It was in 1754, the very next year after Colden wrote as above, that the second great epidemic of throat-distemper arose in New Hampshire and the neighbouring parts of Massachusetts. The figures of its mortality which have been preserved for the town of Hampton, New Hampshire, may serve as a sample of its prevalence subsequent to the original explosion of 1735-36. In the first epidemic, 1735-36, there died at Hampton of the throat-distemper, 55 persons, mostly children. In the second, from January 1754 to July 1755, there died of it 51 persons. The deaths from all causes in those two years were 85, and the births 70.

The following table shows the proportion of deaths from throat-distemper to the deaths from all causes in Hampton from 1735 to 1791[1263].

It was once more described, for New York city, by Dr Samuel Bard in 1771[1264]. He identifies it with the disease described by Douglass in 1735, and gives an account of it on the whole like Colden’s.

The last time of its general spreading (within the period covered by Belknap’s History of New Hampshire, 1791) was in 1784-85-86 and -87. It was first seen at Sandford in the county of York, and thence diffused itself very slowly through most of the towns of New England; but its virulence and the mortality which it caused were comparatively small[1265].

Angina maligna in England from 1739.

Although there had been an extensive prevalence of angina with miliary or scarlet or erysipelatous rash in Devon and Cornwall in 1734 and following years, a slight amount of sore-throat with scarlet fever in and near Edinburgh in 1733, a great prevalence of throat-distemper with scarlet or miliary rash in the North American colonies in 1735-37, and an ill-favoured erysipelatous quinsy as well as an anomalous scarlet fever in Barbados, St Christopher, &c., during the same period, yet it was not until the end of the year 1739 that cases more or less similar occurred in London. The incident that first drew attention to the throat-distemper in the capital was the death of the two sons of Henry Pelham, the colleague of his relative the Duke of Newcastle in the premiership[1266]. Horace Walpole, writing twenty years after concerning similar calamities in the family of the Earl of Bessborough, says that not only Mr Pelham’s two sons, but also two daughters and a daughter of the Duke of Rutland all died together. Chandler, writing in 1761, says that he well remembered the disease at the end of 1739. Early in 1740 he had in his own practice as an apothecary two cases of children sick in one family; the first died, and as he was at a loss to account for the death, there being “something in the whole of the case quite new and unknown to me,” he called in Dr Letherland to see the other, who declared that the child would die also, as it did. Letherland then spoke to Chandler of the death of the two Pelhams shortly before, “of the alarm it caused all over this great city, both from its novelty and fatality,” and of his own care and pains in turning over ancient and modern writers to see if he could trace any footsteps of this remarkable and terrible disease: at last, after long search, he had been so happy as to discover the identical disease circumstantially described in the Spanish writers[1267].

The identification of the English throat-distemper of the 18th century with the garrotillo of Spain in the 16th and 17th centuries was thus undoubtedly due to Letherland, so far as English learning was concerned, and he received due credit for it in the Harveian Oration at the College of Physicians on the first occasion after his death[1268].

Chandler thus described the state of the disease at its first breaking out in 1739:

Fothergill, whose name is so closely associated with the outbreak of gangrenous sore-throat a few years after, makes little of the earlier epidemic in London; besides the cases in the Pelham family and some others in the same part of the town, there were, he says, very few observed, so that “the disease and the remembrance of it”—including Letherland’s priority—“seemed to vanish altogether.” The winter of 1739-40, in which these cases had occurred, was one of intense frost and the beginning of a two years’ sickly period in which typhus in Britain, dysentery and typhus in Ireland, reached a height unprecedented in the 18th century.

An epidemic of Throat-disease in Ireland, 1743.

In Ireland the dysenteries, typhus and relapsing fevers, attendant on and following the famine, were hardly over when the plague of the throat began among the children. It was seen first in the summer of 1743 (an influenza having preceded in May and June), it raged through the autumn and winter, and was not extinct for many years after. There were but few instances of it in Dublin, but it was prevalent in the adjoining counties, and exceedingly so in Wicklow, Carlow, Queen’s County, Kilkenny, Cavan, Roscommon, Leitrim, Sligo “and perhaps many others, carrying off incredible numbers, and sweeping away the children of whole villages in a few days.” The country doctors, who knew most of it, were not apt to record their experiences; so that the following account, which Rutty extracted from Dr Molloy, is all the record that remains of an epidemic concerning which one would wish to have known more[1269]:

While there is little in this account to suggest the malignant sore-throat, and no mention of a miliary or scarlet rash, yet Rutty made no doubt that it was the malignant angina, comparing it rather to that described by Starr for Cornwall in 1748 than to that of Fothergill’s description. He adds, from some other source of information, that children had generally clammy sweats upon them, with foetor of the breath. Many died in twenty-four hours; none lived above five days. Some had tumours behind the ears, which mortified. Many had a prodigious weeping behind the ears, which was very corrosive. A case is given of a child recovering after a profuse sweat, which suggested diaphoretic treatment by warm baths and sack-whey. Swellings of the tonsils and uvula were not observed.

Malignant Sore-throat in Cornwall, 1748.

Dr Starr, of Liskeard, calls the Cornish throat-disease the Morbus Strangulatorius. Writing in January, 1750, he said it had raged in several parts of Cornwall “within a few years,” with great severity[1270]: “Many parishes have felt its cruelty, and whole families of children been swept off: few, very few, have escaped.” Cases given by himself belong to the year 1748; and Huxham, who did not meet with it at Plymouth until 1750-51, says that it had been raging with great fatality for a year or two before in and about Lostwithiel, St Austel, Fowey and Liskeard. In the account of the Cornish epidemic the emphasis falls upon the affection of the larynx and trachea; while there are so many other symptoms enumerated, including eruptions and brawny swelling of the neck, that it is clearly impossible to distinguish between exanthematous fever with sore-throat and laryngeal diphtheria pure and simple. Starr says: “Dr Fothergill’s sore-throat with ulcers and Dr Cotton’s St Albans scarlet fever are, in my opinion, but its shadows.”

The symptoms generally pointed to the glottis.

When Huxham came to describe the disease at Plymouth a year or two later, he laid the emphasis on other symptoms than those mostly dwelt upon by Starr, describing really a sloughing sore-throat with rash. But he has this also: “The windpipe itself was sometimes much corroded by it, and pieces of its internal membrane were spit up, with much blood and corruption; and the patients lingered on for a considerable time, and at length died tabid.”

Fothergill’s Sore-throat with Ulcers, 1746-48.

Meanwhile we have to overtake Fothergill’s history of the ulcerous sore-throat in or near London[1271]. It broke out at Bromley, near Bow, Middlesex, in the winter of 1746 (Short says that it was in Sheffield in 1745). So many children died suddenly, some losing all and others the greater part of their families, that people were reminded of the plague.

Such is the main outline; the following symptoms have less general value.

That is the only reference to a possible diagnosis of scarlet fever in the whole essay. In the New England throat-distemper of 1735, “scarlet fever” was in like manner the name given by the laity, and disapproved by the profession. Fothergill, adopting the erudition of Letherland, identified the ulcerous or gangrenous sore-throat of London in 1746-48 with the garrotillo of Spain in the 16th and 17th centuries, the famous throat-plague of Naples and other places in Italy and Sicily from 1618 onwards, and the “plague in the throat” mentioned by a traveller, Tournefort, in 1701 as occurring among children in the island of Milo, (Douglass having already identified the Levantine plague in the throat with the throat-distemper of New England in 1735.)

After the outbreak at Bromley and Bow in the winter of 1746, the ulcerous, or putrid or gangrenous angina continued in London and the villages near until the date of Fothergill’s writing (1748). By credible accounts, he says, it was also “in several other parts of this nation.” Short, of Rotherham, a professed epidemiologist, says that the malignant angina “never left Sheffield entirely since the year 1745[1273].” Fothergill himself, in his monthly accounts of the weather and diseases of London from 1751 to 1755, refers to the sore-throat once or twice; thus, in October, 1751: “epidemic sore-throat, in both children and adults”; and again, in July, 1755: “The ulcerated sore-throat likewise appears in many families, with the greatest part of its usual symptoms, but gives way without much difficulty, if no improper evacuations have been made, to the method heretofore recommended (XXI. 497)[1274].”

“Scarlet Fever” at St Albans, 1748.

The same disease that Fothergill described for London and villages near was seen at St Albans in the autumn of 1748, and described as “a particular kind of scarlet fever,” by Dr Nathaniel Cotton, who kept a madhouse there. Among his friends were the poet Cowper (at one time his patient), and Young, of the ‘Night Thoughts.’ Cotton himself had the same melancholy cast of mind, and found the same solace in making verses, which have probably served more to keep his memory green than his essay in medicine[1275]. He professes to describe “a particular kind of scarlet fever” in his title-page; and in the text he has this remark: “From this diversity of symptoms, I have found some practitioners inclined to think that this disease could not with propriety be called a scarlet fever. But I imagine that such disputes are about words only.” It is, indeed, difficult to find any real difference between his particular kind of scarlet fever and the “sore-throat with ulcers” which Fothergill wrote upon a few months before, or, again, between his scarlet fever and that of Withering thirty years after.

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:

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.

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:

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:

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].