An Account of the Sore Throat Attended With Ulcers / A Disease Which Hath of Late Years Appeared in This City, and in Several Parts of the Nation
Date: 2017-06-15T00:00:00+00:00
Keywords: Diphtheria

The Project Gutenberg eBook of An Account of the Sore Throat Attended With Ulcers

This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

Title: An Account of the Sore Throat Attended With Ulcers

Author: John Fothergill

Release date: June 15, 2017 [eBook #54911]
Most recently updated: October 23, 2024

Language: English

Credits: Produced by readbueno and the Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK AN ACCOUNT OF THE SORE THROAT ATTENDED WITH ULCERS ***

This cover was produced by the Transcriber
and is in the public domain.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

℞ Decoct. Pectoral. ℥ xij. cui inter coquendum add. Rad. Contrayerv. contus. ℥ ss. Liquori colato admisce Acet. Vin. Alb. ℥ ij. Tinct. Myr. ℥ i. Mel. opt. ʒ 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.

℞ Gargarism. præscript. ℥ ij. Mel Ægypt. ʒ j. m.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FINIS.

FOOTNOTES:

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.

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.

3. Severin. de recondita Abscessuum natur. p. 446.

4. Joh. Wieri Observat. lib. i. de Angina pestilenti Epidemica, Oper. p. 910.

5. Pet. Forrest. Observat. lib. vi. de Febribus publice grassantibus, p. m. 150.

6. Bern. Ramazzini Constitutiones Epidem. Oper. p. 195, & seq.

7. Medical Essays, vol. iii. p. 26.

8. Tournefort's Voyage to the Levant, vol. i. p. 133.

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.

10. Joannis Baptistæ Cortesii, medici ac philosophi, in Messanensi academia praxim ordinariam e prima sede interpretantis, Miscellaneorum Medicinalium Decades Denæ. Messanæ 1625. in fol.

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.

12. De morbo strangulatorio, opus Ætii Cleti Signini, doctoris medici et philosophi. Romæ 1636. 8vo.

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.

14. Thomæ Bartholini de Angina Puerorum Campaniæ Siciliæque epidemica exercitationes. Lut. Parisior. 1646.

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

16. Ibid.

17. Idem ibid.

18. Idem, p. 440.

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.

20. Ætii Cleti Op. de Morbo Strangulatorio.

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.

22. Æt. Clet.

23. Severin. p.

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.

25. Severin. ubi supra. Cort. Miscel. p. 697.

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.

27. Cortes. Miscel. p. 703.

28. Sgambat. de Affectu Faucium pestilente.

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.

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

Transcriber's Notes.

The original spelling and punctuation has been retained.

This Book is 300 years old and the advice given has been superceded by more modern methods and is of historical value only.

*** END OF THE PROJECT GUTENBERG EBOOK AN ACCOUNT OF THE SORE THROAT ATTENDED WITH ULCERS ***

Updated editions will replace the previous one—the old editions will be renamed.

Creating the works from print editions not protected by U.S. copyright law means that no one owns a United States copyright in these works, so the Foundation (and you!) can copy and distribute it in the United States without permission and without paying copyright royalties. Special rules, set forth in the General Terms of Use part of this license, apply to copying and distributing Project Gutenberg™ electronic works to protect the PROJECT GUTENBERG™ concept and trademark. Project Gutenberg is a registered trademark, and may not be used if you charge for an eBook, except by following the terms of the trademark license, including paying royalties for use of the Project Gutenberg trademark. If you do not charge anything for copies of this eBook, complying with the trademark license is very easy. You may use this eBook for nearly any purpose such as creation of derivative works, reports, performances and research. Project Gutenberg eBooks may be modified and printed and given away—you may do practically ANYTHING in the United States with eBooks not protected by U.S. copyright law. Redistribution is subject to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free distribution of electronic works, by using or distributing this work (or any other work associated in any way with the phrase “Project Gutenberg”), you agree to comply with all the terms of the Full Project Gutenberg™ License available with this file or online at www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™ electronic works

1.A. By reading or using any part of this Project Gutenberg™ electronic work, you indicate that you have read, understand, agree to and accept all the terms of this license and intellectual property (trademark/copyright) agreement. If you do not agree to abide by all the terms of this agreement, you must cease using and return or destroy all copies of Project Gutenberg™ electronic works in your possession. If you paid a fee for obtaining a copy of or access to a Project Gutenberg™ electronic work and you do not agree to be bound by the terms of this agreement, you may obtain a refund from the person or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be used on or associated in any way with an electronic work by people who agree to be bound by the terms of this agreement. There are a few things that you can do with most Project Gutenberg™ electronic works even without complying with the full terms of this agreement. See paragraph 1.C below. There are a lot of things you can do with Project Gutenberg™ electronic works if you follow the terms of this agreement and help preserve free future access to Project Gutenberg™ electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the Foundation” or PGLAF), owns a compilation copyright in the collection of Project Gutenberg™ electronic works. Nearly all the individual works in the collection are in the public domain in the United States. If an individual work is unprotected by copyright law in the United States and you are located in the United States, we do not claim a right to prevent you from copying, distributing, performing, displaying or creating derivative works based on the work as long as all references to Project Gutenberg are removed. Of course, we hope that you will support the Project Gutenberg™ mission of promoting free access to electronic works by freely sharing Project Gutenberg™ works in compliance with the terms of this agreement for keeping the Project Gutenberg™ name associated with the work. You can easily comply with the terms of this agreement by keeping this work in the same format with its attached full Project Gutenberg™ License when you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern what you can do with this work. Copyright laws in most countries are in a constant state of change. If you are outside the United States, check the laws of your country in addition to the terms of this agreement before downloading, copying, displaying, performing, distributing or creating derivative works based on this work or any other Project Gutenberg™ work. The Foundation makes no representations concerning the copyright status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other immediate access to, the full Project Gutenberg™ License must appear prominently whenever any copy of a Project Gutenberg™ work (any work on which the phrase “Project Gutenberg” appears, or with which the phrase “Project Gutenberg” is associated) is accessed, displayed, performed, viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived from texts not protected by U.S. copyright law (does not contain a notice indicating that it is posted with permission of the copyright holder), the work can be copied and distributed to anyone in the United States without paying any fees or charges. If you are redistributing or providing access to a work with the phrase “Project Gutenberg” associated with or appearing on the work, you must comply either with the requirements of paragraphs 1.E.1 through 1.E.7 or obtain permission for the use of the work and the Project Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted with the permission of the copyright holder, your use and distribution must comply with both paragraphs 1.E.1 through 1.E.7 and any additional terms imposed by the copyright holder. Additional terms will be linked to the Project Gutenberg™ License for all works posted with the permission of the copyright holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™ License terms from this work, or any files containing a part of this work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this electronic work, or any part of this electronic work, without prominently displaying the sentence set forth in paragraph 1.E.1 with active links or immediate access to the full terms of the Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary, compressed, marked up, nonproprietary or proprietary form, including any word processing or hypertext form. However, if you provide access to or distribute copies of a Project Gutenberg™ work in a format other than “Plain Vanilla ASCII” or other format used in the official version posted on the official Project Gutenberg™ website (www.gutenberg.org), you must, at no additional cost, fee or expense to the user, provide a copy, a means of exporting a copy, or a means of obtaining a copy upon request, of the work in its original “Plain Vanilla ASCII” or other form. Any alternate format must include the full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying, performing, copying or distributing any Project Gutenberg™ works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing access to or distributing Project Gutenberg™ electronic works provided that:

- • You pay a royalty fee of 20% of the gross profits you derive from the use of Project Gutenberg™ works calculated using the method you already use to calculate your applicable taxes. The fee is owed to the owner of the Project Gutenberg™ trademark, but he has agreed to donate royalties under this paragraph to the Project Gutenberg Literary Archive Foundation. Royalty payments must be paid within 60 days following each date on which you prepare (or are legally required to prepare) your periodic tax returns. Royalty payments should be clearly marked as such and sent to the Project Gutenberg Literary Archive Foundation at the address specified in Section 4, “Information about donations to the Project Gutenberg Literary Archive Foundation.”

- • You provide a full refund of any money paid by a user who notifies you in writing (or by e-mail) within 30 days of receipt that s/he does not agree to the terms of the full Project Gutenberg™ License. You must require such a user to return or destroy all copies of the works possessed in a physical medium and discontinue all use of and all access to other copies of Project Gutenberg™ works.

- • You provide, in accordance with paragraph 1.F.3, a full refund of any money paid for a work or a replacement copy, if a defect in the electronic work is discovered and reported to you within 90 days of receipt of the work.

- • You comply with all other terms of this agreement for free distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™ electronic work or group of works on different terms than are set forth in this agreement, you must obtain permission in writing from the Project Gutenberg Literary Archive Foundation, the manager of the Project Gutenberg™ trademark. Contact the Foundation as set forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable effort to identify, do copyright research on, transcribe and proofread works not protected by U.S. copyright law in creating the Project Gutenberg™ collection. Despite these efforts, Project Gutenberg™ electronic works, and the medium on which they may be stored, may contain “Defects,” such as, but not limited to, incomplete, inaccurate or corrupt data, transcription errors, a copyright or other intellectual property infringement, a defective or damaged disk or other medium, a computer virus, or computer codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right of Replacement or Refund” described in paragraph 1.F.3, the Project Gutenberg Literary Archive Foundation, the owner of the Project Gutenberg™ trademark, and any other party distributing a Project Gutenberg™ electronic work under this agreement, disclaim all liability to you for damages, costs and expenses, including legal fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a defect in this electronic work within 90 days of receiving it, you can receive a refund of the money (if any) you paid for it by sending a written explanation to the person you received the work from. If you received the work on a physical medium, you must return the medium with your written explanation. The person or entity that provided you with the defective work may elect to provide a replacement copy in lieu of a refund. If you received the work electronically, the person or entity providing it to you may choose to give you a second opportunity to receive the work electronically in lieu of a refund. If the second copy is also defective, you may demand a refund in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied warranties or the exclusion or limitation of certain types of damages. If any disclaimer or limitation set forth in this agreement violates the law of the state applicable to this agreement, the agreement shall be interpreted to make the maximum disclaimer or limitation permitted by the applicable state law. The invalidity or unenforceability of any provision of this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the trademark owner, any agent or employee of the Foundation, anyone providing copies of Project Gutenberg™ electronic works in accordance with this agreement, and any volunteers associated with the production, promotion and distribution of Project Gutenberg™ electronic works, harmless from all liability, costs and expenses, including legal fees, that arise directly or indirectly from any of the following which you do or cause to occur: (a) distribution of this or any Project Gutenberg™ work, (b) alteration, modification, or additions or deletions to any Project Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of electronic works in formats readable by the widest variety of computers including obsolete, old, middle-aged and new computers. It exists because of the efforts of hundreds of volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the assistance they need are critical to reaching Project Gutenberg™’s goals and ensuring that the Project Gutenberg™ collection will remain freely available for generations to come. In 2001, the Project Gutenberg Literary Archive Foundation was created to provide a secure and permanent future for Project Gutenberg™ and future generations. To learn more about the Project Gutenberg Literary Archive Foundation and how your efforts and donations can help, see Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit 501(c)(3) educational corporation organized under the laws of the state of Mississippi and granted tax exempt status by the Internal Revenue Service. The Foundation’s EIN or federal tax identification number is 64-6221541. Contributions to the Project Gutenberg Literary Archive Foundation are tax deductible to the full extent permitted by U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up to date contact information can be found at the Foundation’s website and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread public support and donations to carry out its mission of increasing the number of public domain and licensed works that can be freely distributed in machine-readable form accessible by the widest array of equipment including outdated equipment. Many small donations ($1 to $5,000) are particularly important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws regulating charities and charitable donations in all 50 states of the United States. Compliance requirements are not uniform and it takes a considerable effort, much paperwork and many fees to meet and keep up with these requirements. We do not solicit donations in locations where we have not received written confirmation of compliance. To SEND DONATIONS or determine the status of compliance for any particular state visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we have not met the solicitation requirements, we know of no prohibition against accepting unsolicited donations from donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot make any statements concerning tax treatment of donations received from outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation methods and addresses. Donations are accepted in a number of other ways including checks, online payments and credit card donations. To donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project Gutenberg™ concept of a library of electronic works that could be freely shared with anyone. For forty years, he produced and distributed Project Gutenberg™ eBooks with only a loose network of volunteer support.

Project Gutenberg™ eBooks are often created from several printed editions, all of which are confirmed as not protected by copyright in the U.S. unless a copyright notice is included. Thus, we do not necessarily keep eBooks in compliance with any particular paper edition.

Most people start at our website which has the main PG search facility: www.gutenberg.org.

This website includes information about Project Gutenberg™, including how to make donations to the Project Gutenberg Literary Archive Foundation, how to help produce our new eBooks, and how to subscribe to our email newsletter to hear about new eBooks.

Table of Contents

- AN ACCOUNT OF THE SORE THROAT
- PREFACE.
- OF THE SORE THROAT Attended with ULCERS;
- OF THE SORE THROAT Attended with ULCERS;
- FOOTNOTES:
- THE FULL PROJECT GUTENBERG LICENSE