious; and that those Persons in common are in the greatest Danger, if at- tacked with it, who have been previously in- disposed, 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 cheerful 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 exter- nal 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 Ap- petite, and either an obstinate Costiveness, 4 or [43] or a troublesome Diarrhœa; the Menses were pale, and in small Quantities; and her Health in general was greatly impaired. She had scarce recover'd from this weak State, when the Death of a near Relation brought her almost into the same Circum- stances; from which she was slowly recruit- ing, when she married. Her Sickness, Vo- miting, 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 Cold- ness 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. To- wards 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 ap- proaching. She slept little that Night; and next Morning her Pulse, which before was very quick and small, seemed to be some- what more full, but not sensibly slower; and she complained of Faintness and Anxiety. The Parts about the Fauces were much re- lax'd, very red, in some Places almost livid, F2 with [44] 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 disap- peared, 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 Dis- ease. 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, na- turally inactive, averse to Exercise, and was thought to have indulged some painful So- licitude, 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 pre- sent to Opiates; but constantly return’d when their Effects were over. The other Sym- ptoms, such as Heat, Restlessness, Anxiety, and Faintness, increased with the Purging; the Pulse was small, quick, and hard; a Dif- ficulty of breathing came on, the small Re- mains [45] mains of Lustre in the Eye perish’d and she died early on the fourth Day of the Dis- temper. No Marks of any Sloughs in the Throat appeared in either of these Cases; but the Redness became daily more intense, and ap- proached nearer to Lividness, whilst the Fauces could be inspected; which, from the great Difficulty they had in breathing, was impracticable several Hours before the Pa- tients expired. Warm aromatic Cordials, and anodyne Astringents, were administered 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 Sym- ptom; for tho’ 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 fail into profuse Sweats; Respiration be- comes [46] comes difficult and laborious; the Pulse sinks; 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 or dim several Hours before Death; and, as Ætius Cletus hath observed, is a fatal Presage of its Ap- proach (i). A copious Flux of pituitous Matter to the Glands, and other Parts about the Fauces, seem'd (i) Heredia's Description of this fatal Progress of the Disease, and the necessary Cautions he gives in respect to the Prognostic, deserve particular Notice. Fallacissimam esse hujus morbi naturam, consiten- tur omnes.--ulceribus oris, et partiumn quæ visui existe- bant conspicuæ, recte curatis, et sedata inflammatione æger periclitatur.--ex eo quod paulatim serpit putedo per asperam arteriam ad cor, aut per gulam ad ventricu- lum, fine aliquo dolore, aut febre sensibili, cujus fit ha- benda cura: et cum medicis auxiliis, ablata fuerint ul- cera, et inflammationes sedatæ in partibus visui patenti- bus, occulta putredo, paulatim mortificans partes inter- nas, tabe, parvissimis et debilissimis pulsibus extinctione caloris, refrigeratione extremorum faciei extenuatione, inappetentia perpetua, et molesta mutatione decubitus, somno fallaci, et apparente, quia vigilandi impotentia, somnum verum æmulatur, misere ægrotantes interficit, ut visum jam sit subita et inopinata morte periisse aliquos, --e lecto surgentes, et intra domos ambulantes; ob quod etfi quæ vitiata apparebant in faucibus, aut partibus aliis, in melius mutata conspiciantur, non licet salutem pol- liceri, quia solet communicari paulatim putredo, et gan- græna partibus internis. Heredia, p. 99. [47] 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, Head- ach, 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 Quan- tities of Phlegm. About six in the Even- ing 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’d 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 [48] These Circumstances perhaps might contri- bute 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 (k). From the preceding Account of the Sore Throat attended with Ulcers (l), 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 (k)-—Ad prædictarum partium (Uvulæ, Tonsillarum) inflammationem subsequebatur interdum materia quædam pituitosa a capite tam repente et inopinato descendens, ut miseri ægrotantes subito suffocarentur. Cortes. Miscell. p. 697. (l) The Disease here treated of is, strictly, a Sore Throat; since by Soreness we aptly express the uneasy Sensation accompanying an Ulcer (i. e. a Sore) and not that which attends an Inflammation; which is indeed Pain, but not properly Soreness. [49] are weak and infirm: And it seems to af- fect those Adults in the severest manner, who have been previously indisposed, or whose Strength has been reduced by unsea- sonable or immoderate Evacuations. On the contrary, the common Angina, or an Inflammation of the Tonsils, most fre- quently attacks the healthy, the vigorous, and robust; the weak, the delicate, and in- firm are less exposed to it, at least suffer less from it, than the former. As both Diseases are attended with a Fe- ver and as most Fevers come on with Shi- vering 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 to be of the putrefactive kind: But if with these Symptoms an erysipelatous Redness discovers itself in the Fäuces, with Ulcerations or Sloughs, the Disease is evi- dent. In some Cases, the Symptoms have been so obscure, that it was difficult to determine to which disease they properly belonged: But in these Circumstances they were commonly so favourable, that, supposing the Disorder not to be of the ulcerated kind, no other Inconve- G venience [50] nience 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 In- flammation is the Disease: All the Sym- ptoms are derived from this Source: An acute throbbing Pain, greatly increased upon swal- lowing even Liquids, is the principal Griev- ance. 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 Dis- ease we are acquainted with. To have this Symptom appear in the Disease we are treating of on the first Night, is not un- common; 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 appear- ing [51] ing to be light-headed. She had made no Complaint of her Throat, nor was this Part thought to be affected, till, upon Examina- tion, I found it so; being led to suspect it by the Colour of her Hands, and the De- lirium. She got well through the Disease, tho’ its Progress, at first, appear’d to be very swift. A common sore Throat, if the Patient re- covers, either goes off by Resolution, or the Parts affected suppurate, or, if glandular, be- come 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, li- vid, or black Colour, if it is more violent. It will not perhaps be difficult, from this comparative View, to distinguish this Dis- ease from a common sore Throat, or an in- flammatory Affection of those Parts: But there is another no less certain Criterion, tho’ too often a fatal one, which is, the con- stant Increase of Symptoms upon Bleeding, Purging, and the liberal Use of cooling anti- phlogistic Medicines: A Method, which as seldom fails removing a genuine Inflammation if it is early enough and assiduously pursued, as it is too often injurious in the present Case. G2 An [52] An Instance whereof I think evidently ap- peared 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 Le- prosy, had sometimes appeared on his Head and Arms, was seized one Morning with a general Uneasiness, and a Disposition to vo- mit; he was put to Bed, and a severe Shi- vering 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 common 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 Ten- dency to Delirium; a Blister was applied. On the third, the Symptoms not abating, he lost about ten Ounces of Blood. He had taken a [53] a cooling nitrous Powder every four Hours; this was now changed for one more cordial. At Night he grew delirious, his Fever in- creased, 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 Bright- ness: His Excrements came away invo- luntarily; his Eyes were languid, and dim; he breath’d with Difficulty, fell into profuse clam- my Sweats, 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, sometimes urged me to order Bleeding, espe- cially if there were any Marks of a Plethora; but in these Cases it did not appear to have any advantageous Effects: So that, notwith- standing the Urgency of the Symptoms above- mention’d, it seems proper in general to omit this Evacuation. Cupping [54] 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 Be- nefit. 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 disap- peared, and a Disorder, which with Confine- ment 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 practiced, the Dis- order 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 aro- matic, cordial Medicine, every four or six Hours. The Pulvis Contrayervœ simp. —- comp. [55] comp. Confect. cardiac.--Raleigh. Spec. arom. Vinum croceum; Aq. Menthe. spirit. Aq. Alex. spirit. cum Aceto (k); with others of the like Nature, maybe 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 Faint- ness, sinks the Strength, and in the End pro- duces 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 pro- portion to the Exigence of the Case; such as the Confectio Fracastorii, or Elect. e Scordio, 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 (k) Vegetable Acids, such as the Juice of Lemons, Oranges, Wood-Sorrel, Verjuice, Vinegar in small Doses, and the like, as they are undoubtedly Antiputrescents, may seem to be indicated; but their Proneness to in- crease the Discharge by Stool, or profuse Sweats, ought to render us very circumspect in using them. [56] Discharges abate: It has happen’d that this Colour has gone off sometimes, and the Pa- tient has been brought into imminent Dan- ger, 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 Vo- miting went off, and the Redness of the Skin appeared soon after: The Apothecary who attended her, judging it an inflamma- tory 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 disappear'd; 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 fre- quently 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 [57] Mixture (a) 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 Dis- temper 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 Abate- ment of it may be look'd upon as a sure Pre- sage of Recovery. Warm aromatic and gently stimulating Medicines, such as have been already men- tion'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 re- H quires; (a) Px Aq. Alexet. simp. ℥vj. Alexet. Spir. cum Acet. ℥ss. Conf cardiac. ʒj ss. Pulv. Contray. simp. ʒss. Syr. Croc. ℥ss. f. Mixt, de qua capiat ccgra coch. ij. tertia quaque hora. [58] quires; yet we are not to be governed so much by these Symptoms, as by the Faintness, De- pression of the Pulse, and Increase of Pu- trescency 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 Pa- tient’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 anti- septic, 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-Wa- ter, Gruel, Panada, Sago, and the like; and alone, where the Faintness has been exces- sive; 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 3 Children, [59] Children, who have this Disease, extremely desirous of Chicken, and cheerfully comply- ing with Directions, in hopes of being grati- fied 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 ag- gravate the Disorder they were intended to remove: But no such Effect having appeared from their Use, I have order’d them to be ap- plied, 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 (l). 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 injurious 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 Per- son unacquainted with it. A thin, pale, white Slough seems to accompany the next Degree: A thick, opaque, or ash colour’d one is a further Advance: And if the Parts have H2 a (l) It has been observed by several, that the Discharge from Blisters in this Disease, is in general both more co- pious at first, and continues longer than is usual in other Cases. [60] a livid or black Aspect, the Case is still worse. These Sloughs are not formed of any fo- reign Matter spread upon the Parts affected as a Crust or Coat, but are real Mortifica- tions of the Substance; since whenever they come off, or are separated from the Parts they cover, they leave an Ulcer of a greater or less Depth, as the Sloughs were super- ficial 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 Applica- tions: But it seems by no means advisable to attempt it by Force, or to scrape them off with the Fingers or Instruments, as Seve- rinus proposes; since the Experiment has been tried, but with such unhappy Conse- quences(a), as are sufficient to discourage one from persisting in this Method (b). In (a) Si quis tamen vel digitis, vel aliquo instrumento levi ipsam (materiam albam) auferre tentâsset, quamvis operatic hæc fieret absque dolore, ea tamen ablata bre- vissimo tempore peribant ægrotantes; quod præ cæteris in Petro Soprano genero meo observatum est, cui cum hujus- modi moriificatio apparuisset in suprema superficie dicta- rum glandularum faucium, et palati, ita ut videretur esse maximo respirationi et deglutitioni impedimento, chirur- gus existimans posse facillimo negotio a subjectis partibus eam separari solis digitis, levissime quidem eam abstulit; quæ ablata, tantum abest ut juverit deglutitionem aut re- spirationem, ut utraque potius actio læsa magis suerit, unde brevissimo tempore miser, meo cum maximo dolore, mor- tem [61] In a Case where I was concerned, previous to my being called in, a Surgeon had endea- vour’d to separate the Sloughs by the Assist- ance of his Probe: He succeeded in his At- tempt without much Difficulty; but was sur- prised to see the same Parts cover’d the next Day with thick, dark, ash-colour’d Sloughs, penetrating deep into the Substance. It is true, the Sloughs have been some- times scarified, from an Apprehension, that Matter was lodg’d underneath them, with- out 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 ex- coriate the external Parts upon which it is suf- fer’d to remain. This is sometimes observable in Adults, when the Parts above the Fauces are affected; the Ichor in these Cases flows thro' tem oppetiit; id quod etiam in aliis quamplurimis pueris sæpius observavi, et præsertim 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. (b) Quod si enim adhærentem adhuc crustam avellere aggrediamur, ulcerationes magis in prosundum procedunt, et inflammationes consequuntur, augentur dolores, et in ulcera serpentia proficiunt. Heredia, p. 109. [62] thro’ the Nostrils, and frequently raises Pim- ples and small Blisters on the Skin of the upper Lip; but it is most obvious in Chil- dren, 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 has been already hinted (p. 38), that Part of the same virulent Matter, pass- ing 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, dis- poses 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 As- sistance from others, being generally, if the Distemper is not very mild, either comatous and stupid, or delirious and intractable. 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 [63] 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 (m). 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; tho’ after longer Sleeps than ordinary, or a Neglect of encouraging this Evacuation, they have com- plain’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 Ad- vantages may be expected from the constant Use of gently stimulating aromatic Gargles; as they promote the Discharge of the pitui- tous Matter flowing to the Fauces, and, doubtless, with it, of some Part of the corro- sive Fluid above-mention’d: To which if we add Antiseptics and Detergents, in order to check (m) Heredia takes notice of the same thing, and gives it as a principal Reason why so many Infants and Children suffer’d by this Disease. Insantium et puerorum multitudo maxima periit, quia nec exspuere, nec excreare lentas et crustaceas materias possunt, et minus auxiliis obediunt,--p. 100. [64] 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 Spoon- fuls 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, Re- course must be had to more efficacious Reme- dies: A Composition like the following, va- ried only as the Patient’s Age and the Cir- cumstances of the Disease required, has in ge- neral 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. Px Decoct. Pectoral. ℥xij. cui inter coquen- dum add. Rad. Contrayerv. contus. ℥ fs. Liquori colato admisce Acet.Vin. Alb. ℥ij. Tinct. Myr. ℥i. Mel. opt. ʒvi. f. Gar- garisma. As the Parts about the Gullet are fre- quently so much affected, as to render it painful [65] painful or impracticable for the Sick them- selves 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 pu- trid Sordes adhering to the Ulcers, and pre- vent it from passing into the Stomach and Bowels (n). 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 (o). As so much depends upon the frequent Use of Gargles, or rather of Injections, a strict Atten- tion to this Affair, can scarcely be too strongly enjoin'd to those who have the Care of the Sick committed to them; since an assiduous Repetition of these Lotions not only pro- motes a Discharge from the Glands of the Throat, which is probably of great Use (n) The same Caution was given by Heredia, and al- most in the same Terms.--Cujusque rei deglutitio- nem præcedat excrementorum oris excreatio, detersio, ne lotione venenosa excrementa cum rebus deglutiendis ferantur ad viscera. p. 109. (o) -—cum pueri nequeant gargarismatis uti, injiciantur cum Syringa. Idem ibid. I Use (p), but retards the Progress of the Ul- cers, by washing off the putrefactive corroding Virus, and prevents a large Train of very dan- gerous Symptoms (See p. 62); and has there- fore been strenuously insisted on by several Writers, by Mercatus especially (q). If (p) Heredia, after having observed, that no Evacua- tions by Stools or Sweat were of Use in this Disease, ad- mits that some Advantage may be expected from this Dis- charge. Est autem aliqua spes in frequenti expuitione, quando crassa et glutinosa excreatur. p. 100. As I had not an Opportunity of seeing this Author’s Works till the first Pages of this Edition were printed off, I could not mention him with the rest, to whom I had recourse for information respecting the Symptoms at the first Appearance of this Disease in Europe. He was Physician to Philip IV. of Spain, and in his Disputationes de Morbis acutis, printed in the third Tome of his Works, he treats of this Disease expressly in several Chapters, un- der the Title of Angina maligna. His History of the Symptoms contains several things not mention’d by any other Author I have seen; so that tho’ he was probably among the last of the Spanish Physicians who wrote upon this Subject, yet the Diligence of his Predecessors seems not wholly to have exhausted it. In the second Edition of his Works, which was that I made use of, nothing appears to determine the exact Time when his Account was publish’d; but as he mentions the Polyanthea of De la Parra, which, according to Ren. Moreau in Bartho- line’s Epistles, was printed at Madrid in 1625, that it must have been after this Time, is certain. -- This Edition of Heredia was publish’d at Lyons under the Title of Petri Michaelis de Heredia, Complutensis - Philippi IV. Hispaniarum regis Archiatri —Operum Me- dicinalium Editio altera. Lugduni 1673. (q) Cavendum est diligenter, ne sic affecti deglutiunt propriam salivam, quinimo ora puerorum diligentissime sunt abluenda, Mercat. p. 137. 4 [67] If the Sloughs are large, and cast off slowly, they may be touched with Mel Ægyptiacum, by means of an armed Probe; or if the Con- dition of the Fauces is such, that this cannot conveniently be done, a Spoonful of the fol- lowing Mixture may be injected, and retain’d in the Throat, as long as the Patient can en- dure it; the Parts may then be washed two or three times with the Gargle alone. Px Gargarism. prœscript. ℥ij. Mel Ægypt. ʒj. m. By the constant and regular Use of these Applications, if the Patient is kept warm, and the Method of treating him in other Re- spects 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 Misma- nagement 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 mis- chievous. What Effects improper Treatment pro- duces in this Case has already been observed. With regard to the Matter of Contagion, or the Nature of that Cause which so suddenly brings on such a Train of Symptoms as hath been described, little can be said with any I2 Degree [68] Degree of Certainty: Thus much, however, seems to be true in Fact, that in some Cases this Disease appears to be of so mild a Na- ture, and so benign, as to require but little Assistance from Art: Persons even recover from it under the Disadvantages of unskillful 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 hap- pens in the Small-Pox; the benign and di- stinct 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 dif- ferent 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 de- termined. With respect to Constitution, it may be further observed, that in soft, lax, leuco- phlegmatic Habits, and languid inactive Dis- positions, 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 [69] 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 Phœ- nomenon: 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, as hath been already observed. If the Ves- sel 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 Con- sequences. It is therefore absolutely necessary to en- deavour 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 means of Tents or otherwise, as near to the Orifice of the Vessel as we can: To convey the Steam of [70] of it into the Fauces and Nostrils plentifully, and 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, Re- course must be had to more efficacious ones, amongst which we may rank the Bark and Opium. It is not uncommon for hectic Heats, Night-Sweats, Want of Appetite, and De- jection of Spirits to attend those a considera- ble time, who have had the Disease in a se- vere manner. Asses Milk commonly relieves them, together with a Decoction of the Bark, and Elixir Vitrioli. HAVING thus related, as concisely as I could, the most material Circumstances that have occurred to me in respect to the Sym- ptoms, Progress, and Event of this Distem- per, the Juvantia, Lœdentia, and the Acci- dents 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 distin- guish it from a common Sore Throat, and to treat it with some Degree of Propriety and Success, I shall conclude with observing, I. That the Sore Throat attended with Ulcers seems to be accompanied with a strong [71] strong Disposition to Putrefaction, which affects the Habit in general, but the Fau- ces, and the Parts contiguous, in particu- lar. And it seems not unreasonable to suppose, 2. That the Cause of this Tendency is a pu- trid Virus, or Miasma sui generis, in- troduced into the Habit by Contagion; principally by means of the Breath of the Person affected. 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 Efflo- rescence, 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 success- ful in similar Diseases. 6. That a cordial, alexipharmac, warm Re- gimen has been found by Experience to be of the most Use in such Cases; and that Bleeding, Purging, Antiphlogistics, liberally [72] liberally employed, either retard, or wholly prevent these Discharges. Therefore, as to expel the morbific Mat- ter (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. FINIS.