SCARLATINA AND DIPHTHERIA.
Scarlatina and diphtheria have to be taken together in a historical work
for the reason that certain important epidemics of the 18th century, both
in Britain and in the American colonies, which were indeed the first of
the kind in modern English experience, cannot now be placed definitely
under the one head or the other, nor divided between the two. It may be
that this ambiguity lies actually in the complex or undifferentiated
nature of the throat-distemper at that time, or that it arises out of the
contemporary manner of making and recording observations upon the
prevalent maladies of seasons. The older or Hippocratic method was not
unlike the mason’s rule of lead, said to have been in use in the island of
Lesbos for measuring uneven stones; it took account of gradations,
modifications, affinities, being careless of symmetry, of definitions or
clean-cut nosological ideas, or the dividing lines of a classification.
Sydenham was the great English exponent of this method; but, in one of his
more discursive passages, he sketched out another method of describing
diseases as if they were species or natural kinds[1247]. He did no more
than indicate this analogy, at the same time declining to put it in
practice; so that Sauvages correctly described his great Nosology of 1763
as being constructed “juxta Sydenhami mentem et Botanicorum ordinem.” The
identification of scarlatina in its modern sense, including scarlatina
simplex and scarlatina anginosa, falls really in the time of the
nosologies in the generation following the work of Sauvages, although both
the name and definition in the modern sense were used in England as early
as 1749. On the other hand, the name and definition of diphtheria were
little known until about the years 1856-59, when the form of
throat-distemper which is now quite definitely joined to that name became
suddenly common, having been almost unheard of for at least two
generations before. The only English writer who has attempted to unravel
the accounts of the 18th century epidemics of throat-disease was Dr Willan
in his unfinished work on Cutaneous Diseases, 1808; he swept the whole of
those epidemic types into the species of scarlatina, to which also he
reduced the great Spanish epidemics of “garrotillo” in the 16th and 17th
centuries. Whether he would have used so summary a method if he had seen
the sudden return of diphtheria in 1856, may well be doubted; at all
events the German writers who brought their erudition to bear upon the
question of identity some thirty years ago have discovered true diphtheria
among the 18th century throat-distempers, although no two of them agree as
to which of these should be called diphtheria and which scarlatina
anginosa. It is one advantage of a historical method that the complexities
of things may be stated just as they are, with due criticism, naturally,
of the matters of fact and of the relative credit of observers. The result
is more an impression than a logical conclusion,--an impression which will
take a colour from the pre-existing views or theoretical preferences of
individual readers on such points as fixity of type or the incompetence of
the earlier observers. An author who has puzzled over these difficulties
in detail can hardly help having a tolerably definite impression of the
real state of the case; and I do not seek to conceal mine, namely, that
scarlatina anginosa and diphtheria were not in nature so sharply
differentiated in the 18th century as they have been since 1856.
The significant name of _pestis gutturuosa_ or plague of the throat is
given by the St Albans chronicler to the great pestilence, or some part of
it, in 1315-16, during one of the worst periods of famine and murrain in
the whole English history. But those two words being all that we have to
base upon, there is no use speculating whether the disease was scarlatina
anginosa, or diphtheria, or something different from either. This is
perhaps the only reference to an epidemic throat-distemper in England for
several centuries in which bubo-plague was the grand infection. In the
popular medical handbooks of the Tudor period one naturally looks for
scarlatina among the diseases of children. In Elyot’s _Castel of Health_
(1541), “the purpyles” is mentioned among children’s maladies in company
with smallpox and measles, and the same name is in the London bills of
mortality from their beginning in 1629, although it does not appear
whether the deaths assigned to it were of children or adults. Perhaps the
most common use of purples in the 17th and 18th centuries was for a form
of childbed fever often attended with discoloured miliary vesicles. In
Scotland, according to Sibbald (1684), “the fevers called purple” were any
fevers, even measles or smallpox, in which livid or dark spots occurred as
an occasional thing. Unless a few scarlatinal deaths are included under
“purples” in the London bills (they could not have been many in any case),
there is no other evidence of their existence until 1703, when the entry
of scarlet fever appears for the first time, with seven deaths to it in
the year. The heading remains in the bills until 1730 (the deaths never
more than one figure), after which it is merged with fevers in general.
The same indications of the insignificance of scarlatina among the causes
of death in the 17th century may be got from the medical writers in
London.
Sydenham introduced into the third edition (1675) of his _Observationes
Medicae_ a short chapter entitled “Febris Scarlatina[1248].” It was a
disease that might occur at any time of the year, but occurred mostly in
the end of summer, sometimes infesting whole families, the children more
than the elders. It began with a rigor, as other fevers did, the malaise
being but slight. Then the whole skin became interspersed with small red
spots, more numerous, broader, redder and less uniform than in measles;
they persisted for two or three days and then vanished, and, as the
cuticle returned to its natural state, there were successive desquamations
of fine branny scales, which he compares elsewhere to those following the
measles of 1670. Sydenham took it to be a moderate effervescence of the
blood from the heat of the summer just over, or from some such excitement.
It was a mild affair, not calling for blood-letting nor cardiac remedies,
and requiring no other regimen than abstinence from flesh and spirituous
liquors, and that the patient should keep in doors, but not all day in
bed. The disease, he says, amounted to hardly more than a name (_hoc morbi
nomen, vix enim altius assurgit_); but it appears that it was sometimes
fatal; and in those cases Sydenham was inclined, after his wont, to blame
the fussiness of the medical attendant (_nimia medici diligentia_). If
convulsions or coma preceded the eruption, a large epispastic should be
applied to the back of the neck and paregoric administered. Whether
Sydenham was describing true scarlatina simplex, or a “scarlatiniform
variety of contagious roseola,” it is from him that we derive the name of
scarlatina by continuous usage to the present time[1249].
A few years after Sydenham had thus described scarlatina, Sir Robert
Sibbald, physician and naturalist of Edinburgh, professed to have
discovered the same as a new species of disease. “Just as the luxury of
men,” he says, “increases every day, so there grow up new diseases, if not
unknown to former generations, yet untreated of by them. Nor is this
surprising, since new depravations of the humours arise from unwonted
diets and from various mixtures of the same. Among the many diseases which
owe their origin to this age, there has been most recently (_nuperrime_)
observed a fever which is called _Scarlatina_, from the carmine colour
(named by our people in the vernacular _scarlet_) with which almost the
whole skin is tinged. Of this disease the observations are not so many
that an accurate theory can be delivered or a method of cure constructed.”
He proceeds to append one case--a child of eight, daughter of one of the
senators of the College of Justice, who fell ill with redness of the face
(thought at first to indicate smallpox coming on), became delirious and
restless, then had the redness all over, which disappeared and left the
child well about the fifth day. He had heard from some of his colleagues
that the scarlet rash was sometimes interspersed with vesicles--perhaps
the _miliaria_ so much in evidence a generation or two later. In adults,
Sibbald had seen the cuticle fall from nearly the whole body. But
extremely few (_paucissimi_) had died of this fever. Like Sydenham, he
omits to mention sore-throat and dropsy[1250].
Another 17th century reference is by Morton, who practised in London, in
Newgate Street, from about 1667 to the end of the century, and was
frequently called to consult with apothecaries or other physicians in
cases of sickness in middle-class families. In the second volume of his
_Pyretologia_, published in 1694, he has a chapter “De Morbillis et Febre
Scarlatina,” and a separate chapter “De Febre Scarlatina.” His position
towards scarlet fever is peculiar. He uses the name, he says, in deference
to the common consent of physicians, but, for his own part, he thinks
scarlatina different from measles only in the form of the rash, so-called
scarlatina being confluent measles just as there is a confluent smallpox.
Except in that sense he sees no reason for retaining scarlatina in the
catalogue of diseases. Both arise from the same cause, both have hacking
cough, heaviness of the brain, sneezing, diarrhoea; the single difference
is that in scarlatina the rash is continuous. He gives eleven cases, most
of which are clearly enough cases of measles; but the fourth case, that of
his own daughter, Marcia, aged seven, in 1689, “in quo febris dicta
Scarlatina, tempore praesertim aestivo, quadantenus publice grassabatur,”
had no cough, nor redness of the eyes, nor diarrhoea, nor any other
catarrhal symptoms (such as her sister had in 1685), but on the fourth day
a continuous scarlet rash over the whole skin, which ended, not in a
desquamation of fine branny scales, but in parchment-like peeling. The
eleventh instance is complex enough to show that Morton had some reason,
at that early stage in the history of scarlatina, for hesitating to make
the disease a distinct type under a name of its own.
About midsummer, 1689, he was called to the house of his friend Mr
Hook, merchant, of Pye Alley, Fenchurch Street, and found the whole
household, three young girls, one little boy, and their aunt Mrs
Barnardiston, a matron aged seventy, all suffering from the effects of
some infection of as deleterious a kind as synochus, the symptoms
being hacking cough, coma, delirium, and other signs of malignity. But
on the 4th, 5th, or 6th day, each had a scarlatinal rash all over the
skin, which lasted until the 7th, 8th or 10th day. Two of the girls,
and the boy, had “on the 4th or 5th day of the efflorescence”
extensive parotid swellings, difficulty of swallowing, vibrating
arteries, and other urgent symptoms, for which they were blooded. The
parotid abscesses burst, and discharged a copious acrid, corrosive pus
by the nostrils, ears and throat, for the space of thirty days, during
which the patients gradually got well. The third girl had, on the 3rd
or 4th day of the rash, a painful swelling in the left armpit, not
unlike a bubo; she also was blooded, and recovered completely, the
swelling having broken and discharged pus for many days. The case of
the aunt, aged seventy, was somewhat different; she neglected her
medicines, acquired a “carcinoma” or slough over the pubes, which
became gangrenous, recovered with difficulty, and lived three years
longer.
Morton calls these cases a veritable _pestis_ or plague; and he goes on in
the same context to say: “what swellings have I seen of the uvula, fauces,
nares, and how protracted! At other times, what turgid lips, covered with
sordid crusts and ulcerated!”--instancing the child of Mr Blaney, who had
these symptoms long after the efflorescence, together with fever and
coma[1251]. These cases, all given under the eleventh history illustrating
the chapter on Scarlatina, are perhaps not different from those which
Huxham, next in order, described in 1735, but not under the same name. It
would appear from a reference in Hamilton’s essay on Miliary Fever,
published in 1710, that scarlet fever continued to be seen in London: “If,
in a scarlet fever, miliary pustules should arise, dying away with a red
colour, they promise safety[1252].”
Several of the annalists of epidemic constitutions agree as to fatal
anginas in the year 1727, with an exanthem of the miliary kind.
Wintringham, of York, mentions the two things apart--in one place a putrid
fever with cutaneous eruptions of a fuscous colour, sometimes dry,
sometimes filled with a clear serum; in another place, “about this time
many anginas were prevalent, attended with extreme suffocation, which
proved fatal unless they were speedily relieved.” He mentions the same
putrid fever in the summer of 1728, and again anginae. Hillary, who was
then at Ripon, gives the same fever in 1727 (or perhaps in 1726) with
miliary eruption, and chronicles “a fatal suffocative quinsey” in the
winter of 1727-28, of which many died, especially those that had been
reduced by the fever. Huxham’s account of an epidemic malady of the throat
and neck at Plymouth in January and February, 1728, might relate to mumps
(which Hillary and an Edinburgh observer describe clearly enough under
1731); and under October, 1728, he describes an erysipelatous and
petechial fever, often relieved by an eruption of red miliary vesicles
accompanied by sweats, the same miliary fever being again common in the
autumn of 1729. This association of “putrid” fever with sore-throat
became still more notable in the period 1750-60.
These anginas of 1727-28 are unimportant compared with the outbreak a few
years later. We hear first from Edinburgh in June, 1733, of scarlet fever
and sore throats frequent in several parts of the country near the city,
and continuing all through the summer into the winter and spring of
1734[1253]. Then in April, 1734, begins a series of important notes by
Huxham at Plymouth[1254]. In that month, he says, there began a certain
anginose fever (“for so I shall call it”), raging more and more every day.
It mostly affected children and young people. Among other symptoms were
vomiting and diarrhoea, pain and swelling of the fauces, languor, anxiety,
delirium or stupor, a favourable issue being attended with sweats and red
pustules. In May it was raging worse, with more severe angina and most
troublesome “aphthae.” In June it was now miliary-pustular, and not seldom
erysipelatous, while the throat was “less oppressed.” On the 6th or 7th
day the cuticle looked rough and broken as if thickly sprinkled with bran;
at length the whole desquamated--sometimes the entire skin of the sole of
the foot coming off. The more copious the rash, the better the chance for
life. It was contagious, affecting several in the same house. In July it
cut off several within six days of the onset. Huxham’s references to this
putrid miliary fever in Devon and Cornwall go on for some time, without
farther mention of the throat complication. In April, 1735, “raro nunc
adest strangulans faucium dolor, paucaeque nunc erumpunt pustulae.” But,
in September, 1736, he enters again, “febres miliares, scarlatinae,
pustulosae,” often attended with swelling of the parotid glands and of the
fauces, and with profuse sweats.
The most important scene of fatal angina with rash in the same period
(1734-35) was the North American colonies. Before coming to that
remarkable outburst, I shall mention one curious coincident outbreak in
the island of Barbados. Dr Warren, who occupies his pen chiefly with
yellow fever, says[1255]: “In this space of time [1734 to 1738], there
arose here a few other diseases, that were really epidemical and of the
contagious kind too, few escaping them in families where they had once
got a footing. The first was an obstinate and ill-favour’d erysipelatous
quinsey. The second a very anomalous scarlet fever, in which almost all
the skin, even of the hands and feet, peeled off,”--just as Huxham
described for Devonshire.
It is beyond our purpose to include the evidence from foreign countries;
but it may be noted in this context that Le Cat, in tracing the
antecedents of the great Rouen fever in his paper of 1754, refers to many
fatal anginas in that city about twenty years before[1256]. Thus we find
about the year 1735 evidence of the beginning of a remarkable
“constitution” of throat-disease both in the old world and in the new. But
the facts in America stand out with peculiar prominence, and shall be
given on the threshold of the subject as fully as possible.
The Throat-distemper of New England, 1735-36.
The accounts of the great wave of “throat-distemper” that spread over the
towns and villages of New England in 1735 are singularly clear and even
numerically precise. The arrival of this sickness is one of the most
definite incidents in the whole history of epidemics; it was hardly
possible for the common belief, whether popular or professional, to have
been mistaken about it. Just a hundred years had passed since the first
settlement of the Puritans on Massachusetts Bay and along the Connecticut
river; Boston had grown to a town of some 12,000 inhabitants, and many
small towns and townships had sprung up along the coast and in the
interior. The population was still sparse, although it was growing rapidly
from within; it is difficult to believe that even the largest towns could
then have deserved the strictures which Noah Webster passed upon them two
generations later[1257].
In the mother country at that time, smallpox was the great infectious
malady of infancy and childhood. It was not unknown in the colonies,
Boston having had epidemics in 1721, 1730 and 1752, and Charleston an
epidemic in 1738 after an almost free interval of thirty years. Even in
the chief cities of the colonies such epidemics were only occasional,
affecting adults and adolescents perhaps more than infants and as much as
children; while in such a town as Hampton, for which the register was well
kept from 1735, it is known that there were no smallpox deaths in the
twenty years following, or until the period 1755-63, when four died of the
disease, and that only one death from it occurred in the next recorded
period of ten years, 1767 to 1776. It was in these circumstances of a
growing population, almost untouched, at least in the inland towns, by the
great infantile infectious malady of the old country, that the
throat-distemper broke out and raged in the manner now to be described.
The disease “did emerge,” as Douglass says, on the 20th of May, 1735, at
Kingston township, some fifty miles to the east of Boston[1258]. The first
child seized died in three days; in about a week after three children in a
family some four miles distant were successively seized, and all died on
the third day; it continued to spread through the township, and Douglass
was informed that of the first forty cases none recovered. It was vulgarly
called the “throat illness” or “plague in the throat.” Some died quickly
as if from prostration, but most had “a symptomatic affection of the
fauces or neck: that is, a sphacelation or corrosive ulceration in the
fauces, or an infiltration and tumefaction in the chops and forepart of
the neck, so turgid as to bring all upon a level between the chin and
sternum, occasioning a strangulation of the patient in a very short time.”
In August it was at Exeter, a town six miles distant, but it did not
appear at Chester, six miles to the westward, until October. After the
first fatal outburst in Kingston township it became somewhat milder; but
in the country districts of New Hampshire it was fatal to 1 in 3, or 1 in
4 of the sick, and in scarce any place to less than 1 in 6. This average
was made up by its excessive fatality in some families; Boynton of Newbury
Falls lost his eight children; at Hampton Falls twenty-seven died in five
families. The following table, compiled by Fitch, minister of Portsmouth,
shows the deaths from it in various towns and townships of New Hampshire
during fourteen months from May, 1735, to 26 July, 1736, with the
ages[1259]:
_Deaths from the throat-distemper in 14 months, 1735-36_ (Fitch).
Under Ten to Twenty Thirty Above
ten years twenty to thirty to forty forty Total
Portsmouth 81 15 1 -- 2 99
Dover 77 8 3 -- -- 88
Hampton 37 8 8 1 1 55
Hampton
Falls 160 40 9 1 -- 220
Exeter 105 18 4 -- -- 127
Newcastle 11 -- -- -- -- 11
Gosport 34 2 -- -- 1 37
Rye 34 10 -- -- -- 44
Greenland 13 2 3 -- -- 18
Newington 16 5 -- -- -- 21
Newmarket 20 1 -- 1 -- 22
Stretham 18 -- -- -- -- 18
Kingston 96 15 1 1 -- 113
Durham 79 15 6 -- -- 100
Chester 21 -- -- -- -- 21
--- --- --- --- --- ---
802 139 35 4 4 984
The meaning of these figures in the townships of New Hampshire will appear
from the case of Hampton. In the year 1736 its burials from all causes
were 69, and its baptisms 50; while the throat-distemper alone, during
fourteen months of that and the previous year, cut off 55. As we have
seen, Hampton had no smallpox to ravage its children; but the
throat-disease of 1735-36 had almost the same effect as the occasional
disastrous epidemics of smallpox had upon English towns of a corresponding
population or annual average of births.
This plague in the throat attacked the children of the most sequestered
houses, especially those situated near rivers or lakes. It was least fatal
to those who lived well, both Douglass and Colden assigning the salt diet,
and other things likely to produce _psora_, as the reason of its greater
severity. In the country districts or townships, in which the fatalities
were most numerous, it would appear that an eruption, scarlet or other,
was not only not the rule but even something of a rarity. Douglass, who
was familiar with the exanthem in the Boston cases, assigns its absence in
the country to a mistaken evacuant treatment, by which “the laudable and
salutary cuticular eruption has been so perverted as to be noticeable only
in a few, and in these it was called a scarlet fever.”
When the disease broke out in due course at Boston it proved much less
malignant than in the country. The first case, on the 20th August, had
white specks in the throat and an efflorescence of the skin. A few more
soon followed in the same locality, of which none were fatal; they had
soreness in the throat, the tonsils swelled and speckt, the uvula relaxed,
a slight fever, a flush in the face and an erysipelas-like efflorescence
on the neck and extremities. The first death was not until October, the
disease becoming more frequent and more fatal in November, and reaching
its worst in the second week of March, when the burials from all causes
rose to 24, the average per week in an ordinary season being 10. The
fatalities in Boston were so few for the enormous number of cases that
many could scarce be persuaded that it was the same disease as in the
Townships. In the corresponding weeks (1 Oct. to 11 May) of eight ordinary
years preceding, the average deaths were 268, whites and slaves; during
this sickness they were 382, or an excess of 114, which were probably all
due to the throat-distemper, as many as 76 fatal cases having come to the
knowledge of Douglass himself. He estimates the whole number of attacks at
4000, giving a ratio of one death in thirty-five cases; but it is clear
that very slight cases of sore-throat were counted in.
The fatal cases in Boston seem to have shown a great range of
malignant symptoms: “We have anatomically inspected persons who died
of it with so intense a foetor from the violence of the disease that
some practitioners could not continue in the room.” Among the bad
symptoms were the coming and going of the miliary eruption, dark livid
colour of the same, the vesicles large, distinct and pale, like
crystalline smallpox; an ichorous discharge from the nose; many mucous
linings expectorated, resembling the cuticle raised by blisters; pus
brought up where no sloughs could be seen in the fauces; extension to
the bronchi, with symptoms of a New England quinsey (? croup); in some
children, spreading ulcers behind the ears; the tongue throwing off a
complete slough with marks of the papillae. Among the after-effects in
severe cases were anasarca or dropsy of the skin, haemorrhages,
urtications, serpiginous eruptions chiefly in the face, purulent
pustules, boils, or imposthumations in the groins, armpits and other
parts of the body, indurations of the front of the neck (the same by
which many in the country were suffocated, and a few in Boston),
hysteric symptoms in women, and epileptic fits.
Douglass gives special attention to the eruption, which he calls
miliary in his title-page. Some had a sore-throat without any
eruption, and a very few had an eruption with no affection of the
throat beyond the tonsils and uvula swollen. In some the eruption
preceded the soreness of the throat, in some the two came together,
but in the general case the eruption was a little later than the
affection in the throat. The ordinary course was a chill and
shivering, spasmodic wandering pains, vomiting or at least nausea,
pain, swelling and redness of the tonsils and uvula, with some white
specks: then followed a flush in the face, with some miliary
eruptions, attended by a benign mild fever; soon after, the miliary
efflorescence appears on the neck, chest and extremities; on the third
or fourth day the rash is at its height and well defined, with fair
intervals; the flushing goes off gradually with a general itching, and
in a day or two more the cuticle scales or peels off, especially in
the extremities. At the same time the cream-coloured sloughs or specks
on the fauces become loose and are cast off, and the swelling goes
down. Where the miliary eruptions were considerable the extremities
peeled in scraps or strips like _exuviae_; in one or two, the nails of
the fingers and toes were shed. Some who had little or no obvious
eruption underwent a scaling or peeling of the cuticle.
The epidemic having spent its force upon the New England towns from the
autumn of 1735 until the summer of 1736, gradually travelled westward, and
was two years in reaching the Hudson River, distant only two hundred miles
in a straight line from Kingston, where it first appeared in May, 1735. It
continued its progress, with some interruptions, until it spread over the
colonies from Pemaquid in 44°N. latitude to Carolina; and as Douglass,
writing in 1736, had heard that “it is in our West India Islands,” it was
probably the same disease that Warren recorded for Barbados in the same
years under the names of “an obstinate and ill-favour’d erysipelatous
quinsey,” and “a very anomalous scarlet fever”; and the same as the
epidemic “sore-throats” that another records for the Virgin Islands in
1737[1260].
Although it usually attacked several children in the same house, it did
not seem to be communicable, like smallpox, from person to person or by
the medium of infected clothes. The Boston physicians held a consultation
on the point, and published their opinion that it proceeded entirely from
“some occult quality of the air.”
* * * * *
This was the first appearance of sore-throat with efflorescence of the
skin among the English colonists of North America. For at least two
generations after, the disease remained in the country, breaking out
unaccountably from time to time at one place or another and often cutting
off many children, but never so malignantly as at first[1261]. Colden,
writing from near New York in 1753, says:[1262]
“Ever since I came into this part of the country where I live (now
about fourteen years), it frequently breaks out in different families
and places, without any previous observable cause, but does not spread
as it did at first. Sometimes a few only have it in a considerable
neighbourhood. It seems as if some seeds or leaven or secret cause
remains wherever it goes; for I hear of the like observations in other
parts of the country. Several have been observed to have it more than
once.... In different years and different persons the symptoms are
various. In some seasons it has been accompanied with miliary
eruptions all over the skin; and at such times the symptoms about the
throat have been mild and the disease generally without danger if not
ill treated. Some have had sores, like those on the tonsils, with a
corrosive humour behind their ears, on the private and other parts of
the body, sometimes without any ulceration in the throat” (case given
of a child of ten with sores on the pudenda).
It was in 1754, the very next year after Colden wrote as above, that the
second great epidemic of throat-distemper arose in New Hampshire and the
neighbouring parts of Massachusetts. The figures of its mortality which
have been preserved for the town of Hampton, New Hampshire, may serve as a
sample of its prevalence subsequent to the original explosion of 1735-36.
In the first epidemic, 1735-36, there died at Hampton of the
throat-distemper, 55 persons, mostly children. In the second, from January
1754 to July 1755, there died of it 51 persons. The deaths from all causes
in those two years were 85, and the births 70.
The following table shows the proportion of deaths from throat-distemper
to the deaths from all causes in Hampton from 1735 to 1791[1263].
Deaths from Deaths from
Period throat-distemper all causes
1735-44 91 216
1745-54 60 221
1755-63 30 187
1764-66 -- --
1767-76 3 115
1777-86 7 99
1787-91 0 46
It was once more described, for New York city, by Dr Samuel Bard in
1771[1264]. He identifies it with the disease described by Douglass in
1735, and gives an account of it on the whole like Colden’s.
It was “uncommon and very dangerous,” mostly a malady of children
under ten. They drooped for several days, had a watery eye, then a
bloated livid countenance, and a few red eruptions here and there on
the face. This went on for three or four days, the throat meanwhile
showing white specks on the tonsils. Sudden and great prostration
ensued, with a peculiar hollow cough and tone of voice, or loss of
voice, constant fever, especially nocturnal, and a degree of
drowsiness. In fatal cases there was great restlessness and tossing of
the limbs towards the end. In one family all the seven children took
it one after another; three died out of the four elder; the three
younger recovered, having had ulceration behind the ears, which
continued for several weeks and rendered an acrid, corrosive ichor.
Many other children had these ulcerations behind the ears, sometimes
with swelling of the parotid and sublingual glands. The same
ulcerations might occur also “in different parts of the body.” Sloughs
of the fauces and epiglottis extended as a membranous exudation into
the trachea. Two cases occurred in women, one of them having assisted
to lay out two children dead of the distemper.
The last time of its general spreading (within the period covered by
Belknap’s _History of New Hampshire_, 1791) was in 1784-85-86 and -87. It
was first seen at Sandford in the county of York, and thence diffused
itself very slowly through most of the towns of New England; but its
virulence and the mortality which it caused were comparatively
small[1265].
Angina maligna in England from 1739.
Although there had been an extensive prevalence of angina with miliary or
scarlet or erysipelatous rash in Devon and Cornwall in 1734 and following
years, a slight amount of sore-throat with scarlet fever in and near
Edinburgh in 1733, a great prevalence of throat-distemper with scarlet or
miliary rash in the North American colonies in 1735-37, and an
ill-favoured erysipelatous quinsy as well as an anomalous scarlet fever in
Barbados, St Christopher, &c., during the same period, yet it was not
until the end of the year 1739 that cases more or less similar occurred in
London. The incident that first drew attention to the throat-distemper in
the capital was the death of the two sons of Henry Pelham, the colleague
of his relative the Duke of Newcastle in the premiership[1266]. Horace
Walpole, writing twenty years after concerning similar calamities in the
family of the Earl of Bessborough, says that not only Mr Pelham’s two
sons, but also two daughters and a daughter of the Duke of Rutland all
died together. Chandler, writing in 1761, says that he well remembered the
disease at the end of 1739. Early in 1740 he had in his own practice as an
apothecary two cases of children sick in one family; the first died, and
as he was at a loss to account for the death, there being “something in
the whole of the case quite new and unknown to me,” he called in Dr
Letherland to see the other, who declared that the child would die also,
as it did. Letherland then spoke to Chandler of the death of the two
Pelhams shortly before, “of the alarm it caused all over this great city,
both from its novelty and fatality,” and of his own care and pains in
turning over ancient and modern writers to see if he could trace any
footsteps of this remarkable and terrible disease: at last, after long
search, he had been so happy as to discover the identical disease
circumstantially described in the Spanish writers[1267].
The identification of the English throat-distemper of the 18th century
with the _garrotillo_ of Spain in the 16th and 17th centuries was thus
undoubtedly due to Letherland, so far as English learning was concerned,
and he received due credit for it in the Harveian Oration at the College
of Physicians on the first occasion after his death[1268].
Chandler thus described the state of the disease at its first breaking out
in 1739:
“The first and common appearances are feverishness, sickness, vomiting
or purging; the proper and diagnostic signs which follow are an
ulcerous slough in some part of the fauces, discharging a fœtid
matter.... The nostrils are glandered.... From the absorption of the
fœtid pus, the blood is contaminated; crimson efflorescences and
small putrid pustules break out on the skin of the neck and breast, a
quick depressed pulse, with a tendency rather to stupor than violent
perturbations accompanying all, and, if not relieved, terminate in
delirium, languor, clammy sweats and death.”
Fothergill, whose name is so closely associated with the outbreak of
gangrenous sore-throat a few years after, makes little of the earlier
epidemic in London; besides the cases in the Pelham family and some others
in the same part of the town, there were, he says, very few observed, so
that “the disease and the remembrance of it”--including Letherland’s
priority--“seemed to vanish altogether.” The winter of 1739-40, in which
these cases had occurred, was one of intense frost and the beginning of a
two years’ sickly period in which typhus in Britain, dysentery and typhus
in Ireland, reached a height unprecedented in the 18th century.
An epidemic of Throat-disease in Ireland, 1743.
In Ireland the dysenteries, typhus and relapsing fevers, attendant on and
following the famine, were hardly over when the plague of the throat began
among the children. It was seen first in the summer of 1743 (an influenza
having preceded in May and June), it raged through the autumn and winter,
and was not extinct for many years after. There were but few instances of
it in Dublin, but it was prevalent in the adjoining counties, and
exceedingly so in Wicklow, Carlow, Queen’s County, Kilkenny, Cavan,
Roscommon, Leitrim, Sligo “and perhaps many others, carrying off
incredible numbers, and sweeping away the children of whole villages in a
few days.” The country doctors, who knew most of it, were not apt to
record their experiences; so that the following account, which Rutty
extracted from Dr Molloy, is all the record that remains of an epidemic
concerning which one would wish to have known more[1269]:
“It is peculiar to children, and those chiefly of from a month to
three, four, five, six, eight or nine years old. They commonly for a
day or two, or more, had a little hoarseness, sometimes a little
cough; then in an instant they were seized with a great suffocation
lasting a minute or two, and their face became livid; they have
frequent returns of these fits of suffocation like asthmatic persons.
The said suffocation is ever followed by one symptom which continues
till they die, viz. a prodigious rattling in the upper part of the
aspera arteria [windpipe] resembling that sound which attends colds
when there is phlegm that cannot be got up. It is scarce sensible when
they are awake but very great when they are asleep.”
While there is little in this account to suggest the malignant
sore-throat, and no mention of a miliary or scarlet rash, yet Rutty made
no doubt that it was the malignant angina, comparing it rather to that
described by Starr for Cornwall in 1748 than to that of Fothergill’s
description. He adds, from some other source of information, that children
had generally clammy sweats upon them, with foetor of the breath. Many
died in twenty-four hours; none lived above five days. Some had tumours
behind the ears, which mortified. Many had a prodigious weeping behind the
ears, which was very corrosive. A case is given of a child recovering
after a profuse sweat, which suggested diaphoretic treatment by warm baths
and sack-whey. Swellings of the tonsils and uvula were not observed.
It will be convenient to give here what remains to be said of the 18th
century history of sore-throat in Ireland. In 1744 Rutty enters
“mortal anginas” in Dublin. In March, 1751, tumours of the face, jaws,
and throat, following an epidemic among horses in December, 1750. In
the spring of 1752 “the pestilential angina” made great havoc among
children. In the spring of 1755, “the gangrenous sore-throat” (same as
in 1743) was fatal to some children. In the winter of 1759-60 he
records “scarlet fever,” and a singular form of the same in May, 1762,
noticed under Influenza (p. 356). This must serve for the Irish
experiences, although it is far from satisfactory. But it should be
added that Dr James Sims, of Tyrone, who came to London afterwards and
there wrote on the Scarlatina Anginosa (1786), says in an account of
his Irish practice: “During all my practice here I have not seen one
instance of the malignant ulcerous sore-throat as described by
authors” (_op. cit._ 1773, p. 86).
Malignant Sore-throat in Cornwall, 1748.
Dr Starr, of Liskeard, calls the Cornish throat-disease the Morbus
Strangulatorius. Writing in January, 1750, he said it had raged in several
parts of Cornwall “within a few years,” with great severity[1270]: “Many
parishes have felt its cruelty, and whole families of children been swept
off: few, very few, have escaped.” Cases given by himself belong to the
year 1748; and Huxham, who did not meet with it at Plymouth until 1750-51,
says that it had been raging with great fatality for a year or two before
in and about Lostwithiel, St Austel, Fowey and Liskeard. In the account of
the Cornish epidemic the emphasis falls upon the affection of the larynx
and trachea; while there are so many other symptoms enumerated, including
eruptions and brawny swelling of the neck, that it is clearly impossible
to distinguish between exanthematous fever with sore-throat and laryngeal
diphtheria pure and simple. Starr says: “Dr Fothergill’s sore-throat with
ulcers and Dr Cotton’s St Albans scarlet fever are, in my opinion, but its
shadows.”
The symptoms generally pointed to the glottis.
Agonized breathing for a time was followed by the spitting up of
jelly-like, glairy and somewhat transparent matter, mixed with white
opaque thready matter, which might resemble more or less a rotten body
or slough. The paroxysm returned, and the patient either died suddenly
or sank away gradually, and died worn out, with or without
convulsions. A plate is given of a whitish membrane loosened from the
velum by means of hydrochloric acid on a silver probe; it was not a
slough, but a strong tenacious membrane which would bear handling and
stretching without breaking. In the same case, the child’s father
afterwards pulled from the mouth a complete cast of the trachea
including the bifurcation of the bronchi, of which a figure is given:
“what sweated from it was as sticking as bird-lime”; he lived
twenty-one hours after this second cast was drawn from him and died
somewhat suddenly in his perfect senses. Such formations Starr clearly
believed to be the essence of the disease; but he gives many
variations of it. The train of symptoms was not the same in every
subject: “Some, I am informed, have had corrosive pustules in the
groin and about the anus, eating quick and deep, and threatening a
mortification even in the beginning [as Colden described for the
sore-throat in New York State]. Others after a few days’ illness have
had numbers of the worst and deepest petechiae break out in various
parts of their body: such I have not seen.” But he gives cases of his
own at Liskeard in 1748: “A child here and there had red pustules
which broke out in the nape of the neck and threw off a surprising
quantity of thin transparent ichor”; these pustules sloughed when
poulticed; in another case sloughs followed where blisters had been
applied to the neck and arm. Many had swelling of the tonsils,
parotids, submaxillary and sublingual glands. A few had oedema from
the chin to the thyroid, and up the side of the face. In one case, a
tumour of the fauces broke and yielded some ounces of coffee-coloured
foetid matter, to the patient’s relief and ultimate recovery. Not a
few had gangrenous sloughs in the mouth, which formed quickly. Some
had foetor of the breath as an early symptom, but others had it not.
Some were merely feverish and hoarse.
When Huxham came to describe the disease at Plymouth a year or two later,
he laid the emphasis on other symptoms than those mostly dwelt upon by
Starr, describing really a sloughing sore-throat with rash. But he has
this also: “The windpipe itself was sometimes much corroded by it, and
pieces of its internal membrane were spit up, with much blood and
corruption; and the patients lingered on for a considerable time, and at
length died tabid.”
Fothergill’s Sore-throat with Ulcers, 1746-48.
Meanwhile we have to overtake Fothergill’s history of the ulcerous
sore-throat in or near London[1271]. It broke out at Bromley, near Bow,
Middlesex, in the winter of 1746 (Short says that it was in Sheffield in
1745). So many children died suddenly, some losing all and others the
greater part of their families, that people were reminded of the plague.
It began with a chill and rigor, followed by heat. The throat became
sore, and there were nausea, vomiting and purging. The face turned red
and swollen, the eyes were inflamed and watery, the patient was
restless, anxious and prostrated. The seizure was often in the
forenoon, and in all cases the symptoms became much worse towards
night, to be relieved by a sweat in the morning, as in an intermittent
fever. The uvula, tonsils, velum, inside of the cheeks, and the
pharynx, were florid red, with a broad spot or patch, irregular in
figure, of pale white colour like the blanched appearance of the gums
when they have been pressed by the finger. Usually on the second day
of the disease, the face, neck, breast and hands to the tips of the
fingers became of a deep erysipelatous colour with perceptible
swelling, the fingers in particular being often of so characteristic a
tint as at once to suggest an examination of the throat. A great
number of small pimples, of a deeper red than the skin around 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. With the coming out of this rash, the sickness,
vomiting and purging cease. The white spot or spots on the throat are
now seen to be sloughs; they come first usually in the angles above
the tonsils. They are not formed of any foreign matter covering the
parts but are real mortifications of substance leaving an ulcer with
corrosive discharge behind. The nocturnal exacerbation now takes the
form of delirium and incoherent talking. The parotids are commonly
swelled and painful; and if the disease be violent, the neck and
throat are surrounded with a large oedematous tumour threatening
suffocation. The pulse is 120, perhaps hard and small. The urine is at
first crude and pale like whey; afterwards it is more yellow, as if
from bile; and towards recovery it is turbid and deposits a
“farinaceous” sediment. The initial purging having ceased, the bowels
become irregular. The disease had no crisis, but in general, if the
patient were to recover, the amendment began on the third, fourth or
fifth day, when the redness disappeared and the sloughs in the throat
were cast off.
Such is the main outline; the following symptoms have less general value.
At the outset, the patient complained of a putrid smell in the throat
and nostrils, which caused nausea. The nostrils were often inflamed,
yielding a sanies, and the inside of the lips covered with vesicles
filled with an excoriating ichor. Some had the parts about the anus
excoriated. Fothergill was inclined to think that either the
excoriations or the ichor from them extended down the whole intestinal
tract, and accounted for the purging, with other bowel symptoms,
which sometimes remained for weeks after the primary disease and
caused death by emaciation[1272]. In some there was bleeding at the
nose, or mouth, which might be fatal; in one case there was a like
accident from the ear. Several cases are given in which there were no
sloughs of the throat, but a dry glossy redness or lividity; in these
cases, there was a general brawny swelling of the neck, a coldness of
the hands and feet, involuntary evacuations, a glassy eye and certain
death. Three of Fothergill’s five briefly reported cases are of that
variety. In one of them, a boy of 14 years, he says there was “deep
redness of the face, hands and arms, with a plentiful eruption of
small pimples, which induced those about him to apprehend it was a
scarlet fever.”
That is the only reference to a possible diagnosis of scarlet fever in the
whole essay. In the New England throat-distemper of 1735, “scarlet fever”
was in like manner the name given by the laity, and disapproved by the
profession. Fothergill, adopting the erudition of Letherland, identified
the ulcerous or gangrenous sore-throat of London in 1746-48 with the
_garrotillo_ of Spain in the 16th and 17th centuries, the famous
throat-plague of Naples and other places in Italy and Sicily from 1618
onwards, and the “plague in the throat” mentioned by a traveller,
Tournefort, in 1701 as occurring among children in the island of Milo,
(Douglass having already identified the Levantine plague in the throat
with the throat-distemper of New England in 1735.)
After the outbreak at Bromley and Bow in the winter of 1746, the ulcerous,
or putrid or gangrenous angina continued in London and the villages near
until the date of Fothergill’s writing (1748). By credible accounts, he
says, it was also “in several other parts of this nation.” Short, of
Rotherham, a professed epidemiologist, says that the malignant angina
“never left Sheffield entirely since the year 1745[1273].” Fothergill
himself, in his monthly accounts of the weather and diseases of London
from 1751 to 1755, refers to the sore-throat once or twice; thus, in
October, 1751: “epidemic sore-throat, in both children and adults”; and
again, in July, 1755: “The ulcerated sore-throat likewise appears in many
families, with the greatest part of its usual symptoms, but gives way
without much difficulty, if no improper evacuations have been made, to the
method heretofore recommended (XXI. 497)[1274].”
“Scarlet Fever” at St Albans, 1748.
The same disease that Fothergill described for London and villages near
was seen at St Albans in the autumn of 1748, and described as “a
particular kind of scarlet fever,” by Dr Nathaniel Cotton, who kept a
madhouse there. Among his friends were the poet Cowper (at one time his
patient), and Young, of the ‘Night Thoughts.’ Cotton himself had the same
melancholy cast of mind, and found the same solace in making verses, which
have probably served more to keep his memory green than his essay in
medicine[1275]. He professes to describe “a particular kind of scarlet
fever” in his title-page; and in the text he has this remark: “From this
diversity of symptoms, I have found some practitioners inclined to think
that this disease could not with propriety be called a scarlet fever. But
I imagine that such disputes are about words only.” It is, indeed,
difficult to find any real difference between his particular kind of
scarlet fever and the “sore-throat with ulcers” which Fothergill wrote
upon a few months before, or, again, between his scarlet fever and that of
Withering thirty years after.
The sickness began about the end of September, 1748, in St Albans and some
towns adjacent. At first it attacked children only, afterwards also
adults. The symptoms given are just those detailed by Fothergill, as well
as by Douglass for New England:
Sickness with purging at the outset, rapid swelling of the tonsils and
(or) the parotids and maxillary glands, whitish sloughs on the
tonsils, small ulcers up and down the fauces, the eyelids puffed as in
measles, swelling of the neck, arms and hands in many, in some
swelling of the body also, intense red efflorescence, coming on either
suddenly or tardily, with thick spots as if dipped in blood. On the
face, neck and breast, the rash was even with the surface, elsewhere
it was miliary or shagreen. Some were restless or anxious, and
delirious, others so drowsy that when awakened to receive a draught or
the like, they relapsed at once into stupor. The attack, if not
violent, ended on the fourth or fifth day; there were few in whom the
fever did not return on one, two or more evenings thereafter, so going
off gradually. In one or two, the parotids swelled after the fever was
gone, continuing hard for a fortnight and then suppurating. In nearly
all, the cuticle peeled off “as in other scarlet fevers.” In some the
nervous system was much shaken; in particular they dreaded the
approach of evening with an unusual kind of horror, and started at the
shadows of the candles on the wall. In convalescence some complained
of universal soreness. The spots where blisters had been applied
continued to discharge in some cases eight or ten days or more.
Besides the reference to swelling of the neck, arms or body among the
early symptoms, there is no reference to oedema, while the pallid dropsy
of convalescence, which Withering described in 1779, is not mentioned. It
is noteworthy that Cotton, who lays the emphasis on the scarlatina, and
not on the throat-disease, was of opinion that the copiousness of the
eruption was not a measure of the security of the patient, although that
was clearly the opinion of Huxham and others, who laid the emphasis on the
sore-throat.
Epidemics of Sore-throat with Scarlet rash in the period between
Fothergill and Withering.
The years 1751-52, and indeed the whole of that decade, saw a good deal of
the same diseases, after which little is heard of them until 1778.
Huxham’s accounts for Plymouth, which are of the first importance, begin
with 1751[1276]. They are of importance because his memory went back to
the anginose fever of 1734, in which the miliary eruptions, with sweats,
were critical or relieving to the throat, and because he could not clearly
distinguish between them and the sore-throats of 1751-52, although he
follows Fothergill in identifying the latter with the Spanish
_garrotillo_. The throat affection began in the end of 1751, and became
most severe in October, November and December, 1752, in Plymouth and at
the Dock and all around, carrying off a great many adults as well as
children. It ceased in May, 1753. He describes the sloughing patches in
the throat, the excoriated nostrils with acrid dripping discharge, the
swelling of the parotids and sometimes of the whole neck, just as other
writers had done; and gives the account of laryngeal or tracheal membranes
already cited (p. 695). It is perhaps more important to dwell upon his
account of the rash. Most commonly the angina came on before the
efflorescence, but in many instances the cuticular eruption appeared
before the sore-throat. “A very severe angina seized some patients that
had no manner of eruption, and yet even in these a very great itching and
desquamation of the skin sometimes ensued; but this was chiefly in grown
persons, very rarely in children.” Commonly there was a rash, general or
partial, on the second, third or fourth day.
“Sometimes it was of an erysipelatous kind, sometimes more pustular;
the pustules were frequently very eminent, and of a deep fiery-red
colour, particularly in the breast and arms, but oftentimes they were
very small and might be better felt than seen, and gave a very odd
kind of roughness to the skin. The colour of the efflorescence was
commonly of a crimson hue, or as if the skin had been smeared over
with the juice of raspberries, and this even to the fingers’ ends; and
the skin appeared inflamed and swollen, as it were; the arms, hands
and fingers were often evidently so, and very stiff and somewhat
painful. This crimson colour of the skin seemed indeed peculiar to
this disease.” The eruption seldom failed to give relief; but there
were also cases of an universal fiery exanthem which proved fatal. An
early and kindly eruption, when succeeded by a very copious
desquamation of the cuticle, was one of the most favourable symptoms.
Comparing it with the _febris anginosa_ which he had entered in his annals
under the year 1734, at a time when the ulcerous or malignant sore-throat
was still unheard of, he says that the earlier type differed from the
later in being more inflammatory, and less putrid; the sore-throat of
1751-52 might seem to be a disease _sui generis_, but it differed from the
anginose fever of 1734 only in the above respect: “In a word, the high
inflammatory smallpox differs as much, or more, from the low malignant
kind, as the _febris anginosa_ from the pestilential ulcerous
sore-throat.” In the latter he found the remarkable evidences of putridity
already cited in connexion with putrid fevers[1277]. He gives the case of
a boy of twelve whose tongue, fauces and tonsils were as black as ink; he
swallowed with difficulty, and continually spat off immense quantities of
a black, sanious and very foetid matter for at least eight or ten days;
about the seventh day, his fever being abated, he fell into a bloody
dysentery, but recovered eventually. In a few the face before death became
bloated, sallow, shining and as if greasy, and the whole neck swollen.
Even the whole body might be oedematous in some degree, retaining the
impression of the finger.
Perhaps it may be said that Huxham had really to do with two diseases; and
he does in one place say: “The anginose fever still continued, and we had
several of the malignant sore-throats in September, many more in October,
&c.”--as if the two were not the same. But he generalized the “epidemic
constitution” of 1751-52, in another way: “In all sorts of fevers there
was a surprising disposition to eruptions of some kind or other, to
sweats, soreness of the throat and aphthae. The smallpox were more fatal
in August, and sometimes attended with a very dangerous ulceration in the
throat and difficulty of swallowing. Indeed the malignant ulcerous
sore-throat was now also frequent, probably sometimes complicated with the
smallpox.” Even pleuritic and peripneumonic disorders were attended during
this constitution with a sore-throat, aphthae, and some kind of cuticular
eruption.
Some facts about the throat-disease at Kidderminster and other places in
Worcestershire will complete this part of the somewhat perplexing history.
Dr Wall says it appeared about the beginning of 1748 chiefly in low
situations[1278]: “It then went generally under the name of scarlet fever,
the complaint in the throat not being much attended to, or at least looked
upon only as an accidental symptom.” His first cases were at
Stratford-on-Avon--a young lady who recovered with difficulty, and then
two sisters who died, all three having been treated by blood-letting and
the cooling regimen. By these cases Wall was convinced that the disease
was more putrid than inflammatory, that it was infectious, that the
antiphlogistic treatment was a mistake, that bark was the grand remedy,
that the throat was the principal seat, and that the scarlet efflorescence
was rather an accidental symptom than essential to the disease, some
having petechiae and purple spots. He adopts Mead’s name of _angina
gangraenosa_. The malady had been rife in the city of Worcester, and most
of all at Kidderminster, where it was in a manner epidemical. He was told
that nine or ten poor persons had died of it there one after another.
Having been called to the child of a respectable tradesman, he treated the
case with bark and the cordial regimen. He persuaded the Kidderminster
surgeons and apothecaries to adopt the same method, which they did with
such success that, as he found afterwards in the books of one of them,
there were only 7 deaths in 242 cases of the disease, while Dr Cameron did
not fail once, and Wall himself had fifty recoveries and only two deaths.
It is said, however, on the authority of the parish register, that a
hundred persons died at Kidderminster of the malignant sore-throat in
1750, “in the months of October and November only[1279].” Dr Wall goes on
to say that the “Kidderminster sore-throat” had a vast variety of
symptoms, the only certain ones being aphthous ulcers and sloughs on the
tonsils and parts about the pharynx. “Very few here [which may mean
Worcester] have had the scarlet efflorescence on the skin.” Dr Johnstone,
senior, confirms this in a measure for Kidderminster[1280]: “The anginous
fever was not always, though often, attended with cutaneous eruptions; and
these, for the most part red, were sometimes also of the christalline
miliary kind.” And in writing again in 1779, when Withering’s scarlet
fever was dominant in place of Fothergill’s sore-throat, Dr Johnstone
said: “A scarlet eruption was a much more frequent symptom of this disease
than it used to be when I first became acquainted with it nearly thirty
years ago.” But, as it is known that the rash of true scarlet fever is far
less constant in adults than in children, and as many of the attacks
referred to by Wall and Johnstone were in adults, the so-called
Kidderminster sore-throat may have been a fairly uniform scarlatina.
Still, it is clear that all the leading writers, excepting Cotton, of St
Albans, distinguished between sore-throat (gangrenous, malignant, or
ulcerous) and scarlatina, identifying the former with the old _garrotillo_
of Spain and Italy[1281]. The distinction may have been really between
scarlatina simplex and scarlatina anginosa, as Willan believed; but
whether the disease were malignant scarlatina, or diphtheria, or a mixture
of the two (as in Cornwall), or an undifferentiated type with the
characters of both, it was certainly new as a whole to British experience
in that generation, and, if we except the reference by Morton to certain
cases which may have been sporadic, it was a disease hitherto unheard of
in England since systematic medical writings began. We may realize the
impression which it made, both in the American colonies and in England in
the middle third of the 18th century, by recalling the sudden appearance
of diphtheria some thirty-five years ago; but, whereas the diphtheria of
1856-58 came upon a generation of practitioners who had seen much of the
very worst kinds of scarlatina for twenty years or more, the
contemporaries of Huxham, Letherland, Fothergill, Johnstone and Wall in
England, or of Douglass, Colden and Bard in America, knew no scarlet fever
but scarlatina simplex. The outbreaks of the 18th century throat-distemper
in certain families were of the same tragic kind as diphtherial outbreaks
in our own time. Instances of whole families swept away have been cited
from the New Hampshire epidemic of 1735. Horace Walpole gives the
following instance of a noble family in London:
“There is a horrid scene of distress in the family of Cavendish; the
Duke’s sister, Lady Bessborough, died this morning of the same fever
and sore throat of which she lost four children four years ago. It
looks as if it was a plague fixed in the walls of their house; it
broke out again among their servants, and carried off two a year and a
half after the children. About ten days ago Lord Bessborough was
seized with it and escaped with difficulty; then the eldest daughter
had it, though slightly: my lady attending them is dead of it in three
days. It is the same sore throat which carried off Mr Pelham’s two
only sons.... The physicians, I think, don’t know what to make of
it[1282].”
The medical accounts of the sore-throat of those years are none the easier
to interpret in a modern sense owing to the frequent use of the term
“miliary” to describe the rash. Douglass had used this term in the title
of his Boston essay in 1736. Bisset applies it to a Yorkshire epidemic
some twenty years after[1283]. The disease began among adults at Whitby in
September and October, 1759, and spread over the country between the coast
and Guisborough in the spring of 1760, as well as in some places to the
westward of the latter; afterwards it became epidemic in all the western
parts of Cleveland in August and September of 1760, the summer months
having been almost a clear interval. It was remarkable, he says, that some
persons in the eastern parts of Cleveland who had escaped it when it was
epidemical in the spring, were attacked by it in the autumn after it “had
got a good way to the westward of them.” This epidemic progression is
spoken of as of a single but composite disease,--“the epidemic
throat-distemper and miliary fever that appeared in the Duchy of Cleveland
in 1760.” In adults it was mostly an affection of the throat, few having
the miliary eruption, and only one adult dying “within the circle of my
observations.” But in children the fever with miliary rash was
predominant, and of it the fatality is put at one death in every thirty
cases. There is no discussion as between the names of scarlet fever and
miliary fever; but the following on the peeling of the skin is
significant: “From the ninth to the thirteenth day the scarf-skin begins
to peel off in cases that were attended by a copious rash; and that of the
hands and feet sometimes came off almost entire.” Soreness of throat often
happened in this fever of children; and, to repeat, the sore-throat of
adults and the miliary fever of children are described as parts of one and
the same epidemic[1284]. An account which probably relates to the same
disease comes from Rotherham or Sheffield in a letter by Dr Short, the
epidemiologist, to Rutty, of Dublin. It was very violent, he says, in
July, 1759, and cut off whole families of children. The attack was
attended with diarrhoea, swelled tonsils, oedema of the face, an eruption
like measles all over the body, and a discharge of sanious humour from the
nostrils. “In some there was an efflorescence on the skin like the scarlet
fever, and these recovered[1285].”
Another complication arises owing to the prevalence, in the same period,
of putrid or miliary fevers, which had sometimes an anginous or “throaty”
character. This source of perplexity extends from near the beginning to
near the end of the 18th century, but it is greatest in the middle period,
when the “constitution” was most decidedly “putrid[1286].” The
relationship was most definitely expressed by Johnstone, of Kidderminster:
“This malignant fever (_vide supra_, p. 123) was very often, though not
constantly, complicated with, and in general had great analogy with the
malignant sore-throat which at this time prevailed in many parts of
England.” An Oxford practitioner, in 1766, actually wrote a dissertation
to distinguish the “putrid sore-throat” which attended the “putrid”
continued fever of the time, from the “gangrenous sore-throat” of
Fothergill, Huxham and others: in the former, the aphthae and sloughs of
the tonsils and uvula, as well as of the mouth, were only symptomatic of
the putrid fever, and late in showing themselves; in the latter, the
throat affection was the primary and dominant one, present from the
beginning of the illness[1287].
The last complication of the highly complex circumstances in which
scarlatina first became a great disease in England is with “putrid” or
malignant measles. In the same years as the epidemic described above for
Yorkshire, namely, 1759 and 1760, there occurred an “anomalous malignant
measles,” which for some months had made a melancholy carnage amongst
children in the west of England. The symptoms were difficult breathing, an
amazingly rapid pulse, white or brown tongue, and “some red eruptions
which run in irregular groups and splatches on the surface of the skin.”
The attack was apt to be attended by colliquative diarrhoea. A fatal issue
was indicated by a sunken and very quick pulse, the abatement of the
dyspnoea, and the eruption coming and going. Some rapid cases in infants
ended in convulsions on the third day. Children from one to six years were
attacked most[1288]. Perhaps the only reason for not including this among
epidemics of measles is the author’s remark: “I look upon the poison of
the disease to be a good deal akin to that of the ulcerated sore-throat so
very rife and fatal some years since,” although he does not allege
throat-complications in the malady which he describes.
Three years later, in 1763, there was an epidemic at the Foundling
Hospital, London, which Watson, the physician to the charity, described in
a special essay as one of “putrid measles.” Willan, writing in 1808,
challenged the diagnosis on the ground both of the symptoms as given by
Watson, and of the names given to the malady in the Infirmary Book at the
time. The first entry in the apothecary’s book is on 23 April, 1763, a
case of “fever with a rash,” the next on 30 April, a case of “scarlet
fever,” then on 7 May, ten cases of “eruptive fever,” and, for the rest of
May and all June, very long lists of “eruptive fever,” the name of measles
not occurring at all in that outbreak, while the names of “morbillous
fever” and “fever” are given to a smaller but still considerable outbreak
in November of the same year. Among the symptoms, Watson mentions that the
fauces were of a deep red colour, that the rash came out on the second
day, and that there was no cough. The most remarkable character of the
epidemic as a whole was a tendency to sloughing in various parts:
“Of those who died some sank under laborious respiration: more from
dysenteric purging, the disease having attacked the bowels; and of
these one died of mortification in the rectum. Besides this, six
others died sphacelated in some one or more parts of the body. The
girls who died most usually became mortified in the pudendum. Two had
ulcers in their mouth and cheek, which last was so covered by them
that the cheek, from the ulcers within, sphacelated externally before
they died. Of these one had the gums and jawbone corroded to so great
a degree that most of the teeth on one side came out before she died.
The lips and mouth of many who recovered were ulcerated, and continued
so for a long time.” The anatomical examination of those who died
showed the bronchitic affection, in one case pleurisy, and in some a
gangrenous condition of the lungs. One died of emaciation six weeks
after the attack. Eleven others succumbed shortly after to smallpox,
out of eighteen who caught the latter during recovery from the
preceding epidemic disease[1289].
Long after, in 1808, when the diagnosis between measles and scarlatina was
fixed, Dr James Clarke saw at Nottingham in several cases of measles “a
great tendency to gangrene,” the sites of blisters having mortified in two
(as in scarlet fever) and two having gangrene of the cheek and
mortification of the upper jaw[1290]. Huxham, he says, saw such cases,
Willan never; and that was one of the reasons why Willan claimed the
Foundling cases as scarlatina. The diagnosis is important; for, in the
same year, 1763, the bills of mortality record 610 deaths from measles in
London, and Watson expressly includes the 19 deaths in the Foundling
Hospital (in 180 attacks) as part of the general epidemic in London.
The confusion between measles and scarlatina is farther shown by the
entries in the Infirmary Book of the Foundling Hospital from the beginning
to the end of an extensive epidemic in 1770: On 31 March, 23 children are
in the infirmary with “measles,” and on 7 April, 37 children still with
“measles”; on 12 May the long list is headed “measles and ulcerated
sore-throat,” on 19 May, “putrid fever,” and on 26 May, “fever and
ulcerated sore-throat[1291].”
Whether or not we agree with Willan in taking the Foundling epidemic of
1763 (and perhaps with it the general epidemic in London) for one of
scarlatina, it can hardly be doubted that the Foundling epidemic of 1770
was the latter disease, the names of “measles with ulcerated sore-throat,”
“putrid fever,” and “fever and ulcerated sore-throat” clearly indicating
scarlatina anginosa. Grant also records the prevalence of epidemic
sore-throat in London in 1770[1292], and Dr William Fordyce, writing in
1773, dealt with the “ulcerated and malignant sore-throat” as a question
of the day[1293].
It was not until forty years ago, he says, that they had become
acquainted in England with ulcerated and malignant sore-throat, while
“both kinds” are now very common. His aim is to separate the ulcerated
from the malignant, and he instances an outbreak in a gentleman’s
house at Islington, where the worst symptoms of the malignant occurred
in the children, while only the ulcerous prevailed among the servant
maids. In 1769 it was reported to be seldom fatal in London and
Westminster, and in the villages around; but within these last twelve
months (1773) it had appeared of a bad type in high situations such as
Harrow, in the months of June and July. In a later note, he adds that
“it still continues to make a havock so considerable as to keep up the
alarm about it both in the metropolis and all over England,” his own
last experience of it having been two fatal cases in a noble family a
few miles to the west of London. Fordyce identified this disease with
Fothergill’s sore-throat, and described the eruption as “the general
erysipelatous colour that comes about the second day on the face,
neck, breast and hands to the finger ends, which last are tinged in so
remarkable a manner that the seeing of them only is sufficiently
pathognomonic of the malady [this is a repetition of Huxham and
Fothergill]; and finally a great number of small pimples, of a colour
more intense than that which surrounds them, appearing in the arms and
other parts of the body.” He gives the following as a case of the
malignant sore-throat in a young gentleman five or six years old:
“Every part of the body that bore its own weight was gangrened, as
well as the orifices where he had been blooded twice before I saw him
(which was three days after the seizure); the parotid glands were very
much swelled, the whole body was more or less oedematous, and the skin
throughout of an erysipelatous purple; he died the third day after I
saw him.”
Although Fordyce, and probably most others, still adhered to Fothergill’s
view of the sore-throat with ulcers as a disease apart, yet there appear
to have been at this date some who followed the line taken with regard to
it by Dr Cotton in 1749. Sometime about the end of 1771 or beginning of
1772, a physician at Ipswich sent to a London physician, who sent it to
the _Gentleman’s Magazine_, an account of a “Successful Method of treating
the Ulcerated Sore Throat and Scarlet Fever,” by tartar emetic, calomel
&c.[1294] He begins: “The ulcerated sore-throat and scarlet fever has been
very rife in this place and the neighbourhood for some months past, and
has been in a considerable number of instances fatal. It has in every
respect answered the description given of it by Dr Fothergill”--so much so
that he does not give the symptoms, but only the treatment, which, in his
own hands, had been singularly successful: “I have had considerably more
than one hundred patients, and have not buried one,” his cases, between
the writing and printing of the paper (3 June) having “increased to near
three hundred with the same success.” This must have been an interval of
mild scarlatina, during which the prevalence of the malady, however
extensive, had attracted little notice. The outburst in 1777-78, from
which the diagnosis and naming of scarlatina anginosa properly date, was
obviously an interruption of a quiet time of the disease.
Scarlatina anginosa in its modern form, 1777-78.
Dr Levison[1295], who was physician to a London charity called the General
Medical Asylum located at No. 4, Tottenham Court-road (afterwards in
Welbeck Street), observed the outbreak, on 15 July, 1777, of a malignant
sore-throat, “nearly such as described by Dr Fothergill and Dr Huxham
(only without the efflorescence and attended with costiveness),” among
children from three to seven years, by which many were cut off in the
space of six to eight days, some by suffocation and others by vomiting of
blood. It became more general in August, and in some was very malignant,
being joined with an erysipelatous inflammation and a diarrhoea. It raged
with great fury in Kentish Town, and at Enfield Chase it swept away many
in twenty-four hours. But on the high ground about London, as at Hampstead
and Highgate, it was of a benign type. It was worse in the villages round
than in the capital itself.
In the milder form, there was only a superficial whiteness of the
uvula, tonsils and velum; in the more severe, the same parts were
beset with thick ulcerations, running very deep in the fauces. Both in
the milder and in the more severe cases the neck became swollen on the
second or third day. The commencement was usually with shivering and
nausea, followed by heat, and an efflorescence over the breast, the
limbs, and often the whole body, of a crimson red. “Some were spread
over with a kind of little millets, similar to that in the miliary
fevers, and which scaled off the skin the sixth or seventh day; in
which cases the ulcerations were very slight, as also all other
symptoms of malignancy.” The mouth was apt to be full of sloughs, the
teeth covered with black crusts. The urine was scanty, high-coloured,
with a thin suspended cloud. Some bled from the nose. The nostrils
were apt to be stuffed with greenish sanies, which dropped out
continually. The efflorescence and sore-throat were often met with
separately. Most had cough throughout, great dejection of spirits, and
oppressed breathing. The disease had no regular progress and no
crisis; the whole of the symptoms would often cease suddenly about the
eighth or ninth day. In one case there was recovery after three weeks’
illness. Several cases had suppuration of the glands of the neck. In
one fatal case, a tumour behind the right tonsil was found to contain
three ounces of fœtid pus.
Oedema was frequent after recovery--the lips, nose and face bloated,
sallow, shining and greasy; the belly also might be swollen. This, says
Levison, was a peculiar kind of dropsy; and as he adds that it had not
been remarked by Huxham he intends to distinguish it from the bloated
greasy appearance which Huxham did remark. Some died of it a month after
the fever; many recovered from it by the aid of calomel, rhubarb and
diuretics--the treatment for the scarlatinal dropsy--and full doses of
bark. In the acute disease blisters were sometimes tried, in compliance
with custom; but they did no good, and occasioned a great discharge of
thick matter. Bleeding and antiphlogistics were seldom called for. This
outbreak, which began in July 1777, abated in November. Next year it came
back about the middle of March, but in a benign form, and unattended with
either the efflorescence or the diarrhoea, and so continued until the date
of writing, the 11th May, 1778. Levison distinguishes two or three
types--a malignant sore-throat at the outset early in summer, 1777, to
which in autumn two other epidemics were joined, namely, on the one hand,
scarlet fever (or miliary fever), and on the other hand, a purging like
autumnal dysentery.
The second season of the epidemic in London[1296], the spring and summer
of 1778, saw the outbreak of malignant sore-throat, with rash, in the
Midlands. It appeared in Birmingham about the middle of May, and in June
it was frequent in many of the towns and villages in the neighbourhood. It
continued to the end of October, and revived a little during mild weather
after the middle of November. It seems to have reached Worcestershire in
the autumn, cases having been seen first at Stourbridge and afterwards at
Kidderminster and Cleobury. According to Johnstone, the younger, it broke
out first in schools, and spread very rapidly among children, attacking
adults sometimes. The summer of 1778 was remarkable for heat, which is
described as West Indian in its intensity.
The account of this epidemic which has attracted most attention (and
deservedly) is that of Withering, of Birmingham, who had written his
thesis at Edinburgh twelve years before (1766) on _angina gangraenosa_. He
calls it definitely by the name of “scarlet fever and sore-throat, or
_scarlatina anginosa_,” explaining that it was “preceded by some cases of
the true ulcerated sore-throat,” by which he meant the disease described
by Fothergill in 1748. The elder Johnstone, then of Worcester, who had
described the Kidderminster sore-throat of 1750-51, declared that the
scarlet eruption was a more common symptom of this 1778 disease than it
used to be when he first became acquainted with it near thirty years
before; and dealing with the same epidemic as Withering, he makes out
three varieties:--namely, first the scarlatina simplex of Sydenham, with
no sore-throat, second, the scarlatina anginosa, and third, the ulcerated
sore-throat[1297]. His son, who also wrote upon the epidemic of 1778 as he
saw it at Worcester, having written his Edinburgh thesis upon malignant
sore-throat several years before, says: “The disease which now prevails is
the ulcerous malignant sore-throat, combined with the scarlet fever of
Sydenham[1298].” Saunders, a retired East Indian surgeon, described the
corresponding epidemic in the north of Scotland as one of sore-throat and
fever[1299].
Withering’s account of the symptoms differs little from that given by
Levison the year before, and is chiefly noteworthy for confirming that
writer as to the occurrence of scanty urine and oedema[1300]: