Part 1
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_.
MDCCXLVIII.
PREFACE.
_A simple Inflammation of the Tonsils, or of other Parts about the_ Fauces, _from its frequently happening without any considerable Hazard attending it, is commonly look'd upon as a troublesome, rather than a dangerous Disease: And every one, how little soever conversant in the Practice of Physic, thinks himself qualified to conduct the Patient thro' it with Safety_.
_If a Person complains of Pain in his Throat upon swallowing, with the Symptoms of a Fever, nothing is thought more expedient, or more frequently order'd, than Bleeding, Purging, and such Medicines as are daily observed to remove Inflammations in general: And in simple Inflammations this Method is warranted to be just, by Reason and Experience._
_But a Disease hath of late Years appeared in this City, in many of the neighbouring Villages, and according to the best Informamation I have been able to procure, in several other Parts of this Nation; which, tho' it may be taken for a common Sore Throat, or a simple Inflammation of the Tonsils, by those who are unacquainted with it, is of a very different Nature from the common one, and requires to be treated in as different a Method: For it has been found by Experience, that those Measures, which seldom fail of answering the Prescriber's Expectation in this Case, frequently produce the most unhappy Consequences in the other, and render a Disease almost certainly fatal, which of itself is not often so, in this Country._
_Some Instances of Mistakes in this respect have not long since fallen under my Observation; and there is still a Possibility of the like happening, as the same Disorder continues amongst us: It seems therefore necessary, that some Endeavours should be used to prevent them; and that such a Description of the Disease should be made public, as might enable Practitioners, who have not seen or known it, to distinguish it from that to which it bears some Resemblance; together with an Account of the Method of treating it, which hath in general been attended with Success._
_There are several of the Faculty, who, I readily acknowledge, have it more in their_ _Power to give the Public Satisfaction on this Subject, than I have, but their constant Engagements in the Duties of their Profession, will probably hinder those who are most equal to the Task, from executing it so speedily as public Utility requires: Wherefore, as some Information relative to it seems immediately wanted in several Places, the following, tho' less perfect, will perhaps in the mean time be neither unacceptable, nor wholly useless._
_If any thing in these Sheets should appear, to those who may be better acquainted with the Subject to be inaccurate, or premature; if some Things of little Weight should seem too largely insisted on, whilst others of more Consequence are neglected, this Apology will, I hope, be admitted;_ viz. _that to have delay'd the Publication of this Essay, till it had received those Advantages that further Observations might have added, would have frustrated my Design; which was, to prevent, as much as possible, the Mistakes that might happen in relation to this Disease, by speedily communicating the Remarks, which the Instances I had seen had afforded._
_As this Disease appears to be the same with that which raged in_ Spain, Italy, _and the neighbouring Countries, somewhat more_ _than a Century ago; it may not be improper, in the first place, to give some Account of it, from such of the Authors who then wrote upon it, as have come to my Hands, previous to a Description of the same distemper, as it now appears in this Country._
_'Tis said, that a similar, if not the same Disease hath long been in some of our_ American _Colonies, and the_ West-India _Islands, but as I have met with no Accounts of it from such as were competent Judges, it must be left to Time, and further Inquiries, to determine the Truth or Falsity of the Report._
_London_, Dec. 1. 1748.
OF THE
SORE THROAT
Attended with ULCERS;
As it appeared in _Spain_, _Italy_, _Sicily_, &c.
The Disease which was called by the _Spaniards_ _Garrotillo_[1], by the _Italians_, and other Nations, _Morbus strangulatorius_, _Pestilens Faucium Affectus_, _Epidemica Gutturis Lues_, and by divers other Appellations[2], is said to have appeared first in _Spain_ about the Year 1608, to have spread from thence to _Malta_, _Sicily_, _Otranto_, _Apulia_, _Calabria_, and the _Campagnia_, in the Space of a few Years; and to have broke out at _Naples_ in 1618, where it continued upwards of 20 Years ravaging the different Parts of that Kingdom[3].
It is not certainly known how much longer it remained in these Countries, or to what others it was communicated at that time, its Declension being as obscure as the Causes it sprung from. That it wholly disappeared in these Parts, soon after the Time above-mention'd, seems probable, from the Silence of those Physicians, who have published their Observations made in the Places, which had so severely felt the Effects of this Distemper.
Several Writers, as _Wierus_[4], _Forrestus_[5], _Ramazzini_[6], and others, take notice of epidemic Affections of the Throat, in some respects resembling the Disease here described; but a little Attention to the Symptoms of each, will, I think, discover an essential Difference between them. The same may be said of the Sore Throat and Scarlet Fever, which shew'd itself at _Edinburgh_ in 1733[7].
_Tournefort_, in his Voyage to the _Levant_[8], seems to have found the Disease we are treating of in the Islands of the _Archipelago_; at least as far as one can judge from the imperfect Description we have of it. His Account is as follows.
"When we were in this Island (_Milo_), there raged a terrible Distemper, not uncommon in the _Levant_: It carries off Children in twice 24 Hours: It is a Carbuncle or Plague-Sore in the Bottom of the Throat, attended with a violent Fever. This Malady, which may be called the Child's Plague, is epidemical, tho' it spares adult People. The best way to check the Progress of it, is to vomit the Child the Moment he complains of a sore Throat, or that he is perceived to grow heavy-headed.
This Remedy must be repeated, according as there is Occasion, in order to evacuate a sort of _Aqua fortis_, that discharges itself on the Throat. It is necessary to support the Circulation of the Juices, and the Strength of the Patient, with spirituous Things; such as the _Theriaca_, _Spir. vol. oleos. aromat._ and the like. The Solution of _Liquid Styrax_ in Brandy is an excellent Gargarism upon this Occasion. Tho' it is a Case that requires the greatest Dispatch, the _Levantines_ are seldom much in Haste in the Cure of any Disease."
This Account does not disagree in general with that which has been left us of the _Morbus strangulatorius_; only he is singular in affecting it to arise from a kind of _Aqua fortis_ discharged upon the Parts: But his favourite Study had engrossed his Attention, and to this we must impute both the present Mistake, and his Want of sufficient Accuracy and Precision, when he treats upon medical Subjects.
When it first broke out in the Countries above-mention'd, it soon engaged the Physicians of those Times, as well to observe its Nature and Effects, with whatever might contribute to its Cure, as to vindicate their respective Systems and Opinions, which some of them did with a great deal of Warmth. Out of such of the Tracts that were then published as I have had an Opportunity of perusing, and which indeed are not so many as I could wish, the following Account has been collected. I shall here mention the Authors to whom I am principally indebted for it.
_Johannes Andreas Sgambatus_, a Physician of _Naples_, who published a Treatise upon this Subject in 1620[9]. He gives us a methodical and pretty exact History of the Symptoms of this Disease, and the Method of Cure both general and topical, together with a summary View of the Disputes which at that time were managed with sufficient Heat and Acrimony in relation to its Name, Cause, and Nature; about which they were as much divided as they were about the Method of Cure; each Party appealing to _Hippocrates_, _Galen_, _Avicenna_, _&c._ for the Support of their Opinions concerning a Disease, which it is not certain that those whom they appeal to ever saw.
_Johannes Baptista Cortesius_, in his _Miscellanea medica_[10] takes notice of this Disease, and describes its principal Symptoms, in a Letter to _Jo. Anton. Anguilloni_, Physician in chief to the _Maltese_ Gallies. He considers it indeed as a different Distemper from that which infested _Naples_, and other Parts of _Italy_; tho', from his own Account of it, there appears little Reason to question the Identity. He seems to have been led into this Mistake, by considering the Disease he treats of as contagious only in a certain limited Sense, whilst the _Italians_ declared theirs to be pestilential and contagious without Restriction. He allows, that the Breath of a Person affected might convey the contagious _Effluvia_ to another near at hand; and gives an Instance of one who got the Disease, and died of it, by trying, at his Friend's Request, who then labour'd under this Disease, if his Breath was affected[11]: for from this Circumstance they guessed at the Degree of Danger attending them.
In 1636, _Ætius Cletus_, of _Signia_ in _Italy_, published his Treatise _De Morbo strangulatorio_[12]. He mentions some Facts relating to it, that had escaped _Sgambatus_ and _Cortesius_, which will be taken notice of hereafter.
_Marcus Aurelius Severinus_, Professor of Anatomy and Surgery, and Physician to the Hospital of Incurables at _Naples_, wrote a Dissertation upon this Disease, under the Title of '_Pædanchone Loimodes, seu de pestilente ac præfocante Pueros Abscessu_'; and annexed it to the second Edition of his Book _De recondita Abscessuum Natura_, which was printed
in 1643[13]. From a Person of his Capacity, and furnished with the best Opportunities of seeing the Disease in every Stage and Condition, we might reasonably expect such Observations as would enable one to form a just Idea of this Distemper; but we meet with very little of this kind in his Performance. He has indeed mention'd some Circumstances relating to its History, not taken notice of by the other Writers I have seen, and his Method of Cure is different from the rest; but he refers us to others for an Account of the Symptoms, and contents himself with reciting and commenting upon _Aretæus_'s Description of the _Ulcera Syriaca_, which he takes for granted to be the same with the Disease he treats upon; yet does not put it in our Power to compare them, by giving a candid Relation of the Symptoms.
One might justly expect some curious Observations upon this Disease, from a Person so well qualified for it as _Thomas Bartholine_: He was in _Italy_ whilst it raged there, and it might be supposed, would be attentive to the minutest Circumstance relating to it, and be inquisitive enough to know what Men of Character had said upon it. But the Treatise which he wrote upon this Disease, and publish'd in 1646[14], contains so little to the Purpose, that it is difficult to conceive for what End it was wrote, unless to compliment his Master _Severinus_, which he does very liberally.
ACCORDING to the Accounts which have been left us by these Authors, it appears, that the Disease which they describe was most particularly fatal to Children; tho' Adults, if they were much conversant about the Sick, were very often seized with it; yet more of these recover'd in proportion than of Children; and it was observed, that more Boys got well through the Disease than Girls; some thought, that such of this Sex as had black Eyes suffer'd more from it than others.
As it was sometimes observ'd to carry off whole Families together, and to spread to those Places first, where the Communication with the Country affected by it was most frequent; and also that Children sent away in order to avoid it, escaped whilst they remained there, but had it on their Return, if the Disease was not extinguished; it was almost universally allow'd to be contagious[15].
Those who were Seized with it, first complained of a Pain in the Throat, with a Stiffness of the Neck, an Uneasiness upon Motion, and a Difficulty in Swallowing their usual Nourishment. On Inspection, the _Uvula_, the Tonsils, _Pharynx_, and the whole _Fauces_, appeared of a remarkably florid red Colour, like that attending an _Erysipelas_: This Colour was not uniformly intense, but Some Parts Seemed to be of a deeper Dye than others. The Parts above-mention'd were swell'd more or less, tho' seldom so much as to affect Respiration, as in a common _Angina_; but the Sick could not Swallow without Pain. An acute Fever came on at the same time, which in Some was accompanied with small Pimples and Eruptions like Flea-bites. Several had Vomitings, according to an Observation of _Severinus_[16].
On the same Day, or the Day following, such Parts of the _Fauces_ as at first seem'd to be of a deeper Colour than the rest, turn'd white; this did not proceed from any Crust or Matter superinduced upon the Parts, but from a gangrenous Colliquation, the Substance itself being mortified.
The Voice was hoarse and obscure; not as in a common Cold, but as it is in those People who have venereal Ulcers in the Throat: So that, from this Circumstance alone, some were able to guess at the Disease.
The Neck and Throat soon after began to swell externally; the Tumour was of a soft œdematous kind, and increased in Magnitude as the Disease advanced. All the Symptoms were commonly aggravated during the Night. If the Patients had any Interval of Quiet, it was commonly in the Day-time[17]. About the fourth Day this Tumour was generally grown very large, and the white Places in the _Fauces_ began to turn black; the Breath grew extremely offensive; Respiration, hitherto not much affected, now became difficult, and the Patient expired in a very short time.
Tho' this was the common Progress of the Disease, where it terminated unhappily, yet it often varied from this Type, and was attended with very different Symptoms. Some had a Difficulty of breathing almost from the first; some had a violent Cough; some were comatous; others had a Delirium; some died in a lethargic Stupor; others bled to Death at the Nose; whilst others again had none of these Symptoms, but were carried off suddenly by an instantaneous Suffocation. The _Oesophagus_ in some was sphacelated to the Stomach; the _Aspera Arteria_, in others, to the Lungs: As these could only breathe in an erect Position; so those could swallow nothing when the Parts were so affected. The Nostrils discharged a fetid pituitous Ichor, sometimes mixed with Blood; and sometimes Blood alone, without Mixture. This bleeding at the Nose seem'd at first, in one Case, to give Relief; but the Patient soon after died[18].
These were the Symptoms in general, and they judged of the Event by the Mildness of their Progress, or the contrary: Tho' it was agreed, that nothing could be more fallacious than this Disease; and that the most Experienced were often deceived in their Prognostic.
If the Redness above described, which appeared at the first being seized, was succeeded by an Ulceration, without any of that Whiteness (which for the future I shall call Sloughs), if the Swelling about the Neck and Throat was not large, if the Patient discharged by the Mouth considerable Quantities of thin pituitous Matter, if the Breath was not fetid, and the Patient had no Disgust to his Food, if the Eyes retain'd their proper Lustre, all was judged to be secure.
On the other hand, if this Lustre was in any degree faded[19], if the external œdematous Tumour was very large, if the Breath stunk, if the _Fauces_ were livid or black, with a Coma, or Delirium, if with these the Patient had an Aversion to his Nourishment, and his Breathing became difficult or laborious, the Danger was judged to be extreme.
It was not observed that the Disease had any stated Crisis; or that the Signs of Recovery, or Death, appeared on any certain Day. Some died on the first, others on the second, third, and on every Day, to the seventh. Those who survived the fourteenth, were thought to be out of Danger, at least from the Disease itself[20]; tho' some dropp'd off unexpectedly, after a much longer Reprieve[21].
The Consequences of this Disease were often felt a long time after it had ceased: An excessive Languor and Weakness continued for many Months; and the Voice or Deglutition was frequently affected, so as to be perceivable in some almost a Year after[22].
It was however observed, that notwithstanding the Disease most frequently was accompanied with Symptoms of pestilential Malignity, yet it sometimes appeared with a much more favourable Aspect; its Progress not being so quick, nor its Symptoms so violent and dangerous, as hath here been described to be the Case in general[23]. At its first breaking out in any Place it was commonly the most severe; it then spared no Age or Sex, but swept off Adults together with Infants: By degrees it became less violent, and at length either wholly disappeared, or was of so little Consequence as to be disregarded.
We are directed, by most of the Authors I have seen, to begin the Cure of this Distemper with Evacuations; the chief whereof are Bleeding and Purging; tho' which of the two ought to precede was not a little disputed. Purging was in general preferr'd; and they commonly made use of Manna, Rhubarb, Senna, and Agaric, for this Purpose. _Cortesius_ directs six Ounces of Manna to be given to Adults in a Decoction of Tamarinds. Bleeding, tho' commonly directed at the first, hath been used more sparingly in this, than most other acute Cases[24]. _Severinus_, who was by no means a timid Operator, directs from four to eight Ounces to be taken away; which, considering the common Practice in those Countries, is a very small Quantity[25], But it may not be improper here to give a short Sketch of this Author's Practice, as he differs in several Respects from most others.
He orders an antimonial Vomit to be given at the first Attack, and a cooling gently astringent Gargle to be used Night and Day. He then directs a Clyster, takes away some Blood from the Jugular, and gives from _xv_ to _xxi_ Grains of Bezoar Mineral twice a Day; or oftener, as Occasion requires, with thin diluting Liquors, in order to raise and promote a moderate Sweat. He gives five or six Grains of the same Medicine to Children at the Breast, and commends it highly. He scarifies the discolour'd Parts in the _Fauces_, in order to let out the corrosive _Virus_; a Practice, which, though it was countenanced by some of the _Spaniards_, was disliked and condemned by the most eminent _Italians_. He, as well as _Zacutus Lusitanus_[26], used the _Arsenicum album_ in Gargles in very small Quantities, but with how much Advantage to the Patient is nowhere so fully proved, as to induce one to follow their Example.
Cupping, with Scarification, was universally approved, and commonly practised. Leeches were also applied, by way of Revulsion, to different Parts.
Considerable Benefit was expected from Ligatures made on the Extremities, and from chafing the Limbs with the Hand or a Cloth; also from Cupping without Scarification; apprehending that a Revulsion from the Parts affected was by this means procured; and that some Portion of the morbific Matter, was carried off by the Pores of the Skin.
Some of the _Spanish_ Physicians recommended Vesicatories of _Cantharides_ to be laid on each Side the Neck: The _Italians_ seem not to have been fond of them; and urge it as a Reason against their Use, that the Progress of the Disease was too quick to be relieved by any Discharge they could make.
The internal Medicines they used were such as they deemed Alexipharmics. _Armenian_ Bole, Bezoar both animal and mineral, Pearls, and, according to the Philosophy of those Times, the precious Stones. The _Theriaca_ was excepted against for Children, as _Galen_ had condemned its Use in such young Subjects. But after they had lessened, as they thought, the Plethora by Bleeding, and the Cacochemy, as they stiled it, by a Cathartic; as they found, from Experience, that no Concoction of Humours was to be waited for in this Case[27], without laying much Stress upon Internals, they seem chiefly to have applied themselves to Topics; considering the Disease as local, and a peculiar morbid Affection of the _Fauces_.
In this Part of their Directions they have been more particular; and some of them, in order to point out their Applications with more Propriety, have divided the Course of this Disease into four different Periods[28].
The first is the State of Inflammation. In this Repellents were thought necessary; such as Vinegar in Barley-water, Syrup of Roses, Mulberries, and Purslain.
The second, is that wherein the white Sloughs begin to appear, which is a Step towards a gangrenous Colliquation. In this State they order'd mild Abstergents, of which Honey of Roses was esteemed the chief.
In the third, the _Fauces_ begin to look black, and a real Mortification is come on, sometimes penetrating to a considerable Depth, with great Putrefaction. Here the mild Abstergents were deem'd ineffectual, and Caustics were recommended; such as Alum with Honey, Alum-Water, Oil of Sulphur, and Oil of Vitriol. These were used both to check the Putrefaction, and to destroy the mortified Flesh.
Sometimes the Oil of Vitriol was dextrously applied to the Part affected by an arm'd Probe; but it was oftener mix'd with Syrup of Roses, and in Children pour'd into the Mouth. Bole dissolv'd in Treacle-Water, and the Juice of Wood-Sorrel, was used by some for the like Purposes.
In the fourth Stage the Putrefaction is supposed to be extinguished, the mortified Parts cast off, and an Ulcer only remains. In this Case, the Fume of white Amber thrown on live Coals, and received into the Mouth, as a _Suffitus_, was advised; also the _Vinum Myrrhites_, a Decoction of Guaiacum, Roses, Balaustines, Pomegranate-Peels by way of Gargle; Medicines that were supposed to dry with some Degree of Astringency.
Such was the general Appearance of this Disease at its first being taken notice of in _Europe_; and such, as far as I can collect, the Methods that were pursued in treating it, by the most eminent Practitioners at that time.
The Disease which is described in the following Pages, seems to be the same with this _Angina maligna_, or strangulatory Affection of the _Fauces_, and seems only to differ from it in Degree; in which, as it is much more favourable and mild with us in general, than it was with them, we have greatly the Advantage.
OF THE SORE THROAT Attended with ULCERS;
As it hath appeared in THIS CITY, and PARTS adjacent.
About twelve Years ago, two Children, in a Family of Distinction, and some others in the same Part of the Town, being carried off suddenly, and their principal Complaints having been of a Soreness in their Throats, it occasion'd a Suspicion, that the _Morbus strangulatorius_ was broke out amongst us: But as very few Cases occurred after these, or pass'd unobserv'd, the Disease and the Remembrance of it seemed to vanish together.