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.