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.
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:
From the month of June, 1778, until the 1st September, 1779, there were treated 146 cases of “ulcerated sore-throat,” of which 18 were fatal. The epidemic was at its height in September and October. The ages were: under ten years, 98, ten to twenty, 25, twenty to thirty, 18, above thirty, 5. Dropsy followed in 23; 75 were mild scarlatina and sore-throat, 33 were angina maligna. During the ten years following, until 1789, only 57 more cases were treated from the Newcastle Dispensary, of which 8 were fatal[1304].
In London, according to Dr James Sims, scarlatina with sore-throat occasioned a great mortality in the latter half of 1786. The bills of mortality assign only 19 deaths to sore-throat, while they give 793 for the year to measles. But Sims says that “measles were not present in London during the whole year; at least I saw none, and I saw about two thousand cases in private and at the General Dispensary.”
The deaths from scarlet fever, he thinks, had been given under measles and also under “fevers,” which were a large total for the year. The epidemic was very virulent, going through families; many lost two children, some a larger number; many adults fell victims to it who were supposed to die of common fever.
Sims’ first case was of a youth at Camberwell, in March, with scarlet rash and sloughs of the throat. He saw no more cases for several weeks, and then, on 1 May, he was called to a case of sore-throat in a school at Hampstead; the illness was slight, and there was no efflorescence; but in June there occurred in the same school an explosion of scarlatina, twenty of the girls being seized within a short time. It was in other suburban villages in the summer, but did not enter London until August, after which Sims saw three hundred cases of it; of some two hundred treated by him in a certain way, only two died. The symptoms of the epidemic were the usual ones of scarlet fever with ulcerated or sloughing throat. In November and December, swelling attacked the face and extremities, which were painful but not oedematous. The parotids were swollen. Several had the angina without the rash; others the rash without the angina[1305].
The same epidemic in London was one of the early medical experiences of Dr Robert Willan, who gave some account of it in the volume ‘On Cutaneous Diseases’ which he published in 1808, shortly before his death[1306]. It began in the autumn of 1785, was superseded by measles for a time, and revived again in 1786, to last into 1787. It was most malignant in the narrow courts, alleys and close crowded streets of London, but existed also in the villages near. While admitting the existence of measles in the winter of 1785-86, he confirms Sims in saying that it was not measles (as in the Bills) but scarlatina that caused the high mortality in 1786: “The cases of scarlatina during the year 1786 exceeded in number the sum of all other febrile diseases within the same period.” The deaths were mostly between the seventh and eighteenth day of the fever. The following is his classification of over two hundred cases seen by himself:
1786
| Scarlatina simplex |
Scarlatina anginosa |
Scarlatina maligna |
Sore-throat without eruption | |||||
| April | — | 3 | — | — | ||||
| May | 6 | 10 | 2 | — | ||||
| June | 4 | 12 | 1 | 4 | ||||
| July | 2 | 11 | 1 | 3 | ||||
| August | 1 | 17 | 4 | 4 | ||||
| Sept. | 2 | 29 | 9 | 12 | ||||
| Oct. | 3 | 24 | 5 | 7 | ||||
| Nov. | 0 | 38 | 12 | 10 | ||||
| Dec. | 0 | 8 | 5 | 2 | ||||
| 18 | 152 | 39 | 42 | |||||
The infirmary book of the Foundling Hospital has long lists of patients sick of “scarlet fever with sore-throat” in August and September, 1787, as many as 76 being under treatment in one week, the next week 39 sick of scarlet fever, besides 45 recovering from it. This is the first unambiguous entry of an epidemic of scarlet fever in the Foundling Hospital records[1307]. Under the same year, 1787, Barker, of Coleshill, records “scarlet fever, smallpox, and chincough” in a neighbouring city, as well as pestilential sore-throats “epidemical everywhere in the terrible foul weather of winter.” His next entry of “scarlet fever and sore-throat” is under the year 1791[1308].
An account by Dr Denman, of London, dated 28 November, 1790, of “a disease lately observed in infants,” but otherwise unnamed, appears to relate to diphtheria. Eight cases in young infants were seen, one per month from April to October, of which six proved fatal. The signs were “thrush in the nose,” fulness of the throat and neck, the tonsils red, swelled, and covered by ash-coloured sloughs or extensive ulcerations. The skin sloughed at places where blisters were applied. Nothing is said of a scarlet rash[1309].
One good observer at the end of the 18th century, Rumsey, a surgeon at Chesham, in Bucks, has left full accounts of two epidemics in his district, one in 1788, which he calls “epidemic sore-throat[1310]” and the other in 1793-94, which he calls “the croup[1311].” The one corresponds to scarlet fever, the other to diphtheria. The author does not think it necessary to enlarge on the distinction between the “epidemic sore-throat” and “the croup” as it was so obvious; yet the former was “Fothergill’s sore-throat,” which some English writers of the present time assume to have been diphtheria; while the disease which Rumsey calls “the croup” corresponds with laryngeal and tracheal diphtheria, not unmixed with diphtheritis of the tonsils, uvula and velum. There is hardly anything in the history of scarlatina and diphtheria more instructive than the juxtaposition of those two excellent descriptions by Rumsey, who grudged the name of scarlatina to the former epidemic because the rash was not invariable, and called the latter by the name of croup although it was not confined to the larynx and trachea, and was epidemic in the summer months.
The epidemic of “sore-throat” in 1788 began in April and lasted until November, attacking those of every age except the very old, but especially children, and mostly women among adults.
The throat was slightly sore for twelve or twenty-four hours; it then became fiery red, the uvula and tonsils being much swelled. About the second or third day there were whitish or yellowish sloughs on the tonsils and uvula, which in many cases left deep, ragged ulcers. It was many days before the sloughs were all exfoliated. Some spat up an astonishing quantity of mucus; in young children there was apt to be a discharge of mucus from the nostrils, and in a few cases from the eyes. The parotid and submaxillary glands were often enlarged, sometimes suppurating or sloughing. A white crust separated from the tongue on the third or fourth day, leaving it raw and red. In some cases there was sickness with vomiting, in some diarrhoea. In many cases there was a scarlet eruption over the whole body, usually on the second or third day. The fatal cases had all a very red eruption, and the skin burning to the touch. In some the eruption was so rough as to be plainly felt. In a few cases, after the efflorescence broke out, a number of little pustules made their appearance about the breast, arms, &c., of about the size of millet seeds, which died away in twenty-four or thirty-six hours. This was not common; but in one family the mother and three of the four ailing children had pustules. One young man had large white vesicles on the sixth day; another young man, in November, had vesicles on the arms, thighs and legs as large as a half-crown piece, filled with yellow serous fluid, or gelatinous substance, with a good deal of erysipelas round them. The red efflorescence was always followed by peeling. Many had the throat-disease without rash, but none had the efflorescence without the sore-throat.
Rumsey decides against two distinct types of disease; it was the same contagion acting on different constitutions; yet he could not help thinking that scarlatina anginosa was an improper term for it, inasmuch as the rash was not constant. It was a less putrid disease than that described by Fordyce in 1773 (supra, p. 707), and carried off but few considering the great numbers who were affected by it. Two of the fatalities in children were from the anasarca of the whole body, with scanty urine, which came on a week or two after. He bled only once, applied leeches to the temples in several, and saw many recoveries with no treatment but topical applications.
The epidemic five or six years after in the same town in a valley of Buckinghamshire and on the hills for some six miles round was something unusual. Rumsey had about forty cases of “the croup” from March, 1793, until January, 1794; whereas his father, who had practised there above forty years, could not recall more than eight or ten cases of “croup” in all his experience. The cases were all in children from one to fourteen years; there were sometimes three attacked in one family; most of the fatal cases occurred in summer; the epidemic was distributed impartially in the valley where Chesham stands and upon the hills enclosing it. Rumsey gives full details of seventeen cases, eight that died and nine that recovered, with post-mortem notes for some.
His first case was in March, 1793; then came a succession of cases about June and July, of which four that proved fatal were in children just recovered from measles. All those earlier cases had the disease coming on insidiously, then the peculiar cough and tone of voice, if any voice remained, paroxysms of choking, expectoration of shreds of membrane, giving relief to the distress, and the trachea found after death lined with a coagulated matter[1312]. Among these summer cases were three children in one family, of whom two died, both being just out of the measles. The later series of cases in the winter of 1793-94 were less often fatal; the epidemic constitution, he says, became less severe towards the end; he also used mercurials freely on the later cases; but it is farther noteworthy that “most of the cases which occurred in November and afterwards, were attended with inflammation and swelling of the tonsils, uvula and velum pendulum palati, and frequently large films of a whitish substance were found on the tonsils”—so that the disease was in its extension more than cynanche trachealis, or croup, even if it had not been also an epidemic infection.
In only one case, the eighth recorded, does he seem to have hesitated between “the croup” and sore-throat: “ulcerated sore-throats being at this time [6 Sept. 1793] somewhat prevalent, induced me to inspect the fauces, and I observed a swelling and no inconsiderable ulcer on the left tonsil.” It was in the autumn and winter that these throat complications of “the croup” mostly appeared; and it was because he found “so much disease about the tonsils” in the tracheal and laryngeal cases that he forebore to bleed, and used mercurials. Also in the same season when “the croup” was joined to disease of the tonsils, uvula and velum, there was a certain epidemic constitution prevalent: “In the autumn, likewise, and winter, many children suffered by erysipelatous inflammation behind the ears, in the groins, on the labia of girls, or wherever the skin folded, attended with a very acrid discharge”—precisely the complication of the “throat-distemper” of America described by Douglass and Colden as well as by Bard, also of the Irish throat-epidemic in 1743 mentioned by Rutty, of the morbus strangulatorius in Cornwall described by Starr, and of the sore-throat described by Fothergill. In systematic nosology, do the corrosive pustules behind the ears, in the groins, labia, &c., belong to scarlatina or to diphtheria?
It is perhaps the same juxtaposition, or intermixture of scarlatina anginosa and diphtheria, that we find in the north of Scotland about the same time of the 18th century. Various parish ministers who contributed to the first edition of the Statistical Account make mention of “the putrid sore-throat” about 1790 and 1791, without any reference to fever or scarlet rash. The following relates to three localities in Aberdeenshire:
New Deer: “In the autumn of 1791, a putrid kind of sore-throat, which first made its appearance about the coast side, found its way into this parish. Since that, it has continued to rage in different places with great virulence and little intermission, and is peculiarly fatal to the young and people of a full constitution[1313].” Crimond, a coast parish: “The putrid sore-throat raged with great violence two or three years ago [1790 or 1791] in most parishes in the neighbourhood, and carried off great numbers: but though a few were seized with it in Crimond, none died of that disorder[1314].” Fyvie, an upland parish:—“There has been no prevalent distemper for some time except the putrid sore-throat, which raged about two years ago [probably 1791] and proved fatal to several people. It has appeared this winter, but is not so violent as formerly[1315].”
From Aberdeen the epidemic is reported in a letter by one of the physicians, in May, 1790, in such terms as not to imply that it was scarlatina: “The malignant sore-throat has been most prevalent and very fatal, no period of life being exempted.” In children from six months to three years there was observed a livid appearance behind the ears which, in seven or eight cases, spread over the external ear, causing the latter on one or both sides to drop off by sloughing before death[1316].
The scarlet fever, with sore-throat, which reappeared in London about 1786-87 (and at Chesham in 1788) is said to have been somewhat steady until 1794. Willan, who began his exact records in 1796, says retrospectively that the scarlet fever with an ulcerated sore-throat had been prevalent every autumn from the year 1785 to 1794, “and proved extremely fatal[1317].” Lettsom gave a particular account of it in the spring of 1793[1318]; it was seen first in the higher villages about London, gradually descended into lower situations, and visited the metropolis pretty generally about the end of February. “It has been remarked for many years that this disease appears in the vicinity of London before it visits the metropolis,” beginning often among the numerous boarding-schools in the suburbs, to be carried thence by the dispersion of pupils to their homes. In some villages private families suffered greatly; in a few Lettsom heard of half the children dying, as well as of deaths among the domestics and other adults. The same epidemic of 1793 also called forth one of the numerous essays of Dr Rowley, who had written on the “malignant ulcerated sore-throat” in 1788[1319].
The history of scarlatina in London, as of most epidemic maladies, is enriched for a few years by Willan’s monthly or quarterly accounts of the cases treated at the Carey Street Dispensary. From the beginning of 1796 to the end of 1800, scarlet fever is hardly ever wanting, and is occasionally the principal epidemic. It is only now and then, however, that a death from it appears in the Parish Clerks’ bills of mortality. Willan remarks that they gave only one death from that cause between the 8th and 29th November, 1796, “a period during which there occurred many fatal cases of that disease.” The bills have only three deaths from it in the quarter 27 Sept.-27 Dec. 1796. The Parish Clerks did not adopt scarlet fever fully into their classification until 1830; long after it had become an important factor in the mortality, they placed the deaths from it under “fevers” or under “measles.” According to Willan’s experience, it must have been as common as measles from 1796 to 1801. It was, he says, always most virulent and dangerous in the month of October and November, but generally ceased on the first appearance of frost. He records a spring epidemic as an exceptional thing in 1797: “Since the beginning of May, the scarlatina anginosa has become more frequent than any other contagious disease, both in town and in many parts of the country; the disease has generally occurred in its malignant and fatal form, which, at this season of the year, is very unusual.” The bills give only one death from 18th April to 18th May. Willan says that it was rife again in the autumn of 1797 and of 1798. Dr James Sims, who had described the scarlatina of London in 1786, found the epidemic in the end of 1798 so different from the former, and attended with so great fatality, that he made it the subject of a second paper[1320]. It was preceded in the winter and spring of 1797-98 by a remarkable epidemic among the cats of London (an angina, with sanious discharge from the nostrils and running at the eyes), which killed “myriads” of them[1321]. In Sept.-Oct. 1798, he heard that a scarlet fever had been fatal to some adults about South Lambeth, and afterwards to several children there, five dying in one family and three in another. The swellings on each side under the jaw were so great as to force the chin up into the horizontal; there was much acrid foetid discharge from the nostrils, the pulse sank about the seventh day, and the scarlet eruption remained out until near death, which took place usually about the ninth or tenth day. Along with this malignant type, a mild or simple scarlatina was also prevalent. Sims wrote when the epidemic seemed to be “in its infancy,” and so it proved; for Willan describes it as prevailing to the end of 1798 and rising still higher in the first months of 1799, his report for February and March being: “Scarlatina anginosa in its malignant form has been very prevalent, and has proved in many instances fatal; and in those who recovered, it produced after the cessation of the fever, anasarca, swelling of the abdomen, swelling of the lips and parotid glands, strumous ophthalmia, with an eruption of the favus, and hectical symptoms of long duration. The disease spread from London to the adjacent villages, and was almost universal in Somers Town during the month of February.” It continued throughout the year, and into 1800, being second in importance among the epidemic maladies only to typhus, which, in that time of distress, was the grand trouble of the poorer classes in London. Willan’s reports cease with the year 1800; but it appears from other sources that a very malignant scarlet fever and sore-throat prevailed in London in the summers and autumns of 1801 and 1802, becoming milder in 1803[1322], and in various parts of England during the same three years. The provincial accounts for those years give the impression that this was the first general outbreak for some time, perhaps since the one described by Withering and others in 1778; and that is also suggested by the statistics of the Newcastle Dispensary: in the two first years of its practice, from 1 October, 1777, it treated 146 cases, with 18 deaths; in the next ten years 1779-1789, it treated only 57 cases, with 8 deaths; and from 1790 to 1802, it treated 152 cases, with 7 deaths[1323]. Accounts of very general scarlatina come from various parts of England. In the summer and autumn of 1801 it ran through many parishes of Cornwall, sparing others. In the parish of Manaccan, twelve out of the twenty-five burials in the year 1801 were from scarlatina—the malignant or putrid form, which was often fatal before the third day. In many other cases, the first untoward symptom was the dropsical swelling which came on as the fever went off. Three years after, in 1804, there was much scarlatina in and around Falmouth[1324]. In 1805 it caused 12 in a total of 20 deaths in Revelstoke parish, South Devon.
In Northamptonshire in 1801 it was observed “in a form similar to the epidemic described by Dr Withering[1325].” At Cheltenham in 1802 it was also compared to the epidemic described by Withering: “in consequence of the number of persons who have gone through the disease, it has for this month past (20th December) been gradually on the decline[1326].” At Derby, in 1802, it had been the prevailing complaint in the last eight months of the year[1327]. In the district of Framlingham, Suffolk, in 1802-3, it had proved very malignant and fatal in many families[1328]. It is heard of also from Lancaster[1329], and from various other parts of England, being casually mentioned in reports on the influenza of 1803.
To this period also belong several incidents of a kind that had attended scarlatina from its first appearance, namely, school epidemics of it. One of these was an outbreak in the Quaker boarding-school for boys and girls at Ackworth, in Yorkshire, in 1803. Although many of the children dispersed, yet no fewer than 171, in a total of 298 on the roll, were attacked with scarlatina in the course of four months, of whom seven died[1330]. In the same year Dr Blackburne published a treatise on the preventive aspect of the disease, with directions for checking the spread of it “in schools and families[1331].” It broke out in 1804 among the boys in Heriot’s Hospital, Edinburgh, and in the city generally in 1805[1332]. Ferriar makes mention of a “destructive epidemic of scarlet fever” in Manchester in 1805, which he supposed to have been introduced from Liverpool[1333].
The general prevalence of malignant scarlet fever in the first years of the 19th century is farther shown by the accounts from Ireland, which were recalled by Graves in a clinical lecture of the session 1834-35, during the prevalence of a scarlet fever as malignant as that of thirty years before[1334].
“In the year 1801,” he says, “in the months of September, October, November and December, scarlet fever committed great ravages in Dublin, and continued its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character; and although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution. The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death (as appears by the notes of Dr Percival kindly communicated to me) so early as the second day. It thinned many families in the middle and upper classes of society, and even left not a few parents childless. Its characters seem to have answered to the definition of the scarlatina maligna of authors.”
The long immunity from malignant scarlatina which Graves asserts for Ireland after 1804, is made probable also for England and Scotland after 1805, by the fewness of the references to it in medical writings. Bateman in 1804 resumed the regular reports on the prevalent diseases of London, which Willan had left off at the end of 1800, and continued them until 1816[1335]; but he makes very few references to scarlatina compared with his predecessor. The two occasions when it is said to have been somewhat common were in 1807-8, during the severe epidemic of measles (and then it was “generally mild, presenting the eruption with a slight sore-throat”), and in 1814 when it was “very prevalent” along with measles. In Scotland during the same epidemic of malignant measles, in 1808, scarlatina was only occasional, and mild. It is heard of in its old malignant form from two localities of England, during the time of distress and typhus fever in 1810-11. At Nottingham it was “very prevalent, passing through whole families,” in September, 1810, and in October became more violent and often fatal[1336]. In the district around Debenham, in Suffolk, where it was last reported by the same observer in 1803, it made its appearance in February, 1810, in its very worst forms, causing deaths of children and adults in many houses, and destroying some children within forty-eight hours from the first attack. “All the surgeons for ten miles round have had to attend to scarlatina maligna in a variety of cases in all ages, from infants to fifty and sixty years.” It was still raging in October, 1810, and was breaking out “in different spots around this country, that appear to have had no communication with the afflicted[1337].”
It is not until 1831 that we begin to hear much of malignant scarlatina again. But it is clear that scarlet fever was common enough all through that interval, probably in its milder form. It was now the usual epidemic trouble of schools. In September and October, 1814, there were fifty-five cases, mostly mild, in children and two in adults in the Asylum for Female Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal Military College at Marlow, having been followed by anasarca in only one instance[1339]. Heysham, whose exact records of epidemics at Carlisle were made twenty or thirty years earlier, mentions casually in 1814 that scarlet fever had been “more frequent of late,” but that it did not spread as formerly[1340]. Other references to it in this interval are to show how seldom fatal it was under the cold water treatment or the lowering regimen[1341]. At the Newcastle Dispensary fully twice as many cases of scarlatina were attended in the twenty-five years 1803-27 (795 cases) as in the twenty-five years 1777-1802 (355 cases); but in the larger total, which an increasing population might account for, there were actually fewer fatalities (30) than in the smaller (33); the highest number in any one year was 71 in 1824, of which every one is entered as having recovered. This is the impression derived from various sources—that the scarlatina from about 1803 until about 1830 may have been frequent, but that it was mild, or easily treated, or not often fatal. Macmichael, writing in 1822, not only testified that the “scarlatina of last summer was very mild,” but argued that the malady in general was taken by many in those years in so mild a form that it was not recognized as scarlatina, “a name that sounds so fearfully in the ears of mothers,” and a rare disease in families compared with measles or even with smallpox. His point is that scarlet fever was in fact as nearly universal as measles, but that, as it was often extremely slight, it passed for rose rash or the like; at the same time he identified these slighter forms with true scarlatina by simply pointing to the oedema which might follow them[1342].
The testimony of Graves, of Dublin, who occupies many pages of his ‘Clinical Medicine’ with the disastrous scarlatina in various parts of Ireland about 1834, is conclusive that the severe type was new in the experience of that generation: