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.