CHAPTER VII.

SCARLATINA AND DIPHTHERIA. Scarlatina and diphtheria have to be taken together in a historical work for the reason that certain important epidemics of the 18th century, both in Britain and in the American colonies, which were indeed the first of the kind in modern English experience, cannot now be placed definitely under the one head or the other, nor divided between the two. It may be that this ambiguity lies actually in the complex or undifferentiated nature of the throat-distemper at that time, or that it arises out of the contemporary manner of making and recording observations upon the prevalent maladies of seasons. The older or Hippocratic method was not unlike the mason’s rule of lead, said to have been in use in the island of Lesbos for measuring uneven stones; it took account of gradations, modifications, affinities, being careless of symmetry, of definitions or clean-cut nosological ideas, or the dividing lines of a classification. Sydenham was the great English exponent of this method; but, in one of his more discursive passages, he sketched out another method of describing diseases as if they were species or natural kinds[1247]. He did no more than indicate this analogy, at the same time declining to put it in practice; so that Sauvages correctly described his great Nosology of 1763 as being constructed “juxta Sydenhami mentem et Botanicorum ordinem.” The identification of scarlatina in its modern sense, including scarlatina simplex and scarlatina anginosa, falls really in the time of the nosologies in the generation following the work of Sauvages, although both the name and definition in the modern sense were used in England as early as 1749. On the other hand, the name and definition of diphtheria were little known until about the years 1856-59, when the form of throat-distemper which is now quite definitely joined to that name became suddenly common, having been almost unheard of for at least two generations before. The only English writer who has attempted to unravel the accounts of the 18th century epidemics of throat-disease was Dr Willan in his unfinished work on Cutaneous Diseases, 1808; he swept the whole of those epidemic types into the species of scarlatina, to which also he reduced the great Spanish epidemics of “garrotillo” in the 16th and 17th centuries. Whether he would have used so summary a method if he had seen the sudden return of diphtheria in 1856, may well be doubted; at all events the German writers who brought their erudition to bear upon the question of identity some thirty years ago have discovered true diphtheria among the 18th century throat-distempers, although no two of them agree as to which of these should be called diphtheria and which scarlatina anginosa. It is one advantage of a historical method that the complexities of things may be stated just as they are, with due criticism, naturally, of the matters of fact and of the relative credit of observers. The result is more an impression than a logical conclusion,--an impression which will take a colour from the pre-existing views or theoretical preferences of individual readers on such points as fixity of type or the incompetence of the earlier observers. An author who has puzzled over these difficulties in detail can hardly help having a tolerably definite impression of the real state of the case; and I do not seek to conceal mine, namely, that scarlatina anginosa and diphtheria were not in nature so sharply differentiated in the 18th century as they have been since 1856. The significant name of _pestis gutturuosa_ or plague of the throat is given by the St Albans chronicler to the great pestilence, or some part of it, in 1315-16, during one of the worst periods of famine and murrain in the whole English history. But those two words being all that we have to base upon, there is no use speculating whether the disease was scarlatina anginosa, or diphtheria, or something different from either. This is perhaps the only reference to an epidemic throat-distemper in England for several centuries in which bubo-plague was the grand infection. In the popular medical handbooks of the Tudor period one naturally looks for scarlatina among the diseases of children. In Elyot’s _Castel of Health_ (1541), “the purpyles” is mentioned among children’s maladies in company with smallpox and measles, and the same name is in the London bills of mortality from their beginning in 1629, although it does not appear whether the deaths assigned to it were of children or adults. Perhaps the most common use of purples in the 17th and 18th centuries was for a form of childbed fever often attended with discoloured miliary vesicles. In Scotland, according to Sibbald (1684), “the fevers called purple” were any fevers, even measles or smallpox, in which livid or dark spots occurred as an occasional thing. Unless a few scarlatinal deaths are included under “purples” in the London bills (they could not have been many in any case), there is no other evidence of their existence until 1703, when the entry of scarlet fever appears for the first time, with seven deaths to it in the year. The heading remains in the bills until 1730 (the deaths never more than one figure), after which it is merged with fevers in general. The same indications of the insignificance of scarlatina among the causes of death in the 17th century may be got from the medical writers in London. Sydenham introduced into the third edition (1675) of his _Observationes Medicae_ a short chapter entitled “Febris Scarlatina[1248].” It was a disease that might occur at any time of the year, but occurred mostly in the end of summer, sometimes infesting whole families, the children more than the elders. It began with a rigor, as other fevers did, the malaise being but slight. Then the whole skin became interspersed with small red spots, more numerous, broader, redder and less uniform than in measles; they persisted for two or three days and then vanished, and, as the cuticle returned to its natural state, there were successive desquamations of fine branny scales, which he compares elsewhere to those following the measles of 1670. Sydenham took it to be a moderate effervescence of the blood from the heat of the summer just over, or from some such excitement. It was a mild affair, not calling for blood-letting nor cardiac remedies, and requiring no other regimen than abstinence from flesh and spirituous liquors, and that the patient should keep in doors, but not all day in bed. The disease, he says, amounted to hardly more than a name (_hoc morbi nomen, vix enim altius assurgit_); but it appears that it was sometimes fatal; and in those cases Sydenham was inclined, after his wont, to blame the fussiness of the medical attendant (_nimia medici diligentia_). If convulsions or coma preceded the eruption, a large epispastic should be applied to the back of the neck and paregoric administered. Whether Sydenham was describing true scarlatina simplex, or a “scarlatiniform variety of contagious roseola,” it is from him that we derive the name of scarlatina by continuous usage to the present time[1249]. A few years after Sydenham had thus described scarlatina, Sir Robert Sibbald, physician and naturalist of Edinburgh, professed to have discovered the same as a new species of disease. “Just as the luxury of men,” he says, “increases every day, so there grow up new diseases, if not unknown to former generations, yet untreated of by them. Nor is this surprising, since new depravations of the humours arise from unwonted diets and from various mixtures of the same. Among the many diseases which owe their origin to this age, there has been most recently (_nuperrime_) observed a fever which is called _Scarlatina_, from the carmine colour (named by our people in the vernacular _scarlet_) with which almost the whole skin is tinged. Of this disease the observations are not so many that an accurate theory can be delivered or a method of cure constructed.” He proceeds to append one case--a child of eight, daughter of one of the senators of the College of Justice, who fell ill with redness of the face (thought at first to indicate smallpox coming on), became delirious and restless, then had the redness all over, which disappeared and left the child well about the fifth day. He had heard from some of his colleagues that the scarlet rash was sometimes interspersed with vesicles--perhaps the _miliaria_ so much in evidence a generation or two later. In adults, Sibbald had seen the cuticle fall from nearly the whole body. But extremely few (_paucissimi_) had died of this fever. Like Sydenham, he omits to mention sore-throat and dropsy[1250]. Another 17th century reference is by Morton, who practised in London, in Newgate Street, from about 1667 to the end of the century, and was frequently called to consult with apothecaries or other physicians in cases of sickness in middle-class families. In the second volume of his _Pyretologia_, published in 1694, he has a chapter “De Morbillis et Febre Scarlatina,” and a separate chapter “De Febre Scarlatina.” His position towards scarlet fever is peculiar. He uses the name, he says, in deference to the common consent of physicians, but, for his own part, he thinks scarlatina different from measles only in the form of the rash, so-called scarlatina being confluent measles just as there is a confluent smallpox. Except in that sense he sees no reason for retaining scarlatina in the catalogue of diseases. Both arise from the same cause, both have hacking cough, heaviness of the brain, sneezing, diarrhoea; the single difference is that in scarlatina the rash is continuous. He gives eleven cases, most of which are clearly enough cases of measles; but the fourth case, that of his own daughter, Marcia, aged seven, in 1689, “in quo febris dicta Scarlatina, tempore praesertim aestivo, quadantenus publice grassabatur,” had no cough, nor redness of the eyes, nor diarrhoea, nor any other catarrhal symptoms (such as her sister had in 1685), but on the fourth day a continuous scarlet rash over the whole skin, which ended, not in a desquamation of fine branny scales, but in parchment-like peeling. The eleventh instance is complex enough to show that Morton had some reason, at that early stage in the history of scarlatina, for hesitating to make the disease a distinct type under a name of its own. About midsummer, 1689, he was called to the house of his friend Mr Hook, merchant, of Pye Alley, Fenchurch Street, and found the whole household, three young girls, one little boy, and their aunt Mrs Barnardiston, a matron aged seventy, all suffering from the effects of some infection of as deleterious a kind as synochus, the symptoms being hacking cough, coma, delirium, and other signs of malignity. But on the 4th, 5th, or 6th day, each had a scarlatinal rash all over the skin, which lasted until the 7th, 8th or 10th day. Two of the girls, and the boy, had “on the 4th or 5th day of the efflorescence” extensive parotid swellings, difficulty of swallowing, vibrating arteries, and other urgent symptoms, for which they were blooded. The parotid abscesses burst, and discharged a copious acrid, corrosive pus by the nostrils, ears and throat, for the space of thirty days, during which the patients gradually got well. The third girl had, on the 3rd or 4th day of the rash, a painful swelling in the left armpit, not unlike a bubo; she also was blooded, and recovered completely, the swelling having broken and discharged pus for many days. The case of the aunt, aged seventy, was somewhat different; she neglected her medicines, acquired a “carcinoma” or slough over the pubes, which became gangrenous, recovered with difficulty, and lived three years longer. Morton calls these cases a veritable _pestis_ or plague; and he goes on in the same context to say: “what swellings have I seen of the uvula, fauces, nares, and how protracted! At other times, what turgid lips, covered with sordid crusts and ulcerated!”--instancing the child of Mr Blaney, who had these symptoms long after the efflorescence, together with fever and coma[1251]. These cases, all given under the eleventh history illustrating the chapter on Scarlatina, are perhaps not different from those which Huxham, next in order, described in 1735, but not under the same name. It would appear from a reference in Hamilton’s essay on Miliary Fever, published in 1710, that scarlet fever continued to be seen in London: “If, in a scarlet fever, miliary pustules should arise, dying away with a red colour, they promise safety[1252].” Several of the annalists of epidemic constitutions agree as to fatal anginas in the year 1727, with an exanthem of the miliary kind. Wintringham, of York, mentions the two things apart--in one place a putrid fever with cutaneous eruptions of a fuscous colour, sometimes dry, sometimes filled with a clear serum; in another place, “about this time many anginas were prevalent, attended with extreme suffocation, which proved fatal unless they were speedily relieved.” He mentions the same putrid fever in the summer of 1728, and again anginae. Hillary, who was then at Ripon, gives the same fever in 1727 (or perhaps in 1726) with miliary eruption, and chronicles “a fatal suffocative quinsey” in the winter of 1727-28, of which many died, especially those that had been reduced by the fever. Huxham’s account of an epidemic malady of the throat and neck at Plymouth in January and February, 1728, might relate to mumps (which Hillary and an Edinburgh observer describe clearly enough under 1731); and under October, 1728, he describes an erysipelatous and petechial fever, often relieved by an eruption of red miliary vesicles accompanied by sweats, the same miliary fever being again common in the autumn of 1729. This association of “putrid” fever with sore-throat became still more notable in the period 1750-60. These anginas of 1727-28 are unimportant compared with the outbreak a few years later. We hear first from Edinburgh in June, 1733, of scarlet fever and sore throats frequent in several parts of the country near the city, and continuing all through the summer into the winter and spring of 1734[1253]. Then in April, 1734, begins a series of important notes by Huxham at Plymouth[1254]. In that month, he says, there began a certain anginose fever (“for so I shall call it”), raging more and more every day. It mostly affected children and young people. Among other symptoms were vomiting and diarrhoea, pain and swelling of the fauces, languor, anxiety, delirium or stupor, a favourable issue being attended with sweats and red pustules. In May it was raging worse, with more severe angina and most troublesome “aphthae.” In June it was now miliary-pustular, and not seldom erysipelatous, while the throat was “less oppressed.” On the 6th or 7th day the cuticle looked rough and broken as if thickly sprinkled with bran; at length the whole desquamated--sometimes the entire skin of the sole of the foot coming off. The more copious the rash, the better the chance for life. It was contagious, affecting several in the same house. In July it cut off several within six days of the onset. Huxham’s references to this putrid miliary fever in Devon and Cornwall go on for some time, without farther mention of the throat complication. In April, 1735, “raro nunc adest strangulans faucium dolor, paucaeque nunc erumpunt pustulae.” But, in September, 1736, he enters again, “febres miliares, scarlatinae, pustulosae,” often attended with swelling of the parotid glands and of the fauces, and with profuse sweats. The most important scene of fatal angina with rash in the same period (1734-35) was the North American colonies. Before coming to that remarkable outburst, I shall mention one curious coincident outbreak in the island of Barbados. Dr Warren, who occupies his pen chiefly with yellow fever, says[1255]: “In this space of time [1734 to 1738], there arose here a few other diseases, that were really epidemical and of the contagious kind too, few escaping them in families where they had once got a footing. The first was an obstinate and ill-favour’d erysipelatous quinsey. The second a very anomalous scarlet fever, in which almost all the skin, even of the hands and feet, peeled off,”--just as Huxham described for Devonshire. It is beyond our purpose to include the evidence from foreign countries; but it may be noted in this context that Le Cat, in tracing the antecedents of the great Rouen fever in his paper of 1754, refers to many fatal anginas in that city about twenty years before[1256]. Thus we find about the year 1735 evidence of the beginning of a remarkable “constitution” of throat-disease both in the old world and in the new. But the facts in America stand out with peculiar prominence, and shall be given on the threshold of the subject as fully as possible. The Throat-distemper of New England, 1735-36. The accounts of the great wave of “throat-distemper” that spread over the towns and villages of New England in 1735 are singularly clear and even numerically precise. The arrival of this sickness is one of the most definite incidents in the whole history of epidemics; it was hardly possible for the common belief, whether popular or professional, to have been mistaken about it. Just a hundred years had passed since the first settlement of the Puritans on Massachusetts Bay and along the Connecticut river; Boston had grown to a town of some 12,000 inhabitants, and many small towns and townships had sprung up along the coast and in the interior. The population was still sparse, although it was growing rapidly from within; it is difficult to believe that even the largest towns could then have deserved the strictures which Noah Webster passed upon them two generations later[1257]. In the mother country at that time, smallpox was the great infectious malady of infancy and childhood. It was not unknown in the colonies, Boston having had epidemics in 1721, 1730 and 1752, and Charleston an epidemic in 1738 after an almost free interval of thirty years. Even in the chief cities of the colonies such epidemics were only occasional, affecting adults and adolescents perhaps more than infants and as much as children; while in such a town as Hampton, for which the register was well kept from 1735, it is known that there were no smallpox deaths in the twenty years following, or until the period 1755-63, when four died of the disease, and that only one death from it occurred in the next recorded period of ten years, 1767 to 1776. It was in these circumstances of a growing population, almost untouched, at least in the inland towns, by the great infantile infectious malady of the old country, that the throat-distemper broke out and raged in the manner now to be described. The disease “did emerge,” as Douglass says, on the 20th of May, 1735, at Kingston township, some fifty miles to the east of Boston[1258]. The first child seized died in three days; in about a week after three children in a family some four miles distant were successively seized, and all died on the third day; it continued to spread through the township, and Douglass was informed that of the first forty cases none recovered. It was vulgarly called the “throat illness” or “plague in the throat.” Some died quickly as if from prostration, but most had “a symptomatic affection of the fauces or neck: that is, a sphacelation or corrosive ulceration in the fauces, or an infiltration and tumefaction in the chops and forepart of the neck, so turgid as to bring all upon a level between the chin and sternum, occasioning a strangulation of the patient in a very short time.” In August it was at Exeter, a town six miles distant, but it did not appear at Chester, six miles to the westward, until October. After the first fatal outburst in Kingston township it became somewhat milder; but in the country districts of New Hampshire it was fatal to 1 in 3, or 1 in 4 of the sick, and in scarce any place to less than 1 in 6. This average was made up by its excessive fatality in some families; Boynton of Newbury Falls lost his eight children; at Hampton Falls twenty-seven died in five families. The following table, compiled by Fitch, minister of Portsmouth, shows the deaths from it in various towns and townships of New Hampshire during fourteen months from May, 1735, to 26 July, 1736, with the ages[1259]: _Deaths from the throat-distemper in 14 months, 1735-36_ (Fitch). Under Ten to Twenty Thirty Above ten years twenty to thirty to forty forty Total Portsmouth 81 15 1 -- 2 99 Dover 77 8 3 -- -- 88 Hampton 37 8 8 1 1 55 Hampton Falls 160 40 9 1 -- 220 Exeter 105 18 4 -- -- 127 Newcastle 11 -- -- -- -- 11 Gosport 34 2 -- -- 1 37 Rye 34 10 -- -- -- 44 Greenland 13 2 3 -- -- 18 Newington 16 5 -- -- -- 21 Newmarket 20 1 -- 1 -- 22 Stretham 18 -- -- -- -- 18 Kingston 96 15 1 1 -- 113 Durham 79 15 6 -- -- 100 Chester 21 -- -- -- -- 21 --- --- --- --- --- --- 802 139 35 4 4 984 The meaning of these figures in the townships of New Hampshire will appear from the case of Hampton. In the year 1736 its burials from all causes were 69, and its baptisms 50; while the throat-distemper alone, during fourteen months of that and the previous year, cut off 55. As we have seen, Hampton had no smallpox to ravage its children; but the throat-disease of 1735-36 had almost the same effect as the occasional disastrous epidemics of smallpox had upon English towns of a corresponding population or annual average of births. This plague in the throat attacked the children of the most sequestered houses, especially those situated near rivers or lakes. It was least fatal to those who lived well, both Douglass and Colden assigning the salt diet, and other things likely to produce _psora_, as the reason of its greater severity. In the country districts or townships, in which the fatalities were most numerous, it would appear that an eruption, scarlet or other, was not only not the rule but even something of a rarity. Douglass, who was familiar with the exanthem in the Boston cases, assigns its absence in the country to a mistaken evacuant treatment, by which “the laudable and salutary cuticular eruption has been so perverted as to be noticeable only in a few, and in these it was called a scarlet fever.” When the disease broke out in due course at Boston it proved much less malignant than in the country. The first case, on the 20th August, had white specks in the throat and an efflorescence of the skin. A few more soon followed in the same locality, of which none were fatal; they had soreness in the throat, the tonsils swelled and speckt, the uvula relaxed, a slight fever, a flush in the face and an erysipelas-like efflorescence on the neck and extremities. The first death was not until October, the disease becoming more frequent and more fatal in November, and reaching its worst in the second week of March, when the burials from all causes rose to 24, the average per week in an ordinary season being 10. The fatalities in Boston were so few for the enormous number of cases that many could scarce be persuaded that it was the same disease as in the Townships. In the corresponding weeks (1 Oct. to 11 May) of eight ordinary years preceding, the average deaths were 268, whites and slaves; during this sickness they were 382, or an excess of 114, which were probably all due to the throat-distemper, as many as 76 fatal cases having come to the knowledge of Douglass himself. He estimates the whole number of attacks at 4000, giving a ratio of one death in thirty-five cases; but it is clear that very slight cases of sore-throat were counted in. The fatal cases in Boston seem to have shown a great range of malignant symptoms: “We have anatomically inspected persons who died of it with so intense a foetor from the violence of the disease that some practitioners could not continue in the room.” Among the bad symptoms were the coming and going of the miliary eruption, dark livid colour of the same, the vesicles large, distinct and pale, like crystalline smallpox; an ichorous discharge from the nose; many mucous linings expectorated, resembling the cuticle raised by blisters; pus brought up where no sloughs could be seen in the fauces; extension to the bronchi, with symptoms of a New England quinsey (? croup); in some children, spreading ulcers behind the ears; the tongue throwing off a complete slough with marks of the papillae. Among the after-effects in severe cases were anasarca or dropsy of the skin, haemorrhages, urtications, serpiginous eruptions chiefly in the face, purulent pustules, boils, or imposthumations in the groins, armpits and other parts of the body, indurations of the front of the neck (the same by which many in the country were suffocated, and a few in Boston), hysteric symptoms in women, and epileptic fits. Douglass gives special attention to the eruption, which he calls miliary in his title-page. Some had a sore-throat without any eruption, and a very few had an eruption with no affection of the throat beyond the tonsils and uvula swollen. In some the eruption preceded the soreness of the throat, in some the two came together, but in the general case the eruption was a little later than the affection in the throat. The ordinary course was a chill and shivering, spasmodic wandering pains, vomiting or at least nausea, pain, swelling and redness of the tonsils and uvula, with some white specks: then followed a flush in the face, with some miliary eruptions, attended by a benign mild fever; soon after, the miliary efflorescence appears on the neck, chest and extremities; on the third or fourth day the rash is at its height and well defined, with fair intervals; the flushing goes off gradually with a general itching, and in a day or two more the cuticle scales or peels off, especially in the extremities. At the same time the cream-coloured sloughs or specks on the fauces become loose and are cast off, and the swelling goes down. Where the miliary eruptions were considerable the extremities peeled in scraps or strips like _exuviae_; in one or two, the nails of the fingers and toes were shed. Some who had little or no obvious eruption underwent a scaling or peeling of the cuticle. The epidemic having spent its force upon the New England towns from the autumn of 1735 until the summer of 1736, gradually travelled westward, and was two years in reaching the Hudson River, distant only two hundred miles in a straight line from Kingston, where it first appeared in May, 1735. It continued its progress, with some interruptions, until it spread over the colonies from Pemaquid in 44°N. latitude to Carolina; and as Douglass, writing in 1736, had heard that “it is in our West India Islands,” it was probably the same disease that Warren recorded for Barbados in the same years under the names of “an obstinate and ill-favour’d erysipelatous quinsey,” and “a very anomalous scarlet fever”; and the same as the epidemic “sore-throats” that another records for the Virgin Islands in 1737[1260]. Although it usually attacked several children in the same house, it did not seem to be communicable, like smallpox, from person to person or by the medium of infected clothes. The Boston physicians held a consultation on the point, and published their opinion that it proceeded entirely from “some occult quality of the air.” * * * * * This was the first appearance of sore-throat with efflorescence of the skin among the English colonists of North America. For at least two generations after, the disease remained in the country, breaking out unaccountably from time to time at one place or another and often cutting off many children, but never so malignantly as at first[1261]. Colden, writing from near New York in 1753, says:[1262] “Ever since I came into this part of the country where I live (now about fourteen years), it frequently breaks out in different families and places, without any previous observable cause, but does not spread as it did at first. Sometimes a few only have it in a considerable neighbourhood. It seems as if some seeds or leaven or secret cause remains wherever it goes; for I hear of the like observations in other parts of the country. Several have been observed to have it more than once.... In different years and different persons the symptoms are various. In some seasons it has been accompanied with miliary eruptions all over the skin; and at such times the symptoms about the throat have been mild and the disease generally without danger if not ill treated. Some have had sores, like those on the tonsils, with a corrosive humour behind their ears, on the private and other parts of the body, sometimes without any ulceration in the throat” (case given of a child of ten with sores on the pudenda). 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]. Deaths from Deaths from Period throat-distemper all causes 1735-44 91 216 1745-54 60 221 1755-63 30 187 1764-66 -- -- 1767-76 3 115 1777-86 7 99 1787-91 0 46 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. It was “uncommon and very dangerous,” mostly a malady of children under ten. They drooped for several days, had a watery eye, then a bloated livid countenance, and a few red eruptions here and there on the face. This went on for three or four days, the throat meanwhile showing white specks on the tonsils. Sudden and great prostration ensued, with a peculiar hollow cough and tone of voice, or loss of voice, constant fever, especially nocturnal, and a degree of drowsiness. In fatal cases there was great restlessness and tossing of the limbs towards the end. In one family all the seven children took it one after another; three died out of the four elder; the three younger recovered, having had ulceration behind the ears, which continued for several weeks and rendered an acrid, corrosive ichor. Many other children had these ulcerations behind the ears, sometimes with swelling of the parotid and sublingual glands. The same ulcerations might occur also “in different parts of the body.” Sloughs of the fauces and epiglottis extended as a membranous exudation into the trachea. Two cases occurred in women, one of them having assisted to lay out two children dead of the distemper. 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: “The first and common appearances are feverishness, sickness, vomiting or purging; the proper and diagnostic signs which follow are an ulcerous slough in some part of the fauces, discharging a fœtid matter.... The nostrils are glandered.... From the absorption of the fœtid pus, the blood is contaminated; crimson efflorescences and small putrid pustules break out on the skin of the neck and breast, a quick depressed pulse, with a tendency rather to stupor than violent perturbations accompanying all, and, if not relieved, terminate in delirium, languor, clammy sweats and death.” 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]: “It is peculiar to children, and those chiefly of from a month to three, four, five, six, eight or nine years old. They commonly for a day or two, or more, had a little hoarseness, sometimes a little cough; then in an instant they were seized with a great suffocation lasting a minute or two, and their face became livid; they have frequent returns of these fits of suffocation like asthmatic persons. The said suffocation is ever followed by one symptom which continues till they die, viz. a prodigious rattling in the upper part of the aspera arteria [windpipe] resembling that sound which attends colds when there is phlegm that cannot be got up. It is scarce sensible when they are awake but very great when they are asleep.” 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. It will be convenient to give here what remains to be said of the 18th century history of sore-throat in Ireland. In 1744 Rutty enters “mortal anginas” in Dublin. In March, 1751, tumours of the face, jaws, and throat, following an epidemic among horses in December, 1750. In the spring of 1752 “the pestilential angina” made great havoc among children. In the spring of 1755, “the gangrenous sore-throat” (same as in 1743) was fatal to some children. In the winter of 1759-60 he records “scarlet fever,” and a singular form of the same in May, 1762, noticed under Influenza (p. 356). This must serve for the Irish experiences, although it is far from satisfactory. But it should be added that Dr James Sims, of Tyrone, who came to London afterwards and there wrote on the Scarlatina Anginosa (1786), says in an account of his Irish practice: “During all my practice here I have not seen one instance of the malignant ulcerous sore-throat as described by authors” (_op. cit._ 1773, p. 86). 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. Agonized breathing for a time was followed by the spitting up of jelly-like, glairy and somewhat transparent matter, mixed with white opaque thready matter, which might resemble more or less a rotten body or slough. The paroxysm returned, and the patient either died suddenly or sank away gradually, and died worn out, with or without convulsions. A plate is given of a whitish membrane loosened from the velum by means of hydrochloric acid on a silver probe; it was not a slough, but a strong tenacious membrane which would bear handling and stretching without breaking. In the same case, the child’s father afterwards pulled from the mouth a complete cast of the trachea including the bifurcation of the bronchi, of which a figure is given: “what sweated from it was as sticking as bird-lime”; he lived twenty-one hours after this second cast was drawn from him and died somewhat suddenly in his perfect senses. Such formations Starr clearly believed to be the essence of the disease; but he gives many variations of it. The train of symptoms was not the same in every subject: “Some, I am informed, have had corrosive pustules in the groin and about the anus, eating quick and deep, and threatening a mortification even in the beginning [as Colden described for the sore-throat in New York State]. Others after a few days’ illness have had numbers of the worst and deepest petechiae break out in various parts of their body: such I have not seen.” But he gives cases of his own at Liskeard in 1748: “A child here and there had red pustules which broke out in the nape of the neck and threw off a surprising quantity of thin transparent ichor”; these pustules sloughed when poulticed; in another case sloughs followed where blisters had been applied to the neck and arm. Many had swelling of the tonsils, parotids, submaxillary and sublingual glands. A few had oedema from the chin to the thyroid, and up the side of the face. In one case, a tumour of the fauces broke and yielded some ounces of coffee-coloured foetid matter, to the patient’s relief and ultimate recovery. Not a few had gangrenous sloughs in the mouth, which formed quickly. Some had foetor of the breath as an early symptom, but others had it not. Some were merely feverish and hoarse. 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. It began with a chill and rigor, followed by heat. The throat became sore, and there were nausea, vomiting and purging. The face turned red and swollen, the eyes were inflamed and watery, the patient was restless, anxious and prostrated. The seizure was often in the forenoon, and in all cases the symptoms became much worse towards night, to be relieved by a sweat in the morning, as in an intermittent fever. The uvula, tonsils, velum, inside of the cheeks, and the pharynx, were florid red, with a broad spot or patch, irregular in figure, of pale white colour like the blanched appearance of the gums when they have been pressed by the finger. Usually on the second day of the disease, the face, neck, breast and hands to the tips of the fingers became of a deep erysipelatous colour with perceptible swelling, the fingers in particular being often of so characteristic a tint as at once to suggest an examination of the throat. A great number of small pimples, of a deeper red than the skin around them, appear on the arms and other parts; they are larger and more prominent in those subjects, and in those parts of the same subject, where the redness is least intense, which is generally on the arms, the breast, and lower extremities. With the coming out of this rash, the sickness, vomiting and purging cease. The white spot or spots on the throat are now seen to be sloughs; they come first usually in the angles above the tonsils. They are not formed of any foreign matter covering the parts but are real mortifications of substance leaving an ulcer with corrosive discharge behind. The nocturnal exacerbation now takes the form of delirium and incoherent talking. The parotids are commonly swelled and painful; and if the disease be violent, the neck and throat are surrounded with a large oedematous tumour threatening suffocation. The pulse is 120, perhaps hard and small. The urine is at first crude and pale like whey; afterwards it is more yellow, as if from bile; and towards recovery it is turbid and deposits a “farinaceous” sediment. The initial purging having ceased, the bowels become irregular. The disease had no crisis, but in general, if the patient were to recover, the amendment began on the third, fourth or fifth day, when the redness disappeared and the sloughs in the throat were cast off. Such is the main outline; the following symptoms have less general value. At the outset, the patient complained of a putrid smell in the throat and nostrils, which caused nausea. The nostrils were often inflamed, yielding a sanies, and the inside of the lips covered with vesicles filled with an excoriating ichor. Some had the parts about the anus excoriated. Fothergill was inclined to think that either the excoriations or the ichor from them extended down the whole intestinal tract, and accounted for the purging, with other bowel symptoms, which sometimes remained for weeks after the primary disease and caused death by emaciation[1272]. In some there was bleeding at the nose, or mouth, which might be fatal; in one case there was a like accident from the ear. Several cases are given in which there were no sloughs of the throat, but a dry glossy redness or lividity; in these cases, there was a general brawny swelling of the neck, a coldness of the hands and feet, involuntary evacuations, a glassy eye and certain death. Three of Fothergill’s five briefly reported cases are of that variety. In one of them, a boy of 14 years, he says there was “deep redness of the face, hands and arms, with a plentiful eruption of small pimples, which induced those about him to apprehend it was a scarlet fever.” 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: 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].” 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. 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: 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]. History of Scarlatina after the Epidemic of 1778. 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 Scarlatina Scarlatina Sore-throat simplex anginosa maligna 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]. Scarlatina (1788) and Diphtheria (1793-94) described by the same observer. 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]. Scarlatinal Epidemics, 1796-1805. 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