MEASLES.
In the earliest English writings on medicine, measles is the inseparable
companion of smallpox; so closely are they joined in pathology and
treatment that even the statements as to the pustules and scars of the
eruption are in some compends made to apply to both without distinction.
This singular conjunction of two diseases came originally from the Arabian
teaching, which was everywhere authoritative in the medieval period, and
especially authoritative in all that related to smallpox. In the Latin
compends based upon Avicenna or other Arabic writers, the two names were
_variolae_ and _morbilli_, the former being as it were the _morbus_ proper
and the latter its diminutive. It can hardly be doubted that we owe the
English name of measles as the equivalent of _morbilli_ to John of
Gaddesden. Originally the English word meant the leprous, first in the
Latin form _miselli_ and _misellae_ (diminutive of _miser_), as in the
histories of Matthew Paris, and later in the Norman-French form of
_mesles_, as in the Acts of Parliament of Edward I. and in the ‘Vision of
Piers the Ploughman.’ In the 15th century the leper-houses in the suburbs
of London were called the “lazarcotes” or “meselcotes.”
Gaddesden, by some unaccountable stretch of similarity, coupled the sores
or tubercular nodules on the legs of “pauperes vel consumptivi,” who were
called “_anglicé_ mesles,” with the spotted rash of the Arabian
“morbilli”; and it was doubtless this haphazard bracketting of two unlike
diseases that led in course of time to the name of mesles being disjoined
from its original sense of the leprous and restricted to the second member
of Gaddesden’s strangely assorted couple. In the time of Henry VIII.
smallpox and mezils are familiarly named together just as _variolae et
morbilli_ are an inseparable pair in the treatises of the Arabistic
writers. A still more singular usurpation by “mezils” or “maysilles” or
“measles” is met with in the Elizabethan period. In the vocabulary of
Levins, a schoolmaster who was also a medical graduate of Oxford, the word
_variolae_ is rendered by “ye maysilles,” while _morbilli_ is omitted
altogether among the Latin names and smallpox among the English; and in
the English translation of Latin aphorisms appended to one of the works of
William Clowes, surgeon to St Bartholomew’s Hospital, _variolae_ is in
like manner translated “measles” on every occasion. In the English
dictionary by Baret, belonging to the same period, measles is defined as
“a disease with many reddish spottes or speckles in the face and bodie,
much like freckles in colour”--which seems to exclude the possibility of a
pustular disease having been part of the Elizabethan notion of measles.
Notwithstanding this singular usage of the vocabularies and dictionaries,
the name of smallpox occurs by itself in letters or other memorials of the
Elizabethan period, having been doubtless correctly applied to the true
pustular _variola_. In the short essay on smallpox by Kellwaye, appended
to his book on the plague (1593), measles and smallpox are distinguished
on the whole clearly, according to the definitions of Fracastori or other
foreign writers of the 16th century. The association between measles and
smallpox that survived longest was a peculiar and somewhat uncommon one;
certain cases of smallpox, in which the pustules were wholly or partially
represented by, or changed into, broad spots level with the skin, red or
livid in colour, and in which haemorrhages occurred from the nose, lungs,
bowels or kidneys, that is to say, cases of haemorrhagic smallpox, were
apt to be called, from the time of James I. until as late as the case of
Queen Mary in 1694, by the name of “smallpox and measles mingled.”
From the date of the annual bills of mortality by the Parish Clerks of
London, the year 1629, it is improbable that there was any real confusion
between smallpox and measles; there was certainly some ambiguity in the
entry of measles long after, but that later confusion, especially in the
second half of the 18th century, was with scarlatina[1184]. The entry of
measles is in the bills from the first, apart from that of “flox and
smallpox:”
Measles Smallpox
Year deaths deaths
1629 42 72
1630 2 40
1631 3 58
1632 80 531
1633 21 72
1634 33 1354
1635 27 293
1636 12 127
1647 5 139
1648 92 401
1649 3 1190
1650 33 184
1651 33 525
1652 62 1279
1653 8 139
1654 52 832
1655 11 1294
1656 153 823
1657 15 835
1658 80 409
1659 6 1523
1660 74 354
In the great epidemic of smallpox in 1628, the year before the bills
begin, Thomas Alured wrote to Sir John Coke that his house in London had
been visited “once with the measles and twice with the smallpox, though I
thank God we are now free; and I know not how many households have run the
same hazard[1185].” In the year 1656, which has the highest total in the
above table, two cases of measles are mentioned in a letter of 31st May:
“Young Sir Charles Sedley is at this time very sick of a feaver and the
meazells, of which Sir William dyed”--Charles Sedley being then in his
seventeenth year[1186]. An instance parallel to that of 1628, of measles
and smallpox co-existing in the same household, occurred in the royal
palace at Whitehall in December, 1660. The princess of Orange, sister of
the king, died of smallpox on the 23rd; on that day, or a day or two
before, her sister the princess Henrietta, who had come from France on a
visit with the queen-mother, Henrietta Maria, removed from Whitehall to St
James’s, “for fear of infection.” After a few days she embarked on board
the ‘London’ at Portsmouth to return to France, but the ship had to come
to anchor again owing to the princess being attacked with “the measles.”
Her illness, which delayed the sailing of the vessel until the 24th of
January, 1661, is uniformly spoken of as the measles in the various
letters which make mention of it[1187]. In that year, and in several of
the next ten years, the measles deaths in London reached a considerable
total:
Measles
Year deaths
1661 188
1662 20
1663 42
1664 311
1665 7
1666 3
1667 83
1668 200
1669 15
1670 295
The epidemic of 1670 is the subject of a description by Sydenham, the
diagnostic points of which were doubtless those current at the time.
Sydenham’s description of Measles in London, 1670 and 1674.
Sydenham’s account of the epidemic of 1670 is full enough to leave no
doubt that it was measles of the ordinary kind; the details, indeed, are
as minute for all essential points as they would be in a modern
text-book[1188]:
Measles, he says, is a disease mainly of young children (_infantes_),
and is apt to run through all that are under one roof. It begins with
a rigor, followed by heats and chills during the first day. On the
second day there is fever, with intense malaise, thirst, loss of
appetite, white tongue (not actually dry), slight cough, heaviness of
the head and eyes, and constant drowsiness. In most cases a humour
distils from the nose and eyes, the effusion or suffusion of tears
being the most certain sign of sickening for measles, more certain
indeed than the exanthem. The child sneezes as if it had taken cold,
the eyelids swell, there may be vomiting, more usually there are loose
green stools (especially during dentition), and there is excessive
fretfulness. On the fourth or fifth day small red maculae, like
fleabites, begin to appear on the forehead and the rest of the face,
which coalesce, as they continue to come out in increasing numbers, so
as to form racemose clusters. These maculae will be found by the touch
to be slightly elevated, although they seem level to the eye. On the
trunk and limbs, to which they gradually extend, they are not
elevated. About the sixth day the maculae begin to roughen and scale,
from the face downwards, and by the eighth day are scarcely
discernible anywhere. On the ninth day the whole body is as if dusted
with bran. The common people say that the spots had “turned inwards,”
by which they mean that, if it had been smallpox, they would have
remained out longer, and have proceeded to suppuration or maturation.
The rash having thus “gone in,” there is an access of fever, attended
with laboured breathing and cough, the latter being so incessant as to
keep the children from sleep day or night. If they had been treated by
the heating regimen, they are apt to have the chest troubles pass
into peripneumonia, by which complication measles becomes more
destructive than smallpox itself, although there is no danger in it if
it be rightly treated. When peripneumonia threatens, the patient
should be bled, even if it be a tender infant. Diarrhoea, which
sometimes continues for weeks after an attack of measles, may be cut
short by blood-letting, and so also may whooping-cough.
This epidemic, says Sydenham, began in January, and was almost ended in
July, which agrees exactly with the rise and decline of measles deaths in
the weekly bills of the Parish Clerks.
His account of the epidemic of 1674 is still more important to be set
beside the figures in the bills; for the type, according to Sydenham, was
anomalous, and the total of deaths entered by the Parish Clerks (795) is
exceptionally large. Like the epidemic four years before, it began in
January, came to a height about the vernal equinox, and was nearly over at
the summer solstice[1189].
_Weekly Deaths in London in the first six months of 1674. (Epidemic of
Measles.)_
1674
Week Griping in Convulsions Consumption All
ending Fever Smallpox the guts Measles Teeth causes
Jan. 6 35 13 35 0 37 15 78 332
13 35 19 32 1 32 22 65 369
20 37 12 29 0 39 18 65 327
27 34 15 38 0 38 17 68 354
Feb. 3 32 23 39 7 45 26 75 418
10 47 18 35 4 48 35 86 430
17 55 21 46 15 70 38 98 537
24 62 17 45 28 54 44 97 510
March 3 58 31 28 59 48 49 87 547
10 55 22 31 87 85 58 122 688
17 63 15 46 95 79 57 113 695
24 59 23 44 65 57 39 96 568
31 51 19 49 60 77 51 105 622
April 7 44 13 40 43 65 48 118 547
14 53 20 32 31 60 50 98 535
21 40 17 43 38 55 42 106 517
28 50 17 44 53 67 34 87 520
May 5 51 31 28 30 56 24 75 452
12 38 26 47 30 54 37 79 479
19 50 35 33 26 47 28 82 461
26 67 27 33 13 45 28 63 415
June 2 48 24 28 14 41 26 77 365
9 35 26 38 15 48 27 66 369
16 64 34 38 19 38 22 70 419
23 34 33 34 9 52 15 71 368
30 37 39 30 9 30 21 59 343
It will be seen that the highest weekly mortality from measles is only 95,
in the week ending 17th May. But in that week the deaths from all causes
reached the enormous total of 695, which was nearly three hundred above
the weekly average of the time. This appears to have been the epidemic of
measles which Morton declares to have destroyed three hundred in a week, a
mode of reckoning which would claim for measles, directly or indirectly,
the excess of mortality from all causes during the height of the
epidemic[1190].
These high weekly mortalities in February, March, April and May are
remarkable for the season of the year. Usually when the weekly figures
reach six or seven hundred, it is in a hot autumn, and the cause is
infantile diarrhoea, represented in the bills by the excessive number of
deaths from “griping in the guts” and “convulsions;” more rarely, and then
only for three or four weeks, correspondingly high figures are reached in
a season of influenza. But in this case the epidemic measles is the only
relevant thing. The measles deaths by themselves do by no means account
for the enormous weekly totals; but two of the three columns of figures
which help them, and indeed keep pace with the rise of the measles deaths,
namely, “convulsions” and “teeth,” are infantile deaths obviously related
to the prevailing epidemic; while the third column, “consumption,” which
contributes most of all, did not in the London bills mean pulmonary
consumption exclusively, but also the wasting or marasmus which followed
or attended acute fevers in general, and was specially apt to follow or
attend measles[1191].
Sydenham gives no indication that the spring of 1674 was unusually
productive of pneumonia or pleurisy among adults; the winter, he says, was
unusually warm, the weather in spring turning colder. But, as to the
measles, he does say that the epidemic was anomalous or irregular; while
both he and Morton refer the fatalities more especially to the sequelae of
measles,--to the “suffocation” of infants and children by the bronchitis
or peripneumonia, or to “angina,” as Morton says, meaning perhaps the same
as in Scotland was understood by “closing” in infants. Measles itself was
a milder disease than smallpox, according to the experience of all times;
and yet, by its sequelae (bronchitis, capillary bronchitis and pneumonia,
including what Morton calls “angina,” and excluding, for the present,
whooping-cough), it raised the weekly mortalities of February, March,
April and May, 1674, to far above the average. Sydenham said, with
reference to the much milder epidemic of 1670, that these after-effects of
measles “destroyed more than even smallpox itself” (_quae_
[_peripneumonia_] _plures jugulat quam aut variolae ipsae_). We shall not
correctly understand the part played by measles among the infective
maladies of children unless we keep that grand character of it in
mind--that its effects upon the mortality of infancy and childhood are
only in part expressed by the deaths actually appearing under its name.
The London bills for 1674 afford us the opportunity of testing Sydenham’s
paradox that measles, by its after-effects, destroyed more than smallpox
itself. The epidemic of measles was nearly over in June; and immediately
thereafter an epidemic of smallpox began (not of course from zero but from
the usual level of the disease), which reached a maximum of 122 deaths in
the week ending 20th October. The second half of the year was thus marked
by a sharp outburst of smallpox, as the first half was marked by a sharp
outburst of measles; and those two diseases were the only epidemic
maladies that gave character to the respective seasons, each being in its
proper season, according to Sydenham--measles in the spring, smallpox in
the autumn. Although the measles deaths were only 795 for the whole year,
the smallpox deaths being 2507, yet the former epidemic was attended by so
great an excess of deaths under various other heads that the half of the
year in which it fell was far more unhealthy than the succeeding half in
which the smallpox mainly fell, the weekly average of the first six months
having been 468 deaths, and of the second six months 349 deaths. The
following table shows the weekly mortalities for the second half of the
year; it will be observed that no column of figures keeps pace with the
rise of the smallpox deaths, as three columns had kept pace with the rise
of the measles deaths in the first six months of the year.
_Weekly Deaths in London in the last six months of 1674. (Epidemic of
Smallpox.)_
1674
Week Griping in Convulsions Consumption All
ending Fever Smallpox the guts Measles Teeth causes
July 7 31 44 35 9 44 24 69 351
14 38 55 34 5 37 17 54 353
21 40 71 47 6 42 25 56 395
28 43 71 37 3 49 18 48 367
Aug. 4 38 68 39 6 31 23 47 347
11 33 66 48 -- 18 8 45 324
18 49 86 41 1 26 20 48 374
25 35 85 23 3 32 10 46 328
Sept. 1 60 96 41 -- 32 18 57 414
8 32 99 48 3 22 16 32 374
15 28 102 38 2 30 19 55 362
22 27 72 32 3 29 11 57 327
29 39 81 34 2 41 9 53 358
Oct. 6 37 98 29 -- 34 10 63 391
13 36 75 25 -- 35 17 49 311
20 42 122 35 1 34 10 68 402
27 24 75 36 -- 38 15 45 294
Nov. 3 34 83 21 -- 30 11 41 322
10 30 81 15 -- 31 12 49 321
17 31 70 16 -- 24 10 58 304
24 35 70 28 -- 38 14 57 344
Dec. 1 33 85 29 -- 32 14 68 378
8 33 66 28 -- 36 11 53 327
15 29 61 26 -- 39 16 49 339
22 34 68 21 -- 32 11 52 335
29 41 41 19 -- 33 7 74 337
The total of deaths by smallpox for the year, 2507 was the highest since
the bills began, and remained the highest until 1681. It is open to us to
suppose that it would not have been so high but for the epidemic of
measles preceding. The measles not only made the first half of the year
far more deadly than the second, within which most of the smallpox fell,
but its effects may have aided the high mortality of smallpox itself,
according to the experience of later times that infants and young children
recovering from measles in a greatly weakened condition fell an easier
prey to smallpox coming after[1192].
Morton passes from the fatal epidemic of 1674 (or, as he says, 1672), with
the remark that the malady had not been epidemic again in London from that
time until the date of his writing, 1692-94, a period of nearly twenty
years; and that is on the whole borne out by the London bills and by
Sydenham’s records so far as they extend. From 1687 to 1700, inclusive,
the London bills grouped the measles deaths along with the deaths from
smallpox, under the heading, “Flox, Smallpox and Measles”; in 1701 the
total of measles, 4 deaths, is given as a separate item in the same
bracket with smallpox; and in 1702 the heading of “Measles,” is restored
to the place in the alphabetical list which it had held, except for that
unaccountable break, from the beginning of the published bills in 1629.
The following are the annual totals from and including the great epidemic
of 1674:
Death from
Year measles
1674 795
1675 1
1676 83
1677 87
1678 93
1679 117
1680 49
1681 121
1682 50
1683 39
1684 6
1685 197
1686 25
Thus for a good many years after the general prevalence of measles in 1674
the deaths from it in London averaged only about one and a half in the
week, while in no year until 1705-6 is there an epidemic comparable to
that of 1674. It is clear that the severe epidemics of measles came at
first at very long intervals, and that the years between had a very
moderate mortality from that disease.
Measles in the 18th century.
There is hardly a reference to be found to measles in medical or other
writings until the annual accounts of the public health at Ripon, York,
Plymouth, etc. in the third decade of the 18th century. The annual deaths
from it in London, according to the bills, were as follows, from 1701,
when the disease was restored to its separate place in the classification:
Year Measles
deaths
1701 4
1702 27
1703 51
1704 12
1705 319
1706 361
1707 37
1708 126
1709 89
1710 181
1711 97
1712 77
1713 61
1714 139
1715 30
1716 270
1717 35
1718 492
1719 243
1720 213
1721 238
1722 114
1723 231
1724 118
1725 70
1726 256
1727 72
1728 82
1729 41
1730 311
1731 102
1732 30
1733 605
1734 20
1735 10
1736 169
1737 127
1738 216
1739 326
1740 46
The high mortalities of 1705 and 1706 belonged to one continuous epidemic
from October, 1705, to April, 1706 (Sir David Hamilton says that smallpox
was common in London in July, 1705, but the deaths in the bills are not
excessive). The epidemic followed a great prevalence of the autumnal
diarrhoea of infants, so that it is probable the high mortality was due as
much to a greater fatality of cases from the antecedent weakening, as to
an unusual number of cases[1193]. The following were the weekly deaths in
a population about one-sixth that of London now:
1705-1706
Week Measles
ending deaths
Oct. 16 9
23 9
30 12
Nov. 6 10
13 30
20 34
27 29
Dec. 4 37
11 46
18 44
25 22
Jan. 1 35
8 33
15 28
22 20
29 18
Feb. 5 27
12 11
19 26
26 28
Mar. 5 10
12 10
19 9
26 13
Apr. 2 9
9 9
The unusually large mortalities from measles in 1718-19 and in 1733 were
again associated with a “constitution” otherwise sickly. The epidemic in
the latter year, from the middle of March to the end of July, which had a
maximum of 47 deaths in each of the two middle weeks of May, followed
close upon a severe influenza. Like the epidemic of 1674, it was attended
by a high mortality from other causes, especially “convulsions” and
“consumption”; and, as the bills had now begun to give the ages at death,
it is no longer doubtful, or merely conjectural, that the great excess of
deaths under these and other heads was really among infants, or that a
rise in “consumption” at that time of the year meant an increase in the
wasting diseases of infancy. This was a period when any epidemic malady
among London children was sure to go hard with many of them, the period,
namely, when spirit drinking, besides ruining the health of the parents,
rendered them, in the opinion of the College of Physicians, “too often the
cause of weak, feeble and distempered children[1194].”
The intervals between epidemics of measles in London having been so
considerable as the table shows, it is not surprising to find but casual
mention of the disease in the chronicles of Wintringham, Hillary, and
Huxham for England, of Rogers, O’Connell and Rutty for Ireland, and of the
Edinburgh annalists. Wintringham, of York, whose annals extend from 1715
to 1730, records an epidemic of measles in 1721, which began in April and
lasted all the summer, being for the most part of a bad type, attended
with continual cough and inflammation of the lungs. Hillary, of Ripon,
enters measles in 1726, “very common but mild,” autumn and winter being
the season of it. Wintringham briefly mentions the same epidemic. Huxham
of Plymouth has an entry of measles in the first year of his annals, 1727,
in the month of July, followed by whooping-cough in December. Wintringham
again enters measles at York in 1730 in the company of smallpox. In the
annual accounts of the disease at Edinburgh, for a series of years
beginning with 1731, measles is first mentioned in 1735[1195]. The
epidemic began in June and became universal in December: “The progress of
these measles along the west road of England towards Edinburgh was very
remarkable, for they could be traced from village to village; and it was
singular that the first person in Edinburgh who was seized with them was a
lady in childbed, who saw nobody but her nurse and a friend who lived in
the house with her”--an argument, apparently, for the doctrine of an
epidemic “morbillous” constitution of the air. Five years after, we obtain
the mortality statistics of Edinburgh, in the two great years of scarcity,
typhus fever and sicknesses of all kinds, the years 1740 and 1741: in
those two years measles must have been as general as smallpox if it were
half as mortal, for the deaths set down to it in each year are 110 and
112, as compared with 274 and 206 from the more usual infantile infection.
In like manner the second year of the disastrous epidemic of typhus in
1741-42, had the highest total of measles deaths in London until the great
epidemic of 1808. While the high mortality of that year was due to special
causes, it is at the same time clear from the following table that measles
had not yet become a steady or perennial cause of death to the infancy of
the capital:
Year Measles
deaths
1741 42
1742 981
1743 17
1744 5
1745 14
1746 250
1747 81
1748 10
1749 106
1750 321
1751 21
1752 111
1753 253
1754 12
1755 423
1756 156
1757 24
1758 696
1759 316
1760 175
1761 394
1762 122
1763 610
1764 65
1765 54
1766 482
1767 80
1768 409
1769 90
1770 325
1771 115
1772 211
1773 199
1774 121
1775 283
1776 153
1777 145
1778 388
1779 99
1780 272
1781 201
1782 170
1783 185
1784 29
1785 20
1786 793[1196]
1787 84
1788 55
1789 534
1790 119
1791 156
1792 450
1793 248
1794 172
1795 328
1796 307
1797 222
1798 196
1799 223
1800 395
The considerable epidemic of 1755 is thus referred to by Fothergill in his
monthly notes:
_May_: the measles more common than for some years, adults, who had
not before had it, rarely escaping. _June_: measles common, smallpox
rare. _September and October_: no epidemic disease but measles; few
perished in proportion to all who took it[1197]. The epidemic of 1758
was more fatal, but Fothergill’s notes are not continued to that year.
The elder Heberden says that measles was remarkably epidemical (in
London) in 1753, which year has only 253 deaths in the bills, whereas
the year 1755 has 423 deaths and the year 1758 has 696; but, as he
implies that the type was mild, there would have been a multitude of
cases to produce that number of deaths. It was a peculiarity of that
epidemic, he says, that the cough preceded the outbreak of measles by
seven or eight days, whereas it was usually but two or three days in
advance of the eruption[1198].
At that period there would have been an epidemic of measles in London
every other year, or once in three years, with a fatality from the direct
effects seldom more than a sixth part that of an epidemic of smallpox. A
London writer some twenty years after said that few escaped measles in
infancy or childhood, while the deaths put down to it were only a tenth
part of those due to smallpox on an average of years[1199]. The proportion
of measles deaths to smallpox deaths was nearly the same in Manchester for
twenty years from 1754 to 1774, according to Percival’s table of the
burials in the register of the Collegiate Church where most of the poorer
class were buried[1200]:
_Annual averages of Burials from Measles etc. at the Collegiate
Church, Manchester._
All deaths Deaths at
Period Measles Smallpox under two all ages Baptisms
1754-58 21 64 209 651 678
1759-63[1201] 10·6 95 213 639 731
1764-69 9·6 98 229 659 827
1770-74 21·6 102 242 651 1062
The ages of those who died of measles “in six years from 1768 to
1774,” to the number of 91, were as follows:
Total 3 mo. -6 mo. -12 mo. -2 years -3 -4 -5 -10 -20 -30
91 2 3 10 31 25 7 9 2 1 1
Fifty were males, forty-one females--a preponderance of males which is
according to rule. Of the whole ninety-one, no fewer than fifty-one
died in June of the several years.
In the smaller and more healthy towns, such as Northampton, the
epidemics of measles came at long intervals and caused but few deaths:
_Infantile Causes of Death, All Saints, Northampton_[1202].
Year Measles Whooping-cough Convulsions Teething
1742 3 1 10 8
1743 -- -- 21 2
1744 -- 3 14 4
1745 -- -- 22 7
1746 -- 3 19 3
1747 7 -- 29 --
1748 -- -- 24 4
1749 -- 6 15 4
1750 1 -- 17 1
1751 -- -- 14 6
1752 -- 1 13 6
1753} not published
1754}
1755 -- 1 8 1
1756 -- 2 10 2
1757 1 1 28 4
In the parish of Holy Cross, a suburb of Shrewsbury, there were 4
deaths from measles in the ten years 1750-60, and 15 in the ten years
1760-70, the smallpox deaths having been respectively 33 and 46.
Ackworth, in Yorkshire, may represent the country parishes. It had no
deaths from measles from 1747 to 1757, two deaths from 1757 to 1767.
At Kilmarnock during thirty-six years from 1728 to 1764, there were 93
deaths from measles, 52 of them in the period 1747-52, and only 11 in
the next twelve years. Sims, of Tyrone, having described an epidemic
of smallpox which desolated the close of 1766 and spring of 1767 with
unheard of havoc (it had been out of the country for some years),
mentions farther that an epidemic of measles followed immediately:
“Before the close of the summer solstice the measles sprang up with a
most luxuriant growth,” and was followed in harvest by whooping-cough.
Wherever we have the means of comparison by figures, it appears that
measles caused by its direct fatality not more than a sixth part of the
deaths by smallpox in Britain generally. But in the colonies, where an
epidemic of smallpox was a rare event of the great seaports, and as much
an affair of adults as of children, measles seems to have been more fatal,
dividing with diphtheria or scarlatina the great bulk of the infectious
mortality of childhood. Thus Webster enters under 1772: “In this year the
measles appeared in all parts of America with unusual mortality. In
Charleston died 800 or 900 children”; and under 1773: “In America the
measles finished its course and was followed by disorders in the
throat”--especially in 1775[1203]. It is only among the children of
public institutions in England that we find in the corresponding period a
similar predominance of measles and scarlatina over smallpox. In the
Infirmary Books of the Foundling Hospital the more general outbreaks of
smallpox cease after 1765, while epidemics of measles, extending to
perhaps a third or more of the inmates, as well as great epidemics of
scarlatina, begin after that date to be common[1204].
In the Infirmary Book from which the following extracts are taken, the
number of deaths is not stated. The number of children in the Hospital
was 312 in 1763, 368 in 1766 and 438 in 1768.
1763. Before the date of the Infirmary Book, Watson records an
epidemic of putrid measles from 21 April to 9 June, 1763, which
attacked 180 and caused 19 immediate deaths.
Nov. 19. Nine in the infirmary with “morbillous fever”; many cases of
“fever” until the 17th December.
1766. May to July. Many entries in the book; Watson says:
“Seventy-four had benign measles, and all recovered.”
1768. Great epidemic, May to July; one hundred and twelve in the
infirmary with measles on June 4th; Watson gives the total cases at
139, of which 6 were fatal.
1773. Nov. and Dec. Great epidemic: maximum of 130 cases of measles in
the infirmary on 27th November. Next week there were 40 with measles,
and 90 convalescing therefrom.
1774. May. A slight outbreak (8 cases at one time).
(_Records from 1776-1782 not seen._)
1783. March and April. Great epidemic: maximum number of cases in the
infirmary with measles 94, on March 22nd.
1784. June. Eleven cases of measles at once.
1786. March and April. Maximum on April 5th--measles 47, recovering
from measles 19.
The records from 1789 to 1805 have not been seen, but Willan gives the
following dates and numbers, on the information of Dr Stanger,
physician to the charity[1205].
1794. 28 had measles, all recovered.
1798. 69 had measles, 6 girls died.
1800. 66 had measles, 4 boys died.
1802. 8 had measles, one died.
The general testimony in the last quarter of the 18th century is that
measles, if a common affection, was not usually a severe one. Heysham, of
Carlisle, says that measles came thither in 1786 from the south-west of
Northumberland, “where, I am informed, they proved very fatal”; the
epidemic began at Carlisle in August, and continued very general until
January, 1787, but extremely mild and favourable, only 28 having died (26
under five years, 2 from five to ten), out of “some six or seven hundred,
I suppose.” The previous epidemic of measles at Carlisle in 1780
(mortality not stated), had followed a most fatal epidemic of smallpox in
1779; and although the epidemic of mild measles in 1786 did not follow a
great epidemic of smallpox, it followed a high and steady annual average
of deaths of infants and young children from that cause year after
year[1206]. In both years of the measles at Carlisle, there were no deaths
from smallpox. In like manner at Leeds, in 1790, measles followed
smallpox, and was extremely mild; Lucas wrote of it, “I have not seen one
instance of a fatal termination[1207].” This was the time (1785) when
Heberden said of the disease in London, just as Willis, Harris and others
had said of it and of smallpox together a century before: “The measles
being usually attended with very little danger, it is not often that a
physician is employed in this distemper.”
Increasing mortality from Measles at the end of the 18th century.
There were epidemics of measles with high mortality in the 17th and 18th
centuries, occurring in special circumstances of time and place, of which
instances have been given. But in general the position of measles was not
then so high among the causes of death in infancy and childhood as it
afterwards became. It is not easy to demonstrate the exact proportions by
figures, even for London; the bills of the Parish Clerks are less
trustworthy for measles than for smallpox, for the reason that deaths from
scarlatina were probably included among the former (see under Scarlatina).
For example, the ratio of 1·10 per cent. measles deaths for the ten years
1781-90 in the following table should be only 0·70 if the 793 deaths in
1786, supposed scarlatinal, be left out. But, taking the bills as they
stand, they show an increasing ratio of measles (as well as of
whooping-cough) among the deaths from all causes towards the end of the
18th century.
_Percentage of Measles and Whooping-cough in all London deaths,
1731-1830._
Ten-year Share of Share of
periods measles whooping-cough
1731-40 0·70 0·41
1741-50 0·68 0·40
1751-60 1·15 1·03
1761-70 1·11 1·12
1771-80 0·93 1·66
1781-90 1·10 1·32
1791-1800 1·34 1·97
1801-10 3·11 3·14
1811-20 3·52 3·49
1821-30 3·17 3·13
During the same period, the ratio of deaths from all causes under two
years of age had decreased, while the ratio of deaths from two to five,
and at all ages above five, had increased as in the following table, also
compiled from the London bills beginning with the year 1728 when the ages
at death were first published.
_Ratios of Deaths from all causes under two years, from two to five, and
above five, London, 1728-1830._
Ratio Ratio Ratio of
Total under from all ages
Period deaths Two years Two to Five above Five
1728-30 (3 yrs.) 84,293 36·7 8·7 54·6
1731-40 246,925 38·6 8·9 52·5
1741-50 254,717 33·6 7·9 58·5
1751-60 204,617 30·9 9·3 59·8
1761-70 234,412 34·1 9·1 56·8
1771-80 214,605 34·4 9·6 56·0
1781-90 192,690 32·5 9·5 58·0
1791-1800 196,801 31·8 10·9 57·3
1801-10 185,823 29·3 11·5 59·2
1811-20 190,768 27·7 9·8 62·5
1821-30 209,094 28·0 9·7 62·3
Thus, while measles (with whooping-cough) was usurping, so to speak, a
larger share of all the deaths, the two first years of life were claiming
a smaller share of the deaths from all causes as the probability of life
was improving. The saving of infant life was due to various things, but
especially due to the decline of smallpox, as described in another
chapter. We may now turn to consider, by a less abstract method, the
increase of measles mortality from the last years of the 18th century.
In Willan’s periodical reports of the prevailing diseases of London[1208],
scarlatina declined in 1795 and became sporadic, after having been
extremely fatal for a long period, while measles and smallpox began to
extend about the end of that year, the former being for the most part mild
in its symptoms and favourable in its termination, the latter often
confluent, and fatal to children. The report for March and April, 1796, is
that measles had become more severe, and had been followed by obstinate
coughs; for May, that “smallpox and measles have prevailed more during
this spring than has been known for many years past.” However, it was
smallpox that occasioned the larger share of the deaths among infants and
children. The next general view that Willan gives us of the relative
importance of measles among the infectious diseases is under Oct.-Nov.
1799: “The measles, though extensively diffused, have continued mild and
moderate. The scarlet fever has increased, since the last report, both in
extent and in the violence of its symptoms; but the contagious malignant
fever [typhus] has been the most frequent, as well as the most fatal, of
all acute diseases.” There is little sign of fatal measles in the London
bills during the years of distress, 1799-1801; but we hear of it in
Scotland and Ireland, where there was probably less scarlatina. An
Edinburgh observer of the prevailing diseases says that “several hundreds”
died of measles there in the winter of 1799[1209]. In the Irish emigration
to America, which took one of its periodic starts owing to the repressive
measures following the rebellion of 1798 and the union with England,
measles appears to have been the fatal form of infection among the
children on board ship. A medical letter from Philadelphia, 10 December,
1801, says that measles had been imported to Newcastle and Wilmington in
the summer of 1801 by some vessels from Ireland, on board which a great
many children died during the voyage; the epidemic at length reached
Philadelphia and had become general throughout the city[1210]. At
Whitehaven large numbers of infants were attended in measles from the
Dispensary in 1796 and 1799, but the deaths (2 in 202 cases, and 2 in 266
cases) are probably only a few that came to the knowledge of the visiting
physician. An epidemic at Uxbridge, Middlesex, in the winter of 1801-2 was
certainly malignant or fatal more than ordinary, whatever its anomalous
type may have meant.
The epidemic began in September, and was at first of so mild a type as
to need no medical assistance. Towards November the cases increased in
number and severity, but still, says the narrator, “I believe every
case terminated favourably, not in my practice only, but in that of
other gentlemen also.” Towards the middle of November, the attacks
were more sudden and more violent while they lasted, and were soon
over either in death or recovery. In some the eyes became all at once
as red as blood, the pulse full, quick and hard, the cough incessant,
with a rattling noise in the throat and quick laboured breathing, the
skin hot and parched. “Another peculiarity in this epidemic was that
the cuticle in many children did not separate after the disappearance
of the eruption, and in several others that I particularly noticed, it
came off in large flakes instead of branny scales; and the appearance
of the rash in others assumed so striking a resemblance to the scarlet
fever that, had it not been for the violent cough and other measly
symptoms, many such cases occurring singly might, upon a superficial
view, have been considered and treated as that disorder.” The various
forms occurred in the same family; thus, of four children, one had
typical measles, ending in a branny scurf, two others had the sneezing
and the watery inflamed eyes, but the eruption in the form of an
universal red fiery rash, after which the skin peeled in large flakes,
while the fourth had the disease of a low typhoid type and recovered
with difficulty. The epidemic “continued its destructive career”
through December and January, after which the type became as mild as
it had been at first. If the author had not discussed the diagnosis as
between measles and scarlatina, deciding in favour of the former, one
might have suspected that there were cases of both. But even the
sphacelation that followed the application of blisters, the
pemphigus-like eruption turning gangrenous, and the petechiae, were
signs of malignancy in more than one of the exanthematous fevers. The
sequelae of this epidemic of measles were as anomalous as the symptoms
themselves; instead of the inflamed eyes, and the distressing cough
(sometimes ending in consumption) there were aphthous fever and
dysenteric purging[1211].
The deaths in the London bills for the first twelve years of the century
will be found in the table on p. 655. We find the measles deaths for the
first time equalling the smallpox deaths in 1804, and in 1808 surpassing
them, and we may take it that the deaths so entered were almost wholly of
measles proper. The epidemic of measles in 1807-8 was, in fact, a great
and clearly defined event in British epidemiology, the first of a series
of epidemics in which that disease established not only its equality with
smallpox as a cause of infantile deaths but even its supremacy over the
latter. It would appear, also, to have been more malignant than the
scarlatina that coexisted with it. Thus, Bateman, of London, at the outset
of the great measles epidemic of 1807-8, says: “The most prominent acute
disorders have been eruptive fevers and particularly the measles, which
during October and November have been very prevalent, and, when occurring
in young children, have proved very fatal by terminating in violent
inflammation of the organs of respiration.... The scarlatina was generally
mild, presenting the eruption with a slight sore-throat[1212].”
Other accounts of the epidemic in London show it to have been of the type
which Sydenham, in 1674, called anomalous or malignant.
The epidemic began in October-November, 1807, and was remarked as
unusually fatal[1213].
Several children in the same family had fallen victims to it. Some
cases were fatal in a few days, either from the intensity of the fever
or from pneumonic complication. “But when these symptoms have been
less violent, and the patient has passed without much alarm through
the different stages of the disorder, and even after all apprehension
of danger in the mind of parents or friends has been dismissed, a
continuance or recurrence of pneumonic symptoms has laid a foundation
for phthisis pulmonalis.” In some cases attended from the Westminster
Dispensary, death followed from effusion into the chest or from
membranous inflammation of the trachea. Numbers who recovered from the
measles were afterwards affected with debility, cough, emaciation and
oedematous swellings of the face and extremities which proved very
difficult to remove. These particulars are given mostly for the end of
1807, but it is under the year 1808 that the great rise in the measles
deaths appears in the London bills of mortality.
Besides these accounts for London, we have some details of the same
epidemic at Edinburgh and Aberdeen and exact figures for Glasgow. It began
at Edinburgh in the winter of 1807, and at Aberdeen (as at Glasgow) in the
spring of 1808. At both places it was remarked as unusually fatal, chiefly
from a complication of bowel complaint in children and from pulmonary
affections in adults.
The Aberdeen observer says that in town (the disease being milder in
the country) there were troublesome symptoms in almost every case--a
violent pain in the belly, frequently accompanied with diarrhoea (and
even with vomiting), and with the dysenteric symptoms of tenesmus and
mucus in the stools. This bowel complaint usually lasted three or four
days, and wasted the patients remarkably. There was also the usual
catarrh with violent tickling cough, and, after the acute attack, a
tendency to sudden dyspnoea and “fatal coughs.” In some the
convalescence was lingering and very distressing to the patient: “it
consists in a slow kind of fever, with evening exacerbations[1214].”
The observers at Edinburgh and Aberdeen agree that the epidemic was the
worst that had been seen for many years. Says the former[1215]: “I believe
that the present epidemic has been more general in this place and its
vicinity than ever happened within the remembrance of any medical man at
present living, and I am sorry to say it has been very fatal.” The
Aberdeen chronicler says the mortality was “greater than we have witnessed
for a long period,” and that the epidemic was general throughout the whole
of England and Scotland. But, besides this direct testimony, there is a
not less indirectly significant fact of the epidemic. It affected many
adults--“persons of all ages, who had never had them,” says the Aberdeen
writer: few persons escaped, says the Edinburgh observer, “who had been
previously unaffected by this disease.” The deaths from pulmonic
complaints did not often happen among children, but among people somewhat
advanced in life. Significant also was the outbreak in the Invernessshire
Militia, which marched into Edinburgh in March while the epidemic was
raging. Fifty men, all young recruits newly joined, were attacked in the
course of a few days, the others escaping the disease though equally
exposed to it; in some of those who died in the regiment there were found,
on opening the thorax, fibrinous pleurisy and pericarditis, with effusion
of fluid, as well as evidences of bronchial catarrh[1216]. The Aberdeen
writer says: “I always observed that in full-grown persons the eruptions
were more numerous, quicker in appearing, and longer in going off than in
young subjects.... Many full-grown persons were very ill, yet the measles
were more fatal to the young.” The implication of so many adults in the
severe epidemic of 1808 would of itself show that measles had not been for
some time before a steady and universal affection of infancy and
childhood[1217].
Measles in Glasgow in 1808 and 1811-12: Researches of Watt.
The measles epidemic of 1808, which appears to have been somewhat general
in England and Scotland, made an extraordinary impression in Glasgow. That
disease had never before been nearly so mortal there, nor had any
infection since the time of the plague, not even smallpox itself,
engrossed the burial registers so much as measles did in the months of May
and June, 1808. Glasgow had been the worst city in the kingdom for
smallpox; by a somewhat sudden transition the infancy of the city died for
a few months in larger numbers by the new disease than by the old. The
highest monthly mortalities from smallpox had been 114 in October and 113
in November, 1791, the population being 66,578; but in 1808, the
population having increased to 100,749 by the census of 1811, measles
carried off 259 children in May and 260 in June, and in the months before
and after as follows:
_Measles in Glasgow, 1808._
Month Deaths
Jan. 2
Feb. 2
March 5
April 71
May 259
June 260
July 118
Aug. 32
Sept. 22
Oct. 10
Nov. 4
Dec. 2
The figures were not known at the time; but every doctor in Glasgow, as
well as the whole populace, knew that measles was cutting off the infants,
while smallpox had fallen to insignificance. So dramatic was this turn in
the public health that the common people set it down to the new practice
of inoculating children with cowpox: ready to believe anything of
vaccination, they concluded that, if it kept off smallpox, it brought on
measles. Dr Robert Watt took the trouble to refute this singular notion;
he found in his own practice that three children in one family, and in
another two, had died of measles who had neither been vaccinated nor had
smallpox before. Another great epidemic of measles arose in Glasgow three
years after, in the winter of 1811-12:
Measles
1811 deaths
October 12
November 76
December 161
1812
January 130
February 61
March 30
April 19
May 15
June 18
Those two great epidemics of measles in Glasgow, in 1808 and 1811-12, were
the occasion of one of the earliest and most memorable inquiries in vital
statistics in this country, the research by Dr Robert Watt on “the
Relative Mortality of the Principal Diseases of Children, and the numbers
who have died under ten years of age in Glasgow during the last thirty
years[1218].” Having begun with a search of the principal Glasgow
burial-registers for deaths by whooping-cough, he extended it to sixteen
folio volumes of the registers of all the burial-grounds, old and new, and
included the mortalities from all causes with the ages at death, and from
fevers and the principal diseases of infancy and childhood. The increase
of population from 1783, when his figures begin, to 1812, the date of his
writing, was known to him; but as the numbers living at the respective
periods of life were not known, he was obliged to state the change in the
mortalities at the various ages, and from the various diseases, in ratios
of the annual deaths from all causes,--a perfectly scientific comparison
so long as the nature of the ratios compared was clearly stated. It would
have been more satisfactory, of course, if the comparison could have been
made in terms of the annual death-rate, which was much lower (for reasons
already explained), in the second half of his period than in the first;
but, in the circumstances, that was impracticable, and Watt did the next
best thing. The following is the principal part of his table of ratios in
five successive periods of six years each:
_Vital Statistics of Glasgow in sexennial periods, 1783-1812._ (_Watt._)
Per Per
Per cent. cent. Per Per
Sum cent. from from cent. cent.
of all under Two to Five of of
Period deaths Two Five to Ten Smallpox Measles
1783-88 9994 39·40 10·66 3·42 19·55 0·93
1789-94 11103 42·38 11·90 3·79 18·22 1·17
1795-1800 9991 38·82 12·21 3·45 18·70 2·10
1801-06 10304 33·50 13·43 5·10 8·90 3·92
1807-12 13354 35·89 14·22 5·58 3·90 10·76
Per cent. of Per cent. of
Period Whooping-cough “Bowel-hive”
1783-88 4·51 6·72
1789-94 5·13 6·43
1795-1800 5·36 6·47
1801-06 6·12 7·27
1807-12 5·57 9·26
The actual deaths from smallpox, measles and whooping-cough are shown in
the next table, which includes for comparison the corresponding figures
from the London bills of mortality:
_Smallpox, Measles and Whooping-cough in London and Glasgow, 1783-1812._
London
/----------------------------------\
Year Smallpox Measles Whooping-cough
1783 1550 185 268
1784 1759 29 457
1785 1999 20 194
1786 1210 793 200
1787 2418 84 228
1788 1101 55 298
1789 2077 534 374
1790 1617 119 391
1791 1747 156 279
1792 1568 450 311
1793 2382 248 352
1794 1913 172 469
1795 1040 328 311
1796 3548 307 536
1797 522 222 567
1798 2237 196 418
1799 1111 223 451
1800 2409 395 380
1801 1461 136 428
1802 1579 559 1004
1803 1202 438 586
1804 622 619 697
1805 1685 523 703
1806 1158 530 623
1807 1297 452 439
1808 1169 1386 326
1809 1163 106 591
1810 1198 1031 449
1811 751 235 486
1812 1287 427 508
Glasgow
/----------------------------------\
Year Smallpox Measles Whooping-cough
1783 155 66 153
1784 425 1 41
1785 218 0 34
1786 348 2 173
1787 410 23 57
1788 399 1 17
1789 366 23 45
1790 336 33 177
1791 607 4 117
1792 202 58 68
1793 389 5 112
1794 235 7 51
1795 402 46 180
1796 177 92 60
1797 354 5 76
1798 309 3 98
1799 370 43 95
1800 257 21 27
1801 245 8 125
1802 156 168 90
1803 194 45 60
1804 213 27 52
1805 56 90 129
1806 28 56 162
1807 97 16 85
1808 51 787 92
1809 159 44 259
1810 28 19 147
1811 109 267 62
1812 78 304 103
The ratio of deaths under the age of two had decreased greatly in Glasgow,
while the ratios from two to five and from five to ten had increased. At
the same time smallpox had almost ceased (but only temporarily, as it
appeared) to be the great infectious scourge of infancy, while measles had
come in its place. “Now that the smallpox are in great measure expelled,”
(Watt believed that cowpox inoculation had done this), “the measles are
gradually coming to occupy the same ground which they formerly occupied. I
am sorry to make this statement, but the facts, at least with regard to
Glasgow, are too strong to admit of doubt.”
In order to explain the enormous increase of deaths by measles, he had
recourse to the following argument. Formerly nearly all children, say
nine-tenths, had both smallpox and measles, the attack of smallpox in
most cases coming first. Children who had survived smallpox were
fortified by that ordeal, not merely as selected lives, but
positively fortified, so that measles, when it assailed them in due
time afterwards, was taken mildly or was “modified,” not one in a
hundred cases proving fatal. But now (1813), when so few children have
been through the smallpox, measles has become ten times more fatal to
them, although it could hardly be more common than it used to be.
Having found it necessary to assume that children in former times took
smallpox before they took measles, nine-tenths of them taking both, he
qualifies this in another passage: “Still, however, as the measles
came round now and then, as a very general epidemic, they must
occasionally have had the precedence, and it was perhaps chiefly among
such patients that the disease proved fatal.”
The measles which came round now and then as a general epidemic was
nearly the whole of it; even in London there were intervals of several
years with only a few annual deaths, and in smaller towns or country
districts the clear intervals were longer. The prevalence of measles
on the great scale being more casual than that of smallpox, it is
likely that most children had taken smallpox before they incurred
measles. But it is clear from such instances as the London epidemic of
1674, and the epidemic in the Foundling Hospital in 1763, that measles
might attack children just before smallpox, and by its weakening
effects, increase the number of victims of the latter. As to the
fatality of measles itself in the 17th and 18th centuries, the
statement of Watt that it did not amount to one death in a hundred
attacks, while it can neither be proved nor disproved by an array of
figures, can be shown to be inconsistent with the language of
annalists. The epidemics of measles varied in severity then as
afterwards: that of 1670 in London was regular and mild, that of 1674
in the very same months of the year was anomalous and fatal; Huxham
characterizes the measles at Plymouth in the winter of 1749-50 as
“maximé epidemici, imo et saepe pestiferi”; at Kidderminster, in 1756,
after fevers had been very fatal to adults, the measles went through
the town so that an immense number of children “died tabid”; in the
West of England about 1760 a disease called measles made “a melancholy
carnage amongst children.”
While Watt’s theory of the working of this principle of substitution is
open to criticism on some points of detail, the law itself, as enunciated
by him, remains to the present time one of the soundest and most
instructive generalities in epidemiology. He based it upon a laborious
search of the burial registers, such as no one before him in this country
had undertaken. Next he saw correctly that a great rise in the deaths of
infants by such a disease as measles could only be accounted for by a
great increase in the rate of fatality. Thirdly, he connected the loss
from measles with the saving from smallpox. Adopting an old opinion, which
may be discovered in Willis[1219], he argued that smallpox, when taken
first, served to fortify children so that they passed easily through the
measles afterwards; but in the following passage he indicated a better
reason why the absence of smallpox gave measles the chance of proving more
fatal: “In this point of view we are not to consider the smallpox as so
peculiarly fatal in their nature. They perhaps prove so fatal merely by
having the start of other diseases. The measles, the chincough, the croup,
the scarlet fever, and perhaps many others, would have proved equally
fatal had they occurred first.” The principle is true to this extent, that
a certain proportion of weakly infants, or children of poor stamina, will
succumb to almost any disease--if not to smallpox, then to measles, and if
not to measles directly, then to the sequelae of measles. This was
perceived in the form of a necessary truth by Haygarth in 1793: “A
considerable number of those who now die of the smallpox would die in
childhood of other diseases if this distemper were exterminated[1220].” It
was commonly believed that smallpox had at length found its real
artificial check, not in the inoculation of itself, but in the inoculation
of cowpox. At all events it had declined greatly in Glasgow. During the
three years before the measles epidemic of 1808, there could hardly have
been more than a thousand children attacked by smallpox, or not one in ten
of all the children born. During several years the infancy of the city had
been spared any great ordeal of infectious disease; the first epidemic
that came along happened to be measles, so that it fell to that infection
to take off the weaklings. In the economy of nature it is impossible to
rear all the young of a species, nor would it be good for the species if
it were possible. It is among the birds that the principle of population,
or of the survival of the fittest, is seen working in the most admirable
way: the annual migration of many species to breed in a remote country
brings with it an ordeal for the birds of the year in finding their way to
the winter feeding-grounds--an ordeal which only the strongest come
through. For some unexplained reason, the young of the human species are
peculiarly tried by infectious diseases, which multitudes pass through
safely, while many of poor stamina or of ill tending are cut off.
Dr Watt’s teaching, as to the displacement of one infectious cause of
death by another was resisted at the time as being of “evil tendency”
for the pretensions of vaccination, although Watt believed as firmly
in the virtues of cowpox as Jenner himself did. Writing to James Moore
on 6 Dec. 1813, Jenner says of Watt’s essay (Baron, II. 392): “There
is nothing in its title that developes its purport or _evil
tendency_.... Is not this very shocking? Here is a new and unexpected
twig shot forth for the sinking anti-vaccinist to cling to.” Sir
Gilbert Blane, who was then president of the Medical and Chirurgical
Society, having a natural fondness for ideas of all kinds expressed in
a paper to that society rather more approval of Watt’s view than was
thought prudent: “An ingenious friend of mine has remarked to me in
conversation that some light is thrown on this subject by considering
that whichever of the epidemic maladies attack children first, it will
be the most fatal, inasmuch as all feeble constitutions will fall in
its way while the stronger will be left to encounter the attacks of
the others; and that the smallpox, owing probably to the greater
abundance and rankness of their effluvia, are generally caught in a
casual way before measles, hooping cough and scarlet fever, and are
therefore reckoned more fatal than any of these. But, a new field of
research being opened,” etc. Efforts were made to correct the effect
of this, by showing that measles in some parts of the country had not
been more fatal than usual. Holland, of Knutsford, attributed the
fatality of the epidemic in 1808 to a change of the wind to the east.
Writers in the _Edinburgh Med. and Surg. Journal_, pointed out that
Watt had compared the absolute deaths by smallpox at one time and by
measles at another without taking account of the increase of
population, and the rates of mortality from each disease. The best
criticism of Watt was by Roberton in his _Mortality of Children_,
1827, p. 49. He offers the following considerations, without seeming
to know that they were really to be found in Watt’s own essay:
Smallpox used to be caught first; it swept off the feeble and sickly,
leaving the strong and vigorous _only_ to encounter the attacks of
other diseases. “That infectious febrile disease to which in early
infancy there is the strongest predisposition will of course in
general make the first attack and prove the most fatal of any.” There
were reasons why measles used to have comparatively few victims, “and
why, when they now prevail epidemically, they, as was the case with
smallpox, are caught at an earlier age than other diseases in general
and prove so very fatal: which happens not more from their priority in
attack than from being in their nature what they were ever
considered--a severe and dangerous disease. We are to recollect,
however, that measles do not in general attack at so early an age as
smallpox; nor ever, like the latter, destroy eight or nine-tenths of
all the children that die in the place where they happen to prevail,
as was the case in the variolous epidemics of Chester and Warrington
[this is an error, _vide supra_, p. 554]; consequently we have reason
to hope that neither measles nor any other infantile disease will, as
Dr Watt imagined, ‘come to occupy the place which smallpox once
occupied,’” (p. 58). A feeble echo of Roberton’s criticism, with all
its scientific candour left out and its points against Watt emphasized
in a spirit of paltry cavilling, was heard next year in the
Goulstonian Lectures of Bisset Hawkins on _Elements of Medical
Statistics_, 1829.
Many years after, when the enormous increase of deaths by scarlatina
was illustrating the doctrine of displacement in a new way, Dr Farr
gave a full analysis of Watt’s essay in his annual Letter to the
Registrar-General for the year 1867, and endorsed the Glasgow teaching
of 1813 with more heartiness than it had hitherto received. Although
Farr did not take the Malthusian view that the loss of weakly children
by one means or another was inevitable, yet he could not help seeing,
in his work upon the registration returns from 1837 onwards, that one
infection had been taking what another spared. He recurred to Watt’s
doctrine time after time in his annual reports, and in that of 1872
(p. 224), expressed his belief thus plainly: “The zymotic diseases
replace each other; and when one is rooted out, it is apt to be
replaced by others which ravage the human race indifferently whenever
the conditions of healthy life are wanting. They have this property in
common with weeds and other forms of life: as one species recedes,
another advances.”
Two remarks remain to be made under the doctrine of displacement. The
first is that the substitution of measles for smallpox was one of a
series of such changes in the public health of Britain. The great
infective scourge of medieval and early modern periods had been plague,
which destroyed at times immense numbers of the valuable or mature lives.
Its successor was typhus fever, which also cut off the parents more than
the children, but did not retard population as the plague had done. The
saving of life by the extinction of plague was in great part balanced by
the loss from smallpox, which fell, however, more and more upon the
earliest years of life until at length it was almost confined to them. The
first great decline of smallpox itself corresponded to a great decline of
typhus fever during the second half of the French war; but while there was
no great infectious disease in those years to thin the ranks of the
adults, measles took the place of the more loathsome smallpox in cutting
off a certain number of young lives. While the older types of infection
have disappeared, the incidence has shifted from mature lives to children,
so much so that at the present time enteric fever, and occasional choleras
and influenzas, are almost the only infections that correspond to the old
plague and to typhus fever in their age-incidence.
The other remark is that the greater prevalence or fatality of measles, as
if in lieu of smallpox, meant a good deal more for the bills of mortality
than actually appeared under the name of measles. Smallpox was not an
infection that did much constitutional damage to those that came through
it, although it sometimes destroyed the vision and spoiled the beauty of
the face. On the contrary, it was held by many that the general health was
better after an attack of smallpox than before; and, if personal
experience can justify an opinion, that ought to be my own view of the
matter[1221]. But measles is an infection peculiarly apt to leave mischief
behind. The bronchial catarrh, which is an integral part of the malady,
and is often the cause of death in the second stage of the attack, may so
affect weakly children that the respiratory organs are permanently
damaged. Tuberculosis of the lungs is apt to follow measles. Some
children, again, fall into mesenteric disease after measles, and die
tabid, the intestinal catarrh being as dangerous in one way as the
bronchial is in another. Another large proportion of the subjects of
measles take whooping-cough[1222]. While smallpox did its work summarily,
the full effects of measles were longer in being realized. This may in
part explain the fact brought out by Watt, that while fewer children died
under two years of age, measles being the dominant epidemic disease, there
was an increase in the ratio of deaths from all causes between the years
of two and five and from five to ten.
Measles in the Period of Statistics.
The history of measles for nearly a generation after the great epidemics
of 1808 and 1811-12 is little known. No one in Glasgow continued Watt’s
laborious tabulation of the causes of deaths in the numerous burial
registers[1223]; nor was any regular account kept elsewhere except by the
Parish Clerks of London. The following deaths by measles in their bills
from 1813 to 1837, when the modern registration began, were probably no
more than from a third to a half of the deaths in all London:
Measles
Year deaths
1813 550
1814 817
1815 711
1816 1106
1817 725
1818 728
1819 695
1820 720
1821 547
1822 712
1823 573
1824 966
1825 743
1826 774
1827 525
1828 736
1829 578
1830 479
1831 750
1832 675
1833 524
1834 528
1835 734
1836 404
1837 577
The inadequacy of these figures to the whole of London will appear from
the fact that the registration returns under the new Act gave for the last
six months of 1837 the measles deaths at 1354, while the bills of the
Parish Clerks gave them at 577 for the whole year. But the old bills
enable us to compare the deaths from different diseases within the same
area and under the same system of collection, and to compare the deaths
“within the bills” in a series of years since the last of the new parishes
were taken in about the middle of the 18th century. Using the bills so far
legitimately, we find that measles at length came to be of equal
importance with smallpox itself as a cause of death in childhood, and that
it had become a larger and steadier total from year to year.
So far as concerns Glasgow, the high mortality from 1807 to 1812, making
10·76 on an annual average of the deaths from all causes, was not
maintained. When the tabulation of the causes of death was resumed from
1835, the annual average of measles for the five years ending 1839 was
found to be only 6 per cent. of the deaths from all causes, the average of
smallpox having come back to 5·3 per cent. During that unwholesome period,
in which there was much distress among the working class and a great
epidemic of typhus, measles and smallpox were dividing the infectious
mortality of childhood somewhat equally, the age-incidence of measles
being only a little lower than that of smallpox:
_Ages of the Fatal Cases of Measles in Glasgow, 1835-39_[1224].
Under one 1-2 2-5 5-10 10-20 20-30 30-40 40-50 Total
1835 116 141 121 34 10 4 - - 426
1836 86 209 183 38 1 1 - - 518
1837 77 133 122 16 2 1 350
1838 76 124 161 39 3 1 1 405
1839 165 259 275 73 7 2 1 783
--------------------------------------------------------
520 866 863 200 23 9 1 1 2482
In Limerick, which may stand for a typically unhealthy Irish city in the
worst period of over-population, there were many more deaths from smallpox
among children than from measles, the age-incidence being nearly the same,
according to the following dispensary statistics for a number of years
before 1840[1225]:
_Limerick Dispensary Deaths._
Age 0-5 5-10 10-15 15-20 Total
Smallpox 333 55 5 0 393
Measles 187 32 6 1 226
Scarlatina 8 2 10
Although it is impossible to prove it, yet the indications all point to
measles having kept for a whole generation after 1808 the leading place
among infantile causes of death which it then for the first time
definitely took[1226]. Almost the only direct references to the subject
were made by way of controverting the doctrine of Watt; but these are too
meagre, or too general in their terms, to be of any use[1227]. The
epidemics of measles seem to have travelled then, as they do now, from
county to county in successive years. Thus in 1818, while most parts of
England were or had recently been suffering from smallpox, the Eastern
counties were suffering from measles “very frequent and fatal.” Smallpox
at length reached Norwich in 1819, and became the reigning epidemic in the
place of measles, which was “hardly met with” so long as the enormous
mortality of the other disease proceeded[1228]. At Exeter in the spring of
1824 measles became epidemic after a long interval; many susceptible
children had accumulated, and of these few escaped. The mortality was very
great, and was caused by severe pulmonary inflammation, the catarrhal
symptoms being mild. In one day seventeen children were buried in one of
the five parish churchyards of the city; but that high mortality,
according to the parochial surgeon, did not on an average stand for more
than four deaths in one hundred cases[1229].
When the curtain rises, in the summer of 1837, upon the prevalence and
distribution of diseases in England, as ascertained by the new system of
registration of the causes of death, measles is found in the first place
among the infectious maladies of childhood, thereafter yielding its place
to smallpox for a year or more, and taking the lead again until it was
passed by scarlatina.
_Deaths by Measles and Smallpox in London, 1837-39._
1837 1838 1839
3rd Qr. 4th Qr. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. (four quarters)
Measles 822 532 173 96 94 225 2036
Smallpox 257 506 753 1145 1061 858 634
The epidemic of smallpox hardly touched the Eastern counties until 1839;
so that while the home counties in that year had far more deaths by
measles than by smallpox, Norfolk had only 72 deaths by the former against
820 deaths by the latter. In the same year measles took the lead in four
out of six great English towns, scarlatina being the dominant infection in
one (Sheffield), and smallpox in one (Bradford):
_Deaths in 1839 by the three chief infections of Childhood._
Liverpool Manchester Leeds Birmingham Sheffield Bradford
Measles 401 773 383 170 33 70
Scarlatina 374 264 35 133 419 7
Smallpox 259 237 171 56 16 208
In all England and Wales during fully half-a-century of registration,
measles has fluctuated somewhat from year to year but has not experienced
a notable decline among the causes of infantile mortality (see the table
at p. 614). In the decennial period 1871-80, its annual average death-rate
was 377 per million living; in the next decennium it rose to 441, the
previously high rates of scarlatina having fallen greatly. Among the
highest rates for the ten years 1871-80, were those of Plymouth, 1·13 per
1000, East Stonehouse 1·79, and Devonport 1·19 (owing to a great epidemic
in 1879-80), Exeter, 0·82, Liverpool ·91, Bedwelty (Tredegar and
Aberystruth collieries) 0·88, Wigan 0·74, Whitehaven 0·71, Alverstoke
0·81. In the most recent period there have been some very high
death-rates; thus at Jarrow the annual rate, which was only ·27 per 1000
from 1871 to 1880, rose in the nine years 1881 to 1889 to an annual
average of ·94, having been made up almost wholly by great epidemics every
other year--in 1883 (2·9), 1885 (2·4), 1887 (1·4), and 1889 (·9)[1230]. In
the year 1888, an epidemic at Stoke-on-Trent, Hanley, &c. with 342 deaths,
made a rate of 2·8 for the year; in Wolstanton, Burslem, &c., 221 deaths
were equivalent to a rate of 2·6.
The latest reports of the Registrar-General have traced a progression of
the epidemic of measles from county to county or from district to district
in successive years, such as was remarked, both for smallpox and measles,
by some of the 18th century epidemiologists in England, Scotland and
Ireland.
Thus in 1890, measles was epidemic in Cheshire, South Lancashire and
North Staffordshire; in 1891 it ceased in these, but became epidemic
in North Lancashire, South Staffordshire and the West Riding; in 1892
it ceased in its last-mentioned area, and became epidemic in
Warwickshire, Leicestershire, Derbyshire, the East and North Ridings,
Westmoreland and Durham. During the same three years a similar
progression or cycle was observable (on looking over the tables) in
the South-west of England. The epidemic year of measles in Devonshire
was 1889. It ceased there, and became epidemic in 1890 in Cornwall on
the one side and in Somerset on the other, sparing Dorset. In 1891 it
ceased to be epidemic in those parts of Cornwall and Somerset which it
occupied in 1890, and became prevalent in the extreme west of
Cornwall, in parts of Somerset, in Wiltshire and in Gloucestershire.
In 1892 it ceased in all the last-mentioned excepting Gloucestershire,
and became epidemic in Dorset, where there had been no severe
prevalence of measles since 1888[1231].
Measles has no such decided preference for a season of the year as
scarlatina and enteric fever have for autumn or infantile diarrhoea has
for summer. But it often happens that most deaths are recorded from May to
July, owing, doubtless, to the greater number of attacks in summer and not
to any excessive fatality of that season. In London and the great
industrial towns the deaths are spread somewhat uniformly over the year;
or, in the language of statisticians, the maxima do not rise far above the
mean of the year. In a tabulation of the weekly deaths in London from 1845
to 1874[1232], it appears that they touch a higher point in mid-winter
(Nov.-Jan.) than in summer, a fact which may be readily accounted for by
the injurious effects of the London air in winter upon a disease which is
largely a trouble of the respiratory organs. In the great industrial
populations of Lancashire, which resemble London in their high death-rate
from measles, the rise of the deaths in mid-winter is almost the same as
the summer increase[1233].
Most of the deaths from measles fall at present upon the ages from six
months to three years, just as they did when the deaths were comparatively
few, as at Manchester from 1768 to 1774. Deaths of adults, which were not
altogether rare in the first great epidemic of modern times in 1808, are
seldom heard of at present, for the same reason that adult deaths used to
be uncommon in smallpox, namely, that the disease is passed by almost
everyone in infancy or childhood. Although the deaths from measles
sometimes reach large totals--in London during the spring of 1894 they
were in some weeks as high as one hundred and fifty--yet it is the common
experience of practitioners that a strong or healthy child rarely dies of
measles, that the fatalities occur among the infants of weakly
constitution, and especially in the numerous families of the working class
in the most populous centres of mining, manufactures and shipping.
To bring these various characteristics of measles together in a concrete
instance, I shall give briefly the facts of a recent epidemic in a town in
Scotland of some twelve thousand inhabitants. There had been only five
deaths from measles for two years. There had not been a case of smallpox
for at least ten years. The measles epidemic, when its triennial
opportunity came, reached a height in July, on a certain day of which
month there were seven or eight burials from measles or its direct
sequelae. Nearly all the children in the place who had not been through
the measles in the corresponding epidemics of 1889 or 1887 suffered from
it on this occasion, excepting the class of very young infants. The deaths
in the whole epidemic numbered about fifty, which would not all be
registered, however, as from measles. Yet this high mortality was not due
to any unusual malignancy of the disease, but to the feeble stamina of a
certain number of infants, or to the indifferent housing and tending of
the poorer class. One did not hear of a death in the well-to-do families
(probably there was none), although they had their full share of attacks.
The frequency of the burials for a short time, and the effects of the
epidemic on the mortality from first to last, must have been very nearly
the same as in an epidemic of smallpox a century before, when the
population was only a third or fourth part as large. But in the period
when smallpox was in the ascendant, having few rivals among the infective
causes of death in childhood, the general conditions of health in this
town were altogether different. One or two specimens of the thatched huts
of the poorer class had been left standing into the era of photography, so
that we could compare past with present, in externals at least; also, of
the houses of the richer class some still remained, perhaps turned into
tenement-houses, with small windows, low doorways, and crow steps on their
gables; and it was on record by the parish minister at the end of the 18th
century, that within the memory of that generation there had been peat
stacks and dunghills before the doors on the High Street of the burgh.