The sickness began about the end of September, 1748, in St Albans and some towns adjacent. At first it attacked children only, afterwards also adults. The symptoms given are just those detailed by Fothergill, as well as by Douglass for New England:
Sickness with purging at the outset, rapid swelling of the tonsils and (or) the parotids and maxillary glands, whitish sloughs on the tonsils, small ulcers up and down the fauces, the eyelids puffed as in measles, swelling of the neck, arms and hands in many, in some swelling of the body also, intense red efflorescence, coming on either suddenly or tardily, with thick spots as if dipped in blood. On the face, neck and breast, the rash was even with the surface, elsewhere it was miliary or shagreen. Some were restless or anxious, and delirious, others so drowsy that when awakened to receive a draught or the like, they relapsed at once into stupor. The attack, if not violent, ended on the fourth or fifth day; there were few in whom the fever did not return on one, two or more evenings thereafter, so going off gradually. In one or two, the parotids swelled after the fever was gone, continuing hard for a fortnight and then suppurating. In nearly all, the cuticle peeled off “as in other scarlet fevers.” In some the nervous system was much shaken; in particular they dreaded the approach of evening with an unusual kind of horror, and started at the shadows of the candles on the wall. In convalescence some complained of universal soreness. The spots where blisters had been applied continued to discharge in some cases eight or ten days or more.
Besides the reference to swelling of the neck, arms or body among the early symptoms, there is no reference to oedema, while the pallid dropsy of convalescence, which Withering described in 1779, is not mentioned. It is noteworthy that Cotton, who lays the emphasis on the scarlatina, and not on the throat-disease, was of opinion that the copiousness of the eruption was not a measure of the security of the patient, although that was clearly the opinion of Huxham and others, who laid the emphasis on the sore-throat.
Epidemics of Sore-throat with Scarlet rash in the period between Fothergill and Withering.
The years 1751-52, and indeed the whole of that decade, saw a good deal of the same diseases, after which little is heard of them until 1778. Huxham’s accounts for Plymouth, which are of the first importance, begin with 1751[1276]. They are of importance because his memory went back to the anginose fever of 1734, in which the miliary eruptions, with sweats, were critical or relieving to the throat, and because he could not clearly distinguish between them and the sore-throats of 1751-52, although he follows Fothergill in identifying the latter with the Spanish garrotillo. The throat affection began in the end of 1751, and became most severe in October, November and December, 1752, in Plymouth and at the Dock and all around, carrying off a great many adults as well as children. It ceased in May, 1753. He describes the sloughing patches in the throat, the excoriated nostrils with acrid dripping discharge, the swelling of the parotids and sometimes of the whole neck, just as other writers had done; and gives the account of laryngeal or tracheal membranes already cited (p. 695). It is perhaps more important to dwell upon his account of the rash. Most commonly the angina came on before the efflorescence, but in many instances the cuticular eruption appeared before the sore-throat. “A very severe angina seized some patients that had no manner of eruption, and yet even in these a very great itching and desquamation of the skin sometimes ensued; but this was chiefly in grown persons, very rarely in children.” Commonly there was a rash, general or partial, on the second, third or fourth day.
“Sometimes it was of an erysipelatous kind, sometimes more pustular; the pustules were frequently very eminent, and of a deep fiery-red colour, particularly in the breast and arms, but oftentimes they were very small and might be better felt than seen, and gave a very odd kind of roughness to the skin. The colour of the efflorescence was commonly of a crimson hue, or as if the skin had been smeared over with the juice of raspberries, and this even to the fingers’ ends; and the skin appeared inflamed and swollen, as it were; the arms, hands and fingers were often evidently so, and very stiff and somewhat painful. This crimson colour of the skin seemed indeed peculiar to this disease.” The eruption seldom failed to give relief; but there were also cases of an universal fiery exanthem which proved fatal. An early and kindly eruption, when succeeded by a very copious desquamation of the cuticle, was one of the most favourable symptoms.
Comparing it with the febris anginosa which he had entered in his annals under the year 1734, at a time when the ulcerous or malignant sore-throat was still unheard of, he says that the earlier type differed from the later in being more inflammatory, and less putrid; the sore-throat of 1751-52 might seem to be a disease sui generis, but it differed from the anginose fever of 1734 only in the above respect: “In a word, the high inflammatory smallpox differs as much, or more, from the low malignant kind, as the febris anginosa from the pestilential ulcerous sore-throat.” In the latter he found the remarkable evidences of putridity already cited in connexion with putrid fevers[1277]. He gives the case of a boy of twelve whose tongue, fauces and tonsils were as black as ink; he swallowed with difficulty, and continually spat off immense quantities of a black, sanious and very foetid matter for at least eight or ten days; about the seventh day, his fever being abated, he fell into a bloody dysentery, but recovered eventually. In a few the face before death became bloated, sallow, shining and as if greasy, and the whole neck swollen. Even the whole body might be oedematous in some degree, retaining the impression of the finger.
Perhaps it may be said that Huxham had really to do with two diseases; and he does in one place say: “The anginose fever still continued, and we had several of the malignant sore-throats in September, many more in October, &c.”—as if the two were not the same. But he generalized the “epidemic constitution” of 1751-52, in another way: “In all sorts of fevers there was a surprising disposition to eruptions of some kind or other, to sweats, soreness of the throat and aphthae. The smallpox were more fatal in August, and sometimes attended with a very dangerous ulceration in the throat and difficulty of swallowing. Indeed the malignant ulcerous sore-throat was now also frequent, probably sometimes complicated with the smallpox.” Even pleuritic and peripneumonic disorders were attended during this constitution with a sore-throat, aphthae, and some kind of cuticular eruption.
Some facts about the throat-disease at Kidderminster and other places in Worcestershire will complete this part of the somewhat perplexing history. Dr Wall says it appeared about the beginning of 1748 chiefly in low situations[1278]: “It then went generally under the name of scarlet fever, the complaint in the throat not being much attended to, or at least looked upon only as an accidental symptom.” His first cases were at Stratford-on-Avon—a young lady who recovered with difficulty, and then two sisters who died, all three having been treated by blood-letting and the cooling regimen. By these cases Wall was convinced that the disease was more putrid than inflammatory, that it was infectious, that the antiphlogistic treatment was a mistake, that bark was the grand remedy, that the throat was the principal seat, and that the scarlet efflorescence was rather an accidental symptom than essential to the disease, some having petechiae and purple spots. He adopts Mead’s name of angina gangraenosa. The malady had been rife in the city of Worcester, and most of all at Kidderminster, where it was in a manner epidemical. He was told that nine or ten poor persons had died of it there one after another. Having been called to the child of a respectable tradesman, he treated the case with bark and the cordial regimen. He persuaded the Kidderminster surgeons and apothecaries to adopt the same method, which they did with such success that, as he found afterwards in the books of one of them, there were only 7 deaths in 242 cases of the disease, while Dr Cameron did not fail once, and Wall himself had fifty recoveries and only two deaths. It is said, however, on the authority of the parish register, that a hundred persons died at Kidderminster of the malignant sore-throat in 1750, “in the months of October and November only[1279].” Dr Wall goes on to say that the “Kidderminster sore-throat” had a vast variety of symptoms, the only certain ones being aphthous ulcers and sloughs on the tonsils and parts about the pharynx. “Very few here [which may mean Worcester] have had the scarlet efflorescence on the skin.” Dr Johnstone, senior, confirms this in a measure for Kidderminster[1280]: “The anginous fever was not always, though often, attended with cutaneous eruptions; and these, for the most part red, were sometimes also of the christalline miliary kind.” And in writing again in 1779, when Withering’s scarlet fever was dominant in place of Fothergill’s sore-throat, Dr Johnstone said: “A scarlet eruption was a much more frequent symptom of this disease than it used to be when I first became acquainted with it nearly thirty years ago.” But, as it is known that the rash of true scarlet fever is far less constant in adults than in children, and as many of the attacks referred to by Wall and Johnstone were in adults, the so-called Kidderminster sore-throat may have been a fairly uniform scarlatina. Still, it is clear that all the leading writers, excepting Cotton, of St Albans, distinguished between sore-throat (gangrenous, malignant, or ulcerous) and scarlatina, identifying the former with the old garrotillo of Spain and Italy[1281]. The distinction may have been really between scarlatina simplex and scarlatina anginosa, as Willan believed; but whether the disease were malignant scarlatina, or diphtheria, or a mixture of the two (as in Cornwall), or an undifferentiated type with the characters of both, it was certainly new as a whole to British experience in that generation, and, if we except the reference by Morton to certain cases which may have been sporadic, it was a disease hitherto unheard of in England since systematic medical writings began. We may realize the impression which it made, both in the American colonies and in England in the middle third of the 18th century, by recalling the sudden appearance of diphtheria some thirty-five years ago; but, whereas the diphtheria of 1856-58 came upon a generation of practitioners who had seen much of the very worst kinds of scarlatina for twenty years or more, the contemporaries of Huxham, Letherland, Fothergill, Johnstone and Wall in England, or of Douglass, Colden and Bard in America, knew no scarlet fever but scarlatina simplex. The outbreaks of the 18th century throat-distemper in certain families were of the same tragic kind as diphtherial outbreaks in our own time. Instances of whole families swept away have been cited from the New Hampshire epidemic of 1735. Horace Walpole gives the following instance of a noble family in London:
“There is a horrid scene of distress in the family of Cavendish; the Duke’s sister, Lady Bessborough, died this morning of the same fever and sore throat of which she lost four children four years ago. It looks as if it was a plague fixed in the walls of their house; it broke out again among their servants, and carried off two a year and a half after the children. About ten days ago Lord Bessborough was seized with it and escaped with difficulty; then the eldest daughter had it, though slightly: my lady attending them is dead of it in three days. It is the same sore throat which carried off Mr Pelham’s two only sons.... The physicians, I think, don’t know what to make of it[1282].”