Chapter VII: Scarlatina and Diphtheria (1)

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.