Part 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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