Chapter VII: Scarlatina and Diphtheria (2)

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]:

The rash came out on the third day, continued scarlet, the colour of a
boiled lobster, for two or three days, then turned to brown colour,
and desquamated in small branny scales. He had been told of three
instances in which the desquamation was so complete that even the
nails separated from the fingers. In the colder weather of October the
scarlet colour was less frequent and less permanent. Many had no
appearance of it at all; while others, especially adults, had on
tender parts of the skin a very few minute red pimples crowned with
white pellucid heads. The worst cases fell into delirium at the
outset, had the scarlet rash on the first or second day, and might die
as early as the second day; if they survived, the rash turned to
brown, and they would lie prostrate for several days, nothing seeming
to afford them any relief. “At length a clear amber-coloured matter
discharges in great quantities from the nostrils, or the ears, or
both, and continues so to discharge for many days. Sometimes this
discharge has more the appearance of pus mixed with mucus. Under these
circumstances, when the patients do recover, it is very slowly; but
they generally linger for a month or six weeks from the first attack,
and die at length of extreme debility.” These discharges, compared by
a writer a generation before to glandered secretions, are not to be
confused, says Withering, with the matter from abscesses on both sides
of the neck, under the ears, which “heal in a few days without much
trouble.” The submaxillary glands were generally enlarged. Adults
usually had a ferretty look of the eyes, and sometimes small circular
livid spots about the breast, knees and elbows. Some had a succession
of boils. One man had “lock-jaw.” Most patients had the fauces,
particularly the tonsils, covered with sloughs, which separated and
left the parts raw, as if divested of their outer membrane. The most
troublesome symptom was exulcerations at the sides and towards the
root of the tongue; these were painful and made it impossible to
swallow solid food. Some threw out several white ash-coloured sloughs,
though no such sloughs were visible upon inspecting the throat.

With reference to the diagnosis between scarlatina anginosa and angina gangraenosa (of Fothergill) Withering says: “They are both epidemic, they are both contagious; the mode of seizure, the first appearances in the throat, are nearly the same in both; a red efflorescence upon the skin, a great tendency to delirium and a frequent small unsteady pulse are likewise common to both. With features so strikingly alike, and these, too, of the most obvious kind, is it to be wondered that many practitioners considered them the same disease?” And again: “But perhaps he will never be able precisely to draw the line where the light begins and where the penumbra ends[1301].”

The extent of the epidemic of scarlatinal sore-throat, of which we have particulars from Middlesex, Warwickshire and Worcestershire in 1778, cannot be ascertained. It is heard of, as we saw, in the north of Scotland in 1777. According to Barker, of Coleshill, the scarlet fever which “in a manner raged in the neighbouring town of Birmingham,” occurred in only a few cases in his own parish, and these mild[1302]. It appears to have been in Carlisle the year after, 1779, under which date Heysham says that “two epidemics swept off a great number of children--smallpox and a species of scarlet fever[1303].” Nothing more is heard of it in Carlisle for the next eight years, during which Heysham kept an account of the diseases. The epidemic of 1778-9 fell also upon Newcastle:

From the month of June, 1778, until the 1st September, 1779, there
were treated 146 cases of “ulcerated sore-throat,” of which 18 were
fatal. The epidemic was at its height in September and October. The
ages were: under ten years, 98, ten to twenty, 25, twenty to thirty,
18, above thirty, 5. Dropsy followed in 23; 75 were mild scarlatina
and sore-throat, 33 were angina maligna. During the ten years
following, until 1789, only 57 more cases were treated from the
Newcastle Dispensary, of which 8 were fatal[1304].

History of Scarlatina after the Epidemic of 1778.

In London, according to Dr James Sims, scarlatina with sore-throat occasioned a great mortality in the latter half of 1786. The bills of mortality assign only 19 deaths to sore-throat, while they give 793 for the year to measles. But Sims says that “measles were not present in London during the whole year; at least I saw none, and I saw about two thousand cases in private and at the General Dispensary.”

The deaths from scarlet fever, he thinks, had been given under measles and also under “fevers,” which were a large total for the year. The epidemic was very virulent, going through families; many lost two children, some a larger number; many adults fell victims to it who were supposed to die of common fever.

Sims’ first case was of a youth at Camberwell, in March, with scarlet
rash and sloughs of the throat. He saw no more cases for several
weeks, and then, on 1 May, he was called to a case of sore-throat in a
school at Hampstead; the illness was slight, and there was no
efflorescence; but in June there occurred in the same school an
explosion of scarlatina, twenty of the girls being seized within a
short time. It was in other suburban villages in the summer, but did
not enter London until August, after which Sims saw three hundred
cases of it; of some two hundred treated by him in a certain way, only
two died. The symptoms of the epidemic were the usual ones of scarlet
fever with ulcerated or sloughing throat. In November and December,
swelling attacked the face and extremities, which were painful but not
oedematous. The parotids were swollen. Several had the angina without
the rash; others the rash without the angina[1305].

The same epidemic in London was one of the early medical experiences of Dr Robert Willan, who gave some account of it in the volume ‘On Cutaneous Diseases’ which he published in 1808, shortly before his death[1306]. It began in the autumn of 1785, was superseded by measles for a time, and revived again in 1786, to last into 1787. It was most malignant in the narrow courts, alleys and close crowded streets of London, but existed also in the villages near. While admitting the existence of measles in the winter of 1785-86, he confirms Sims in saying that it was not measles (as in the Bills) but scarlatina that caused the high mortality in 1786: “The cases of scarlatina during the year 1786 exceeded in number the sum of all other febrile diseases within the same period.” The deaths were mostly between the seventh and eighteenth day of the fever. The following is his classification of over two hundred cases seen by himself:

1786

Scarlatina Scarlatina Scarlatina Sore-throat
simplex anginosa maligna without eruption

April -- 3 -- --
May 6 10 2 --
June 4 12 1 4
July 2 11 1 3
August 1 17 4 4
Sept. 2 29 9 12
Oct. 3 24 5 7
Nov. 0 38 12 10
Dec. 0 8 5 2
-- --- -- --
18 152 39 42

The infirmary book of the Foundling Hospital has long lists of
patients sick of “scarlet fever with sore-throat” in August and
September, 1787, as many as 76 being under treatment in one week, the
next week 39 sick of scarlet fever, besides 45 recovering from it.
This is the first unambiguous entry of an epidemic of scarlet fever in
the Foundling Hospital records[1307]. Under the same year, 1787,
Barker, of Coleshill, records “scarlet fever, smallpox, and chincough”
in a neighbouring city, as well as pestilential sore-throats
“epidemical everywhere in the terrible foul weather of winter.” His
next entry of “scarlet fever and sore-throat” is under the year
1791[1308].

An account by Dr Denman, of London, dated 28 November, 1790, of “a
disease lately observed in infants,” but otherwise unnamed, appears to
relate to diphtheria. Eight cases in young infants were seen, one per
month from April to October, of which six proved fatal. The signs were
“thrush in the nose,” fulness of the throat and neck, the tonsils red,
swelled, and covered by ash-coloured sloughs or extensive ulcerations.
The skin sloughed at places where blisters were applied. Nothing is
said of a scarlet rash[1309].

Scarlatina (1788) and Diphtheria (1793-94) described by the same observer.

One good observer at the end of the 18th century, Rumsey, a surgeon at Chesham, in Bucks, has left full accounts of two epidemics in his district, one in 1788, which he calls “epidemic sore-throat[1310]” and the other in 1793-94, which he calls “the croup[1311].” The one corresponds to scarlet fever, the other to diphtheria. The author does not think it necessary to enlarge on the distinction between the “epidemic sore-throat” and “the croup” as it was so obvious; yet the former was “Fothergill’s sore-throat,” which some English writers of the present time assume to have been diphtheria; while the disease which Rumsey calls “the croup” corresponds with laryngeal and tracheal diphtheria, not unmixed with diphtheritis of the tonsils, uvula and velum. There is hardly anything in the history of scarlatina and diphtheria more instructive than the juxtaposition of those two excellent descriptions by Rumsey, who grudged the name of scarlatina to the former epidemic because the rash was not invariable, and called the latter by the name of croup although it was not confined to the larynx and trachea, and was epidemic in the summer months.

The epidemic of “sore-throat” in 1788 began in April and lasted until November, attacking those of every age except the very old, but especially children, and mostly women among adults.

The throat was slightly sore for twelve or twenty-four hours; it then
became fiery red, the uvula and tonsils being much swelled. About the
second or third day there were whitish or yellowish sloughs on the
tonsils and uvula, which in many cases left deep, ragged ulcers. It
was many days before the sloughs were all exfoliated. Some spat up an
astonishing quantity of mucus; in young children there was apt to be a
discharge of mucus from the nostrils, and in a few cases from the
eyes. The parotid and submaxillary glands were often enlarged,
sometimes suppurating or sloughing. A white crust separated from the
tongue on the third or fourth day, leaving it raw and red. In some
cases there was sickness with vomiting, in some diarrhoea. In many
cases there was a scarlet eruption over the whole body, usually on the
second or third day. The fatal cases had all a very red eruption, and
the skin burning to the touch. In some the eruption was so rough as to
be plainly felt. In a few cases, after the efflorescence broke out, a
number of little pustules made their appearance about the breast,
arms, &c., of about the size of millet seeds, which died away in
twenty-four or thirty-six hours. This was not common; but in one
family the mother and three of the four ailing children had pustules.
One young man had large white vesicles on the sixth day; another young
man, in November, had vesicles on the arms, thighs and legs as large
as a half-crown piece, filled with yellow serous fluid, or gelatinous
substance, with a good deal of erysipelas round them. The red
efflorescence was always followed by peeling. Many had the
throat-disease without rash, but none had the efflorescence without
the sore-throat.

Rumsey decides against two distinct types of disease; it was the same contagion acting on different constitutions; yet he could not help thinking that scarlatina anginosa was an improper term for it, inasmuch as the rash was not constant. It was a less putrid disease than that described by Fordyce in 1773 (_supra_, p. 707), and carried off but few considering the great numbers who were affected by it. Two of the fatalities in children were from the anasarca of the whole body, with scanty urine, which came on a week or two after. He bled only once, applied leeches to the temples in several, and saw many recoveries with no treatment but topical applications.

The epidemic five or six years after in the same town in a valley of Buckinghamshire and on the hills for some six miles round was something unusual. Rumsey had about forty cases of “the croup” from March, 1793, until January, 1794; whereas his father, who had practised there above forty years, could not recall more than eight or ten cases of “croup” in all his experience. The cases were all in children from one to fourteen years; there were sometimes three attacked in one family; most of the fatal cases occurred in summer; the epidemic was distributed impartially in the valley where Chesham stands and upon the hills enclosing it. Rumsey gives full details of seventeen cases, eight that died and nine that recovered, with post-mortem notes for some.

His first case was in March, 1793; then came a succession of cases
about June and July, of which four that proved fatal were in children
just recovered from measles. All those earlier cases had the disease
coming on insidiously, then the peculiar cough and tone of voice, if
any voice remained, paroxysms of choking, expectoration of shreds of
membrane, giving relief to the distress, and the trachea found after
death lined with a coagulated matter[1312]. Among these summer cases
were three children in one family, of whom two died, both being just
out of the measles. The later series of cases in the winter of 1793-94
were less often fatal; the epidemic constitution, he says, became less
severe towards the end; he also used mercurials freely on the later
cases; but it is farther noteworthy that “most of the cases which
occurred in November and afterwards, were attended with inflammation
and swelling of the tonsils, uvula and velum pendulum palati, and
frequently large films of a whitish substance were found on the
tonsils”--so that the disease was in its extension more than cynanche
trachealis, or croup, even if it had not been also an epidemic
infection.

In only one case, the eighth recorded, does he seem to have hesitated between “the croup” and sore-throat: “ulcerated sore-throats being at this time [6 Sept. 1793] somewhat prevalent, induced me to inspect the fauces, and I observed a swelling and no inconsiderable ulcer on the left tonsil.” It was in the autumn and winter that these throat complications of “the croup” mostly appeared; and it was because he found “so much disease about the tonsils” in the tracheal and laryngeal cases that he forebore to bleed, and used mercurials. Also in the same season when “the croup” was joined to disease of the tonsils, uvula and velum, there was a certain epidemic constitution prevalent: “In the autumn, likewise, and winter, many children suffered by erysipelatous inflammation behind the ears, in the groins, on the labia of girls, or wherever the skin folded, attended with a very acrid discharge”--precisely the complication of the “throat-distemper” of America described by Douglass and Colden as well as by Bard, also of the Irish throat-epidemic in 1743 mentioned by Rutty, of the morbus strangulatorius in Cornwall described by Starr, and of the sore-throat described by Fothergill. In systematic nosology, do the corrosive pustules behind the ears, in the groins, labia, &c., belong to scarlatina or to diphtheria?

* * * * *

It is perhaps the same juxtaposition, or intermixture of scarlatina anginosa and diphtheria, that we find in the north of Scotland about the same time of the 18th century. Various parish ministers who contributed to the first edition of the _Statistical Account_ make mention of “the putrid sore-throat” about 1790 and 1791, without any reference to fever or scarlet rash. The following relates to three localities in Aberdeenshire:

New Deer: “In the autumn of 1791, a putrid kind of sore-throat, which
first made its appearance about the coast side, found its way into
this parish. Since that, it has continued to rage in different places
with great virulence and little intermission, and is peculiarly fatal
to the young and people of a full constitution[1313].” Crimond, a
coast parish: “The putrid sore-throat raged with great violence two or
three years ago [1790 or 1791] in most parishes in the neighbourhood,
and carried off great numbers: but though a few were seized with it in
Crimond, none died of that disorder[1314].” Fyvie, an upland
parish:--“There has been no prevalent distemper for some time except
the putrid sore-throat, which raged about two years ago [probably
1791] and proved fatal to several people. It has appeared this winter,
but is not so violent as formerly[1315].”

From Aberdeen the epidemic is reported in a letter by one of the physicians, in May, 1790, in such terms as not to imply that it was scarlatina: “The malignant sore-throat has been most prevalent and very fatal, no period of life being exempted.” In children from six months to three years there was observed a livid appearance behind the ears which, in seven or eight cases, spread over the external ear, causing the latter on one or both sides to drop off by sloughing before death[1316].

The scarlet fever, with sore-throat, which reappeared in London about 1786-87 (and at Chesham in 1788) is said to have been somewhat steady until 1794. Willan, who began his exact records in 1796, says retrospectively that the scarlet fever with an ulcerated sore-throat had been prevalent every autumn from the year 1785 to 1794, “and proved extremely fatal[1317].” Lettsom gave a particular account of it in the spring of 1793[1318]; it was seen first in the higher villages about London, gradually descended into lower situations, and visited the metropolis pretty generally about the end of February. “It has been remarked for many years that this disease appears in the vicinity of London before it visits the metropolis,” beginning often among the numerous boarding-schools in the suburbs, to be carried thence by the dispersion of pupils to their homes. In some villages private families suffered greatly; in a few Lettsom heard of half the children dying, as well as of deaths among the domestics and other adults. The same epidemic of 1793 also called forth one of the numerous essays of Dr Rowley, who had written on the “malignant ulcerated sore-throat” in 1788[1319].

Scarlatinal Epidemics, 1796-1805.

The history of scarlatina in London, as of most epidemic maladies, is enriched for a few years by Willan’s monthly or quarterly accounts of the cases treated at the Carey Street Dispensary. From the beginning of 1796 to the end of 1800, scarlet fever is hardly ever wanting, and is occasionally the principal epidemic. It is only now and then, however, that a death from it appears in the Parish Clerks’ bills of mortality. Willan remarks that they gave only one death from that cause between the 8th and 29th November, 1796, “a period during which there occurred many fatal cases of that disease.” The bills have only three deaths from it in the quarter 27 Sept.-27 Dec. 1796. The Parish Clerks did not adopt scarlet fever fully into their classification until 1830; long after it had become an important factor in the mortality, they placed the deaths from it under “fevers” or under “measles.” According to Willan’s experience, it must have been as common as measles from 1796 to 1801. It was, he says, always most virulent and dangerous in the month of October and November, but generally ceased on the first appearance of frost. He records a spring epidemic as an exceptional thing in 1797: “Since the beginning of May, the scarlatina anginosa has become more frequent than any other contagious disease, both in town and in many parts of the country; the disease has generally occurred in its malignant and fatal form, which, at this season of the year, is very unusual.” The bills give only one death from 18th April to 18th May. Willan says that it was rife again in the autumn of 1797 and of 1798. Dr James Sims, who had described the scarlatina of London in 1786, found the epidemic in the end of 1798 so different from the former, and attended with so great fatality, that he made it the subject of a second paper[1320]. It was preceded in the winter and spring of 1797-98 by a remarkable epidemic among the cats of London (an angina, with sanious discharge from the nostrils and running at the eyes), which killed “myriads” of them[1321]. In Sept.-Oct. 1798, he heard that a scarlet fever had been fatal to some adults about South Lambeth, and afterwards to several children there, five dying in one family and three in another. The swellings on each side under the jaw were so great as to force the chin up into the horizontal; there was much acrid foetid discharge from the nostrils, the pulse sank about the seventh day, and the scarlet eruption remained out until near death, which took place usually about the ninth or tenth day. Along with this malignant type, a mild or simple scarlatina was also prevalent. Sims wrote when the epidemic seemed to be “in its infancy,” and so it proved; for Willan describes it as prevailing to the end of 1798 and rising still higher in the first months of 1799, his report for February and March being: “Scarlatina anginosa in its malignant form has been very prevalent, and has proved in many instances fatal; and in those who recovered, it produced after the cessation of the fever, anasarca, swelling of the abdomen, swelling of the lips and parotid glands, strumous ophthalmia, with an eruption of the favus, and hectical symptoms of long duration. The disease spread from London to the adjacent villages, and was almost universal in Somers Town during the month of February.” It continued throughout the year, and into 1800, being second in importance among the epidemic maladies only to typhus, which, in that time of distress, was the grand trouble of the poorer classes in London. Willan’s reports cease with the year 1800; but it appears from other sources that a very malignant scarlet fever and sore-throat prevailed in London in the summers and autumns of 1801 and 1802, becoming milder in 1803[1322], and in various parts of England during the same three years. The provincial accounts for those years give the impression that this was the first general outbreak for some time, perhaps since the one described by Withering and others in 1778; and that is also suggested by the statistics of the Newcastle Dispensary: in the two first years of its practice, from 1 October, 1777, it treated 146 cases, with 18 deaths; in the next ten years 1779-1789, it treated only 57 cases, with 8 deaths; and from 1790 to 1802, it treated 152 cases, with 7 deaths[1323]. Accounts of very general scarlatina come from various parts of England. In the summer and autumn of 1801 it ran through many parishes of Cornwall, sparing others. In the parish of Manaccan, twelve out of the twenty-five burials in the year 1801 were from scarlatina--the malignant or putrid form, which was often fatal before the third day. In many other cases, the first untoward symptom was the dropsical swelling which came on as the fever went off. Three years after, in 1804, there was much scarlatina in and around Falmouth[1324]. In 1805 it caused 12 in a total of 20 deaths in Revelstoke parish, South Devon.

In Northamptonshire in 1801 it was observed “in a form similar to the epidemic described by Dr Withering[1325].” At Cheltenham in 1802 it was also compared to the epidemic described by Withering: “in consequence of the number of persons who have gone through the disease, it has for this month past (20th December) been gradually on the decline[1326].” At Derby, in 1802, it had been the prevailing complaint in the last eight months of the year[1327]. In the district of Framlingham, Suffolk, in 1802-3, it had proved very malignant and fatal in many families[1328]. It is heard of also from Lancaster[1329], and from various other parts of England, being casually mentioned in reports on the influenza of 1803.

To this period also belong several incidents of a kind that had attended scarlatina from its first appearance, namely, school epidemics of it. One of these was an outbreak in the Quaker boarding-school for boys and girls at Ackworth, in Yorkshire, in 1803. Although many of the children dispersed, yet no fewer than 171, in a total of 298 on the roll, were attacked with scarlatina in the course of four months, of whom seven died[1330]. In the same year Dr Blackburne published a treatise on the preventive aspect of the disease, with directions for checking the spread of it “in schools and families[1331].” It broke out in 1804 among the boys in Heriot’s Hospital, Edinburgh, and in the city generally in 1805[1332]. Ferriar makes mention of a “destructive epidemic of scarlet fever” in Manchester in 1805, which he supposed to have been introduced from Liverpool[1333].

The general prevalence of malignant scarlet fever in the first years of the 19th century is farther shown by the accounts from Ireland, which were recalled by Graves in a clinical lecture of the session 1834-35, during the prevalence of a scarlet fever as malignant as that of thirty years before[1334].