Chapter II: Part 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* * * * *

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

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

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

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

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

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

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

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

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

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

_FINIS._

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FOOTNOTES:

Footnote 1:

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

Footnote 2:

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

Footnote 3:

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

Footnote 4:

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

Footnote 5:

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

Footnote 6:

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

Footnote 7:

Medical Essays, vol. iii. p. 26.

Footnote 8:

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

Footnote 9:

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

Footnote 10:

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

Footnote 11:

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

Footnote 12:

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

Footnote 13:

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

Footnote 14:

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

Footnote 15:

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

Footnote 16:

Ibid.

Footnote 17:

Idem ibid.

Footnote 18:

Idem, _p. 440_.

Footnote 19:

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

Footnote 20:

_Ætii Cleti_ Op. de Morbo Strangulatorio.

Footnote 21:

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

Footnote 22:

_Æt. Clet._

Footnote 23:

_Severin._ p.

Footnote 24:

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

Footnote 25:

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

Footnote 26:

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

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

Footnote 27:

_Cortes._ Miscel. _p. 703_.

Footnote 28:

_Sgambat._ de Affectu Faucium pestilente.

Footnote 29:

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

Footnote 30:

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

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Transcriber's Notes.

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