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].