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: