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
1802. It ceased in summer, but returned at intervals during the years
1803-4, when the disease changed its character; and although
scarlatina epidemics recurred very frequently during the next
twenty-seven years, yet it was always in the simple or mild form, so
that I have known an instance where not a single death occurred among
eighty boys attacked in a public institution. The epidemic of
1801-2-3-4, on the contrary, was extremely fatal, sometimes
terminating in death (as appears by the notes of Dr Percival kindly
communicated to me) so early as the second day. It thinned many
families in the middle and upper classes of society, and even left not
a few parents childless. Its characters seem to have answered to the
definition of the scarlatina maligna of authors.”
The long immunity from malignant scarlatina which Graves asserts for
Ireland after 1804, is made probable also for England and Scotland after
1805, by the fewness of the references to it in medical writings. Bateman
in 1804 resumed the regular reports on the prevalent diseases of London,
which Willan had left off at the end of 1800, and continued them until
1816[1335]; but he makes very few references to scarlatina compared with
his predecessor. The two occasions when it is said to have been somewhat
common were in 1807-8, during the severe epidemic of measles (and then it
was “generally mild, presenting the eruption with a slight sore-throat”),
and in 1814 when it was “very prevalent” along with measles. In Scotland
during the same epidemic of malignant measles, in 1808, scarlatina was
only occasional, and mild. It is heard of in its old malignant form from
two localities of England, during the time of distress and typhus fever in
1810-11. At Nottingham it was “very prevalent, passing through whole
families,” in September, 1810, and in October became more violent and
often fatal[1336]. In the district around Debenham, in Suffolk, where it
was last reported by the same observer in 1803, it made its appearance in
February, 1810, in its very worst forms, causing deaths of children and
adults in many houses, and destroying some children within forty-eight
hours from the first attack. “All the surgeons for ten miles round have
had to attend to scarlatina maligna in a variety of cases in all ages,
from infants to fifty and sixty years.” It was still raging in October,
1810, and was breaking out “in different spots around this country, that
appear to have had no communication with the afflicted[1337].”
It is not until 1831 that we begin to hear much of malignant scarlatina
again. But it is clear that scarlet fever was common enough all through
that interval, probably in its milder form. It was now the usual epidemic
trouble of schools. In September and October, 1814, there were fifty-five
cases, mostly mild, in children and two in adults in the Asylum for Female
Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal
Military College at Marlow, having been followed by anasarca in only one
instance[1339]. Heysham, whose exact records of epidemics at Carlisle were
made twenty or thirty years earlier, mentions casually in 1814 that
scarlet fever had been “more frequent of late,” but that it did not spread
as formerly[1340]. Other references to it in this interval are to show how
seldom fatal it was under the cold water treatment or the lowering
regimen[1341]. At the Newcastle Dispensary fully twice as many cases of
scarlatina were attended in the twenty-five years 1803-27 (795 cases) as
in the twenty-five years 1777-1802 (355 cases); but in the larger total,
which an increasing population might account for, there were actually
fewer fatalities (30) than in the smaller (33); the highest number in any
one year was 71 in 1824, of which every one is entered as having
recovered. This is the impression derived from various sources--that the
scarlatina from about 1803 until about 1830 may have been frequent, but
that it was mild, or easily treated, or not often fatal. Macmichael,
writing in 1822, not only testified that the “scarlatina of last summer
was very mild,” but argued that the malady in general was taken by many in
those years in so mild a form that it was not recognized as scarlatina, “a
name that sounds so fearfully in the ears of mothers,” and a rare disease
in families compared with measles or even with smallpox. His point is that
scarlet fever was in fact as nearly universal as measles, but that, as it
was often extremely slight, it passed for rose rash or the like; at the
same time he identified these slighter forms with true scarlatina by
simply pointing to the oedema which might follow them[1342].
The testimony of Graves, of Dublin, who occupies many pages of his
‘Clinical Medicine’ with the disastrous scarlatina in various parts of
Ireland about 1834, is conclusive that the severe type was new in the
experience of that generation:
“I have already mentioned that the disease called scarlet fever
assumed a very benign type in Dublin soon after the year 1804, and
continued to be seldom attended with danger until the year 1831, when
we began to perceive a notable alteration in its character, and
remarked that the usual undisguised and inflammatory nature of the
attack was replaced by a concealed and insidious form of fever,
attended with great debility. We now began occasionally to hear of
cases which proved unexpectedly fatal, and of families in which
several children were carried off; still, it was not until the year
1834 that the disease spread far and wide, assuming the form of a
destructive epidemic[1343].... Many parents lost three of their
children, some four, and in one instance which came to my knowledge,
five very fine children were carried off.” The severe cases were mixed
with others of scarlatina simplex. The violence of the attack lay in
the throat-affection, the congestion of the brain, or the irritability
of the stomach and bowels, nausea, vomiting and diarrhoea being early
symptoms, as in the malignant sore-throat with rash a century before.
Graves proceeds, with much candour, to show how mistaken had been the
reasons assigned equally for the mild type of scarlatina between 1804 and
1831 and for the severe type of it previous to 1804:
“The long continuance of the period during which the character of
scarlet fever was either so mild as to require little care, or so
purely inflammatory as to yield readily to the judicious employment of
antiphlogistic treatment, led many to believe that the fatality of the
former epidemic was chiefly, if not altogether, owing to the erroneous
method of cure then resorted to by the physicians of Dublin, who
counted among their numbers not a few disciples of the Brunonian
school; indeed, this opinion was so prevalent, that all those whose
medical education commenced at a much later period, were taught to
believe that the diminished mortality of scarlet fever was entirely
attributable to the cooling regimen and to the timely use of the
lancet and aperients, remedies interdicted by our predecessors. This
was taught in the schools, and scarlet fever was every day quoted as
exhibiting one of the most triumphant examples of the efficacy of the
new doctrines. This I myself learned--this I taught: how erroneously
will appear from the sequel. It was argued, that had the cases which
proved fatal in 1801-2 been treated by copious depletion in their very
commencement, the fatal debility would never have set in, for we all
regarded this debility as a mere consequence of previous excessive
reaction. The experience derived from the present [1834-35] epidemic
has completely refuted this reasoning, and has proved that, in spite
of our boasted improvements, we have not been more successful in
1834-5 than were our predecessors in 1801-2.”
From 1829 to 1833 there are numerous references to the scarlatina maligna
in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in
1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346]
in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348]
in 1832-1833. It is in 1830 that scarlet fever begins to have a line to
itself in the old and inadequate bills of the Parish Clerks of London, the
deaths that year being 94; in the next seven years they are 143, 388, 481,
523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths
from it in Glasgow[1349] for five years, during which they fell much below
the deaths from either measles or smallpox.
_Deaths from Scarlatina in Glasgow._
Under one 1-2 2-5 5-10 10-20 20-30 30-40 40 and up. Total
1835 27 50 89 73 23 7 2 2 273
1836 34 57 136 86 25 9 5 3 355
1837 4 9 34 22 5 3 1 1 79
1838 3 15 42 17 7 1 1 1 87
1839 29 45 104 74 10 -- -- -- 262
The two first years of this period, which had the most scarlatina deaths,
correspond to the years of the Dublin epidemic, and were also the years
when it was common in Edinburgh[1350]. Probably the smaller mortality of
Glasgow in 1837 and 1838 was general; for, when registration of the causes
of death began in England and Wales in the latter half of 1837, it found
the scarlatina mortality at a much lower figure than it reached in 1839
and continued to keep thereafter.
Scarlatina since the beginning of Registration, 1837.
The first returns of the causes of death under the new Registration Act
happened to correspond with a great epidemic of typhus fever, and with an
equally great epidemic of smallpox which took its victims in largest part
among infants and young children. The deaths from scarlatina were also
considerable during those two years and a half; but in 1840 scarlatina
nearly doubled its mortality, and continued year after year for a whole
generation to be the leading cause of death among the infectious maladies
of childhood. The figures for England and Wales are given in a table at p.
614, in comparison with the annual deaths by smallpox, measles, and
diphtheria. The enormous number of deaths from scarlatina during some
thirty or forty years in the middle of the 19th century will appear in the
history as one of the most remarkable things in our epidemiology. There
can be no reasonable doubt that this scarlatinal period was preceded by a
whole generation with moderate or small mortality from that disease, just
as it is now being followed by annual death-rates which are less than a
half, perhaps not more than a third, of the average during forty years
before 1880.
The first great epidemic all over England was in 1840 (it had reached a
maximum in London the year before), another came in 1844, a third in 1848
(in which the London death-rate was 2·12 per thousand living). In the next
decennial period, 1851-60, the worst years for scarlatina were 1858-59,
which were also the years of the return of diphtheria; in the period
1861-70, the great scarlatinal years were 1863-64 and 1868-70; in the
period 1871-80, the year 1874 was the epidemic year. The annual average
death-rates per million inhabitants in all England and Wales were as
follows in four decennial periods:
1851-60 832
1861-70 972
1871-80 716
1881-90 338
In the greatest epidemic years since 1863 the death-rates per million for
the whole country have been:
1863 1498
1864 1443
1868 1020
1869 1275
1870 1461
1874 1062
In those years scarlatina made from four to six and a half per cent. of
the deaths from all causes.
While no county of England has been free from this infection, the bulk of
the deaths have fallen upon the capital, the great Lancashire and West
Riding towns, the Black Country of Staffordshire with Warwickshire, the
mining districts of Durham and South Wales, and, in the earlier part of
the period, upon the south-western counties.
_Highest Mortalities by Scarlatina in three Epidemics._
/-----------\ /-----------------\
1863 1864 1868 1869 1870 1874
England and Wales 30475 29700 21912 27641 32543 24922
-------------------------------------------------------------------
London 4955 3244 2916 5841 6040 2648
Lancashire 4580 4854 4445 4890 3702 6404
West Riding 2218 3135 1676 2870 3718 3779
Durham 1216 403 2678 1512 983 1941
South Wales 501 1990 285 804 1370 1388
Staffordshire 1147 1134 943 1198 1064 1270
Devonshire 778 1054 60 155 646 72
Cornwall 995 572 254 161 587 50
Somerset 773 1013 55 154 584 173
In Lancashire and South Staffordshire there has been less fluctuation of
the mortality from year to year than elsewhere. The stress of an epidemic
has not fallen equally on all the principal centres in the same year or
years: thus Durham has had the epidemic in advance of other centres, while
South Wales has had it in arrear. The decline of the south-western
counties from their leading position in 1863-64 has been remarkable.
Plymouth, Devonport and Stonehouse, which had contributed most to the high
scarlatinal death-rate of Devonshire in 1863-64, were found on the average
of the next decennial period to have low rates from scarlatina, but
death-rates from measles which were unapproached in any other region of
England. In the following table four Devonshire towns are compared with
certain Staffordshire registration districts in which the scarlatinal
death-rate has remained high.
_Annual average Death-rates per 1000 living, 1871-80._
All causes Scarlatina Measles
{Plymouth 22·63 ·25 1·13
{E. Stonehouse 28·23 ·33 1·79
{Stoke Damerel 20·42 ·37 1·19
{Exeter 24·99 ·50 ·82
{Stoke-on-Trent 25·80 1·22 ·49
{Wolverhampton 22·78 1·05 ·35
{Walsall 22·82 1·21 ·30
{Dudley 24·24 1·18 ·59
This looks like a correlation between measles and scarlatina. The
excessive death-rate from measles in Plymouth, Stonehouse and Devonport
was due to a disastrous epidemic in the last two years of the decennium,
1879 and 1880 (338 deaths at Plymouth, 121 at Stonehouse, and 235 at
Devonport). Measles remained high in Plymouth all through the next
decennium, scarlatina still continuing low until the very end of it, when
in 1889 there was a mortality of 270, equal to a death-rate of 3·39 per
1000 living. In like manner Stoke-on-Trent had its great epidemic of
measles in 1888, causing 342 deaths, or a rate of 2·8. The high Plymouth
death-rate, after nearly twenty years with extremely little scarlet fever,
was surpassed in 1882 by an epidemic of 346 deaths in the colliery
townships of Aberystruth and Tredegar, Monmouthshire, equal to a
death-rate of 6·1 per 1000. Other high death-rates for single years were
at Wakefield and Swansea in 1889 and at Neath in 1890. The highest
death-rates from scarlatina on an average of ten years, 1871-80, were at
Durham 1·70, Todmorden 1·64, Auckland 1·63, Gateshead 1·60, Sheffield
1·49, Leigh 1·41, Wigan 1·30, Newcastle 1·28. The purely agricultural
counties have the lowest death-rates[1351].
As to age-incidence, the proportion of deaths under five has been almost
exactly two-thirds steadily for the last four decennial periods (supra p.
625). The following table by Dr Ogle, the Superintendent of Statistics,
shows both age and sex of the scarlatina mortality[1352]:
_Mean annual Mortality from Scarlet Fever per million living at successive
age-periods 1859-85. England and Wales._
Age Males Females
0-1 1664 1384
1-2 4170 3874
2-3 4676 4491
3-4 4484 4332
4-5 3642 3556
0-5 3681 3482
5-10 1667 1613
10-15 346 381
15-20 111 113
20-25 59 77
25-35 36 58
35 and upwards 13 15
All ages 778 717
From certain hospital statistics on a large scale, and some figures of
cases and deaths at Christiania, it was also found that the attacks of
scarlatina were much more fatal in the first years of life, the fatality
decreasing rapidly after five. This was only to be expected. But it was
somewhat surprising to find that more girls were attacked than boys, while
the fatalities among boys were more than among an equal number of girls at
all ages until womanhood, when the few females attacked by scarlatina had
more fatalities among them than the somewhat fewer males of the same ages.
A slight excess of fatality in the female sex over the male between the
ages of ten and twenty years, is shown also for smallpox by the table at
p. 618. Recent notifications of infectious diseases to medical officers of
health have enabled a comparison to be made between the number of cases of
scarlatina notified, with age and sex, and the number of deaths certified
in the corresponding time and place to the Registrar-General; from which
the above generalities as to the proportions of fatal cases in the several
age-periods of either sex have been confirmed[1353].
The enormous mortalities of some years may be taken to have depended in
part upon an increased prevalence of the disease, but still more upon an
increased fatality among the subjects of it. Since the establishment of
the Metropolitan Fever Hospitals in 1870 the percentage of deaths to cases
has ranged from 15·3 in 1879 to 6·6 in 1873 and 6·7 in 1891. Among the
smaller totals of the London Fever Hospital the percentage of deaths has
ranged even more widely from year to year[1354]. What is thus
statistically proved is also a matter of common experience; there have
been whole epidemics, extending perhaps over two or three years, marked by
high malignancy, and epidemics just as uniformly marked by mildness of
type. The severe type has usually been made by the sloughing in the neck
or throat; but there has also been a class of cases tending to a fatal
issue early in the attack by a sunken pulse and with few external
manifestations. The cause of these variations in the severity of
scarlatina is the old problem of epidemic constitutions: sometimes the
constitution is “putrid” or “pestilential” or malignant, sometimes it is
mild or benign.
Graves, in the passage above cited, has sufficiently exposed the fallacy
of attributing changes of type to modes of treatment. On the other hand
there is reason to think that the percentage of deaths (by which the
“type” is usually judged) is higher in children carried off to hospitals
than in those treated at home. As the same fact has been uniformly
observed in epidemics of Asiatic cholera, when the ambulances have been
almost as busy as those of the Metropolitan Asylums Board during an
ordinary autumnal rise of scarlatina, it is probable that the reasons
which used to be given in the former case hold good also in the latter.
_Scarlet Fever in London, 1890 and 1891._
All Cases Treated Treated in Fatalities Fatalities in
Year Notified at Home Hospital at Home Hospital
1890 15330 8793 6537 348 510
or 3·95% or 7·8%
1891 11398 6136 5267 232 357
or 3·8% or 6·8%
This is a comparison of two parts of the same epidemic, which had a very
moderate fatality in any case. The real problem of malignity or severity
of type arises over such epidemics as those of 1840, 1848, 1858-59,
1868-70 and 1874, in which the doubling of the deaths, for one year, or
for two or even three consecutive years, had depended less upon an
increased number of seizures than upon a higher ratio of fatalities. An
explanation for each occasion will have to be sought either in the
condition of the patients, or in the inherent properties or external
favouring circumstances of the virus. As to the former, the most fatal
epidemic years of scarlet fever have not been marked in any such uniform
way as the great seasons of typhus or relapsing fever; nor is scarlatina
an infection that keeps mainly within the poorer classes. Among factors of
the external kind, a rainfall below the average has been thought a
relevant thing: thus in the three years 1862-64, the annual average
rainfall at Greenwich was only 20·6 inches, the scarlatina death-rate in
London for the same years reaching the high figure of 1·33 per 1000
inhabitants; in the next three years, 1865-67, the death-rate fell to ·56
(it would have fallen in any case), while the rainfall reached the very
high average of 29 inches; in the three years following, 1868-70, the
death-rate reached the excessive annual average of 1·5 per 1000 in London,
the rainfall of the same period averaging only 22·3 inches. Thereafter for
a number of years the rainfall was moderate and the scarlatina death-rate
low; but in the years 1883-87, they were both low together, the scarlatina
death-rate of ·26 being lower than it had ever been since registration
began[1355].
Although an empirical correspondence between the great scarlatina periods
and a series of dry years has not been made out without important
exceptions, hitherto unexplained, yet there is a very obvious
correspondence between the great rise of scarlatina deaths in London every
year and the season of late autumn, which is the season when the
ground-water touches its lowest level or begins to rise therefrom to the
high water-mark of spring. Of all the curves of seasonal rise and fall
constructed by Buchan and Mitchell from the weekly bills of mortality in
London from 1845 to 1874, that of scarlatina is the most decided next to
that of infantile diarrhoea, the deaths rising in October and November far
above the mean line of the year, and falling farthest below the mean in
spring and early summer[1356]. This was an old observation--by Sydenham
for the scarlatina simplex of that age, by Willan in the end of the 18th
century (one or two spring epidemics being remarked upon as exceptional).
It is a very curious fact, and one that is as certain (for London at
least) as it is curious. Sydenham explained it by the doctrine of his
time, that the favouring things were in the human body, namely, some
susceptibility of the humours owing to the heat of the preceding summer;
but, according to modern views, it should bring scarlatina into the same
class with the soil-poisons of enteric fever, yellow fever and cholera,
which are believed to become more rife owing to the greater activity of
their respective miasmatic viruses when the pores of the ground are
occupied to the greatest depth with air in place of water.
It would be singular indeed if, after all, we should have to include
scarlatina among the miasmatic diseases; for it is an exquisite instance
of an infection which is passed from person to person, or by the agency of
volatile contagion, or by fomites in clothes, bed-linen, house-furnishings
and the like. The controversy which has raged so keenly in the past
between contagionists and non-contagionists over the instances of plague,
yellow fever and Asiatic cholera, would become still more keen over
scarlatina--and be still more confused if it were not stated in more
correct terms at the outset. What we all find so hard to learn is, that
the one way of infection does not exclude the other. Plague was for the
most part a miasmatic infection in the air of a plague-stricken town; but
it could be conveyed in clothes or bales, while it was prudent to remain
not too long in the company of a plague-patient. In like manner contagion
from the person was, as Rush said and Blane confirmed, a “contingency” in
yellow fever; and there are some authentic cases of Asiatic cholera which
cannot well be explained except on the hypothesis of contact with the
persons of those sick or dead of the disease. Scarlatina is more
contagious than any of these, because it shows so much on the surface of
the body and scatters its infective matter into the atmosphere of a room
with the fine scales or dust of desquamation. Still, there are conditions
for the contagiousness of scarlatina, just as there are for the rarer
event of contagion from the persons of the sick in the plague, yellow
fever and cholera. It is a remarkable fact that scarlet fever should ever
be sporadic, or that a single case should appear in the midst of a crowded
population (as I have seen in a coast town filled with strangers during
the herring fishery to the extent of one-half more than its usual
numbers), and no other cases follow for months after, although there had
been not the smallest attempt at isolation. Every medical practitioner
knows, if some laymen and legislators do not, that scarlatina is sometimes
highly contagious, and sometimes hardly contagious at all; and who can say
whether the mechanical routine of “stamping out” contagion, which certain
persons pursue with more zeal than knowledge, may not be the means of
turning a mere potency into an actuality? The tact of individuals rather
than the grinding machinery of an Act of Parliament is needed in dealing
with vagaries such as Willan thus describes:
“I have seen in numerous families one child have scarlatina without
communicating it to any of the rest; yet, perhaps, in the succeeding
autumn, several of them were infected by only passing near a patient
recovering from the disease, or by touching those who had a little
time before visited some persons affected with it[1357].”
There are two special forms of epidemic scarlatina which may prove to be
finger-post instances for the general pathology. It happens from time to
time in the surgical wards of hospitals for children, where many cases of
suppurating diseases (especially of the bones or joints) are aggregated
and kept together perhaps for months, that groups of the patients acquire
a scarlet rash, or an erysipelatous rash, or a hybrid form of rash, along
with the constitutional symptoms of scarlatina. Whether it be from the
suppuration, or from the blood of operations, this disease must be
reckoned a product of so-called “hospitalism.” It is not without
significance that there may be an element of erysipelas in such cases.
They are probably cases of “blood poisoning,” in a double meaning of the
term--poisoning of the living blood by dead blood or by pus which is
closely allied to blood[1358].
The other special kind of epidemic scarlatina is that which has broken out
among the inmates of houses supplied with milk from a common source. There
have been many such outbreaks, including one most remarkable instance in
which a large number of guests at an evening party, who had partaken of
cream with strawberries, were shortly thereafter attacked by scarlet fever
at their widely scattered homes. There can be no question that milk, or
cream, has been the vehicle of scarlatinal infection. The first hypothesis
tried was that of scarlatina on the dairyman’s premises; the effluvia of a
scarlatinal patient might have become mixed with the milk. In some
instances, it was actually shown that there had been a case or cases of
scarlet fever among the dairyman’s children; but there were other
instances in which that could not be shown, and it was, of course,
possible to refer the cases, where they did occur, to a common cause in
the milk used at the dairy and in the milk distributed from it. As more
and more outbreaks of the kind came to be investigated, it was indeed made
probable that the infection had got into the milk from the cow[1359].
Someone threw out the suggestion that the cow suffered from scarlet fever,
the sign of it being soreness of the paps. Without taking seriously so
random a hypothesis as that, we find much agreement as to the fact that
the cows, to which the contaminated milk has been traced, were affected,
one or more of them, with sore paps. In some cases the disease of the
teats had been admitted to be the same as cowpox; in other cases that has
been denied; in a third variety, a cow has had cowpox on one teat and
something else on another. It matters little what name be given to the
affection of the cow’s paps. All soreness of the skin of the teats has the
same effect so far as concerns the purity of the milk. Unless the milk be
drawn off by a catheter (according to a German practice), the paps are
necessarily made to bleed by being “stripped”; it has been admitted by
milkers that the blood, pus, and scabs are apt to become mixed with the
milk; and the discharges from the sore paps have actually been seen, by a
scientific witness, to trickle over the fingers of the milkers into the
milk-pail[1360]. The contamination of the milk which produces scarlatina
in those who use it is neither more nor less specific than that. The
disease is blood poisoning in the double sense of the term--poisoning of
the living blood by dead blood. Blood is a peculiar fluid, and so is milk.
When the two come together the result is peculiar. Both are animal fluids
that curdle by some peculiar ferment-change in their constituents. Again,
milk is peculiar in its property of taking up organic effluvia; thus the
milk standing in shallow vessels has been known to acquire the taste and
odour of tar from a tarpaulin in the adjoining farmyard. With such
properties of the milk, a small quantity of blood or pus in it will go a
long way.
The one thing that connects the scarlatina of surgical wards in children’s
hospitals and the scarlatina of the milk-pail is putrefying blood or pus:
the disease is a septic effect of blood, just as a scarlet rash is known
to be a toxic effect of very various drugs in peculiarly susceptible
subjects. The obviously septic varieties of scarlatina make but an
insignificant part of the whole; but they may be finger-post instances.
Thus, if we assume that the infection may be miasmatic from the ground as
well as contagious from the person, there are certain facts, or
suspicions, that will fit the hypothesis of putrefying blood. A theory of
scarlatina was put forward in 1871, on the basis of observations near
Croydon, that its virus came from the blood and offal of slaughter-houses
collected at particular spots to be used as manure[1361]. The first death
in a recent small epidemic within the writer’s knowledge was of a
school-girl who lived just across the road from a slaughter-house. The
septic hypothesis of scarlatina might be made to include other corrupting
animal matters. Some practitioners have a suspicion that scarlet fever is
bred in the atmosphere of a horse-mews. On the greater scale, others have
traced a connexion between the more signal outbreaks of angina maligna and
preceding murrains of cattle[1362]. The animal matters which may become
toxic to man, in miasmatic or other form, are indeed many. If scarlatinal
drug-eruptions are any clue to the mystery of scarlet fever, we need not
be surprised to find a somewhat uniform disease-effect produced by a
variety of septic agents[1363]. But, in that hypothesis, the refuse of the
shambles will merit most attention. This was thought the one great
nuisance of London in the sanitary ordinances of Edward III., Richard II.
and Henry VII.; it was then considered a danger to health in the measure
of its offensiveness to sight and smell, but there may still be dangers
from it which are subtle and unperceived.
Reappearance of Diphtheria in 1856-59.
The memorable outburst of epidemic throat-disease in Britain about the
years 1858-59 was part of a sudden uprising of the malady all over the
globe--in Europe, America, North Africa, India, China, and the
Pacific[1364]. It was only in some parts of France, and of Norway and
Denmark, that “diphtheria” had been epidemic in the generation before. Of
its novelty to nearly the whole British profession in 1858, familiar as
they were with the angina of scarlet fever, there can be no question. Its
appearance among diseases coincided with the publication of Darwin’s
hypothesis of the origin of species by natural selection; and it was in
the terms of that hypothesis that Farr, of the Registration Department,
spoke of the phenomenon of diphtheria. New diseases, he said, “are only
recognized as distinct species when they have existed for some time.
Diphtheria is an example. It obtains a distinct line in the Tables of this
year [1859] for the first time”--with a total of 9587 deaths. For four
years before that, it had been in a “provisional table” under the names of
“diphtheria” and “cynanche maligna”; but in the general table, the deaths
under these names had been merged with the scarlatinal deaths. This
inclusion for a time of diphtheria under scarlatina could not have been
because practitioners had any difficulty in diagnosing the one from the
other, but probably because scarlatina anginosa seemed the nearest
affinity in the nosological system. Diphtheria in 1858 had no scarlet
rash, and yet it was supposed to be the same disease that had made so much
commotion in England about the middle of the 18th century: “In
Fothergill’s account,” says Farr, “the symptoms are confused by the
introduction of the eruption of scarlatina into his description”--as if
his description had been a patchwork of his fancy, with some characters
taken from “diphtheria” and some from scarlet fever. The greatest of our
nosologists, Cullen, had long before that separated “cynanche maligna”
from “scarlatina anginosa,” but the separation was not made on the ground
of absent or present rash. Both had the rash, the cynanche having, besides
a general exanthem, very distinctively the peculiar scarlet redness, with
swelling and stiffness, of the fingers which Fothergill described, while
the scarlatina rash was “commonly more considerable and universal.” Both
also might have a discharge from the nose; but when the coryza did occur
in scarlatina, “it is less acrid, and has not the foetid smell which it
has in the other disease.” It was really on the ground of malignancy or
fatality that Cullen separated them. In forty years he had seen scarlatina
anginosa six or seven times prevailing as an epidemic in Scotland, and he
had seen two or three epidemics of cynanche maligna. He had seen mild
cases in the latter, as well as in the former; but whereas there would be
only one or two malignant cases in a hundred of scarlatina anginosa, the
malignant or putrid cases in an epidemic of cynanche were four-fifths of
the whole[1365]. On the other hand Willan, writing just fifty years before
the modern diphtheria made its appearance, maintained that “no British
author has yet described any epidemical and contagious sore-throat except
that which attends the scarlet fever,” not even Starr, whose “morbus
strangulatorius” he held to be “the most virulent form of
scarlatina[1366].”
The name diphtheria, which appeared for the first time among the
classified causes of death in England in the report for the year 1855
(published two years after), had been given originally in 1826, with the
termination _itis_ according to the then Broussaisian fashion, by
Bretonneau in his account of epidemics at Tours in 1818-21 and at La
Ferrière in 1824-25[1367]. It was in January, 1855, or just before the
disease became general in Europe, that he changed the termination to
_diphtherie_[1368]. This name was taken from διφθέρα, a prepared skin or
hide, suggesting in strict correctness, a certain toughness and texture
which were actually found in only a small proportion of all the
diphtheritic deposits or exudations or sloughing infiltrations in the
first great epidemic and subsequently.
The interval between 1793-94, the date of Rumsey’s diphtheria or “croup”
at Chesham, and the outbreak of diphtheria in England in 1856-59, affords
several instances of the disease, some of which were contemporaneous with
Bretonneau’s in France, but were still called “croup” in this country.
These I shall merely enumerate in a note, passing at once to the
beginnings of the great outbreak[1369].
The first public notice of the reappearance of a fatal throat epidemic in
England appears to have been in the Registrar-General’s third quarterly
report of the year 1857, when attention was drawn to the remarks by
various local registrars (Thame, Billericay, Maldon, Liskeard, Truro and
Chesterfield) as to fatalities from “inflammation of the throat,” “putrid
sore throat,” “malignant sore throat,” “disease in the throat,” and
“throat-fever.” About this time it was also called the “Boulogne sore
throat.” There had been an epidemic at Launceston from 30 September, 1855,
which had come to a height in August, 1856; several deaths had occurred
near Spalding, in Lincolnshire, in July, 1856, and the disease had been
seen at Ash, in Kent, in November, 1856. When the registered causes of
death during the year 1855 were classified (in 1857), “diphtheria” was
credited with 186 deaths, in the Supplementary Table then first
introduced, “cynanche maligna” having 199 deaths. The following shows the
progress of the epidemic during the four first years, and the mode of
entry:
Scarlatina (inclusive
Cynanche of columns 1 and 2 in
Year maligna Diphtheria the general table)
1855 199 186 17,314
1856 374 229 14,160
1857 1273 310 14,229
1858 1770 4836 30,317
In 1857 and 1858 the deaths from croup were above the average, and
probably included some of the new disease.
Accounts of the epidemic began to come into the medical journals[1370]
from various localities in the course of 1858,--from Lincolnshire, Essex,
Kent, Sussex, etc. A systematic inquiry, conducted by Greenhow and
Sanderson for the Medical Department, under the direction of Simon, gave
an exact picture of the several degrees of throat-distemper that
constituted the epidemic in the year 1858, in certain of the more severely
visited centres of Lincolnshire, South Staffordshire, Cornwall, Kent, and
other counties[1371]. The numerous cases of throat disease occurred often
in the midst of scarlatina, but sometimes also where there was no
scarlatina. One of the worst centres was in and around Spalding, a market
town situated in a flat grazing country within the fen district of
Lincolnshire. A thousand cases were counted in and near Spalding, many of
them mild, a small ratio of them gangrenous and mortal; one practitioner
had 200 cases with 5 deaths, another 200 cases with 2 deaths, another 160
cases with 17 deaths (of 65 tabulated with 9 deaths, which occurred in 35
houses, the first four all died from gangrene in June, 1858). The doctor
at Pinchbeck, in the same district, had some 500 cases of which 300
occurred in the space of about six weeks; most of the 19 deaths in his
extensive series happened in the first cases (this was observed also in
the New Hampshire epidemic of 1735). At Launceston, in Cornwall, there
were about a thousand cases known, the height of the epidemic having been
in the summer and autumn of 1856; among 126 taken as they came in 98
families, 18 died. The mildest and the most severe cases were equally
parts of the epidemic constitution, and occurred side by side in the same
households; many of them were quinsies, ulcerated sore-throats, or the
like, others were gangrenous. In this great variety, only a part could be
reckoned “true diphtheria.” From the first, the remarkable sequel of
paralysis, not only of deglutition but of the motor powers generally, was
remarked here and there. Sometimes an eruption of the skin was seen, but
desquamation did not occur[1372]. Albumen in the urine was somewhat
constant. It is noteworthy, the more so that the coincidence was not
remarked at the time, that the true diphtheritic pellicle,--tough,
leathery, elastic,--was found most distinctively, if not exclusively,
where it was found in 1748, namely in Cornwall[1373].
Although the epidemic was not confined to low and damp situations, yet
there was no mistaking the severity of it in Lincolnshire; and although it
fell upon both clean and filthy houses, yet it is probable that the cases
with most pronounced gangrene or foetor happened amidst the most
unwholesome surroundings. The disease was very general in England in 1858.
When the deaths from it in 1859 (9587) were tabulated for the first time
according to counties, it was found that they came from every part of
England and Wales. The highest death-rate was in Lincolnshire, 1·2 per
1000 on the annual average of 1859 and 1860 (995 deaths in the two years).
Sussex, Kent, Essex and Norfolk had also high death-rates, the
agricultural counties in general having somewhat more than their usual
share of an infective mortality as compared with the industrial centres.
But it would be erroneous to suppose that diphtheria was at all specially
a country disease. The mining districts of Staffordshire, Durham and South
Wales had considerable mortalities, and so had Lancashire and the West
Riding. But the North Riding and East Riding had their full share or even
more than their share; whereas, if it had been scarlatina or enteric
fever, they would have been far behind the great industrial division of
Yorkshire in ratio of their populations. In the more recent prevalence of
diphtheria the country districts have lost their preeminence, according to
the following table of death-rates per million living in registration
districts classified roughly as sparse, dense and medium[1374]:
_Diphtheria Death-rates per million, according to density of population._
Period Dense Medium Sparse
1855-60 123 182 248
1861-70 163 164 223
1871-80 114 125 132
In Scotland, also, the incidence was the same: e.g. in 1862, of 997
deaths, 360 were in the towns, 617 in the mainland rural and 20 in the
insular districts[1375].
The law of incidence of diphtheria upon town and country respectively has
become a good deal confused by the extraordinary severity with which
diphtheria has fallen in the last two or three years upon most parts of
London and upon the adjoining municipal boroughs of Croydon and West Ham.
The following table compares the annual death-rates per million in all
England and Wales and in London from the year of the first recognition of
diphtheria to the present time.
_Death-rates from Diphtheria per million, in all England and in London._
Year England London
1855 20 --
1856 32 --
1857 82 --
1858 339 --
1859 517 284
1860 261 174
1861 225 239
1862 241 288
1863 315 275
1864 261 207
1865 126 144
1866 140 152
1867 120 145
1868 137 155
1869 47 107
1870 120 104
1871 111 105
1872 93 80
1873 108 95
1874 150 122
1875 142 167
1876 129 109
1877 111 88
1878 140 155
1879 120 155
1880 109 144
1881 121 171
1882 151 220
1883 158 241
1884 185 236
1885 163 221
1886 147 205
1887 157 226
1888 168 305
1889 185 371
1890 179 330
1891 173 340
1892 222 460
1893 302 740
The deaths in London in 1893 were 3196, having been 1962 the year before,
but never more than half the latter total in any year previous to 1888.
Besides Croydon and West Ham, Cardiff is the great town which has come
nearest the London rate, having had O·68 deaths from diphtheria per 1000
living in 1892, while Swansea had only 0·05, Wolverhampton (including
Bilston and Willenhall) only 0·06, Huddersfield 0·03 and Blackburn 0·02.
In London the very high death-rate of 1893 was distributed not unequally
over all the divisions, the highest mortality corresponding to the highest
fecundity.
_Diphtheria in London in 1893._
Death-rate Diphtheria
District from all causes Birth-rate death-rate
Eastern 25·1 37·3 1·00
Central 26·6 29·0 0·82
Southern 19·9 31·7 0·73
Northern 20·0 29·3 0·73
Western 18·7 26·4 0·52
Diphtheria shows no such decided preference for the late autumnal or early
winter season as scarlatina, but the winter is on the whole its most
fatal season, according to the following annual averages of the quarters
of the year for twenty years from 1870 to 1889 (total of 67,676 deaths in
England and Wales).
_Annual average of Diphtheria deaths in the quarters of the year._
1st qr. 2nd qr. 3rd qr. 4th qr.
903 713 730 1025
According to some recent returns under the Notification Act, which are of
doubtful value owing to the laxity of diagnosis (greater perhaps in
throat-disorders than in any other class of diseases), the second and
third quarters of the year have also the lowest mortality in proportion to
the number of attacks[1376]. As to the ages at which diphtheria proves
fatal, they are somewhat similar to those of fatal scarlatina, but
slightly higher all over; thus, while two-thirds of the deaths from
scarlatina are of infants and children under five years, only one-half of
the deaths from diphtheria are under that age. In the first epidemic
period, 1855-61, Farr reckoned that 1553 adults had died of diphtheria
above the age of twenty-five, while the deaths under that age had been
28,216. In its age-incidence diphtheria is very different from croup,
which attacks chiefly children of one, two, and three years of age, the
boys dying in greater numbers than the girls[1377]. But in all comparisons
between diphtheria and croup, as regards sex and age, it should be kept in
mind that many cases of angina of the throat, which end in death by
extension to the larynx and trachea, are registered as croup, even in
epidemics. Diphtheria is the only epidemic disease besides whooping-cough
which is more fatal to female children than to males in proportion to the
numbers of each sex living. The following annual average death-rates per
million for the period 1855-80 show the higher death-rates of females at
certain age periods[1378]:
All ages 0- 1- 2- 3- 4- 5- 10- 15-20
Males 157 490 724 617 667 589 325 107 50
Females 168 377 673 668 746 694 413 159 57
It is not until the third year that female children begin to die of
diphtheria in excess of males; which means that the usually greater risk
to male infants holds good also in this disease for the two first years,
while some difference between the sexes becomes thereafter so marked as to
turn the balance of fatality to the side of the females. Something of the
same kind happens in whooping-cough; and it is probable that in both
maladies the cause lies in the earlier acquisition by the male of
secondary sexual characters in the throat and larynx, as suggested in the
chapter on whooping-cough.
Conditions Favouring Diphtheria.
The circumstances of the great and sudden explosion of diphtheria in 1858
and 1859 are as likely as any to throw light on the causes or determining
conditions of the disease. Those two years were remarkable for the Thames
running so low in summer as to give out a stench, which was thought to
forebode much fever[1379]. The expected epidemic of fever did not come; on
the contrary the fever deaths in London were much lower than usual in 1858
and 1859, and, to judge from the few admissions of each kind to the London
Fever Hospital, enteric fever declined as well as typhus[1380]. It was
diphtheria that came. The lowness of the rivers was due to a succession of
years with rainfall below the average:
Low rainfall High rainfall
1855 21·1 inches 1865 29·0 inches
1856 22·2 " 1866 30·7 "
1857 21·4 " 1867 28·4 "
1858 17·8 " 1868 25·2 "
1859 25·9 " 1869 24·0 "
---- ----
Average 21·7 " Average 27·4 "
The low state of the rivers was an index of a low level of the
ground-water. If diphtheria is to be included among the infections that
have the habitat of their virus in the soil, it will probably be found to
be affected by irregularities in the movements of the subsoil water. A
series of observations have been made which seem to favour that
hypothesis.
At Maidstone in each of the three years 1885, 1886 and 1887, the
ground-water rose with the greatest regularity and steadiness to its
highest point towards the end of the first quarter of the year, and
fell with equal steadiness to its lowest point in the autumn. During
two of the years there was little diphtheria, and in one of them none.
But, in the next two years, 1888 and 1889, “the levels of the
ground-water oscillated to and fro with unwonted frequence,” having
several maxima in 1888, and a somewhat uniform high level all through
1889; and during those two years there was a severe outbreak of
diphtheria, as well as an excessive number of deaths registered as
“croup[1381].”
The relationship with the ground-water, if any, will probably be found
to be more than ordinarily complex; but some connexion is indicated by
the remarkable selection of the Fen country of Lincolnshire in 1858.
Among the 18th century observations, it was remarked in New England in
1735-36 that the throat distemper was worst near lakes or rivers, as
at Newbury Falls, Hampton Falls, and the like. The ill-reputed
“Kidderminster sore throat,” was associated with the low situation of
weavers’ houses in the valley of the Stour, subject to inundations.
Practitioners in many parts of England and Scotland have suspected an
association with water, even if it were only a mill dam, in the more
recent prevalence of diphtheria[1382].
Diphtheria has affinities in its pathological nature with enteric fever on
the one hand and with scarlatina on the other. The process in the throat
and pharynx is comparable to the typhoid process in the ileum, which is
often a truly diphtheritic process in the second half of the fever[1383].
The affinities to scarlatina are shown best of all in the real ambiguity
of diagnosis in some whole epidemics of the 18th century, if not also in
the great epidemics of _garrotillo_ in the 16th and 17th centuries.
Another singular affinity both to scarlatina and to enteric fever lies in
the fact that diphtheria, as well as each of these, has been distributed
in milk from some particular dairy, and that contamination of the milk by
the products of disease upon the cows’ teats has been found to be the
relevant thing both for the scarlatina and the diphtheria[1384]. Again,
whatever suspicion pertains to slaughter-houses or animal offal for the
production of a scarlatinal miasm, pertains to them also for the
diphtherial. With such more or less real affinities in the pathology and
etiology, it may be made a question whether the recent increase of the
death-rate by diphtheria in London and some other places has depended, as
if in the way of correlation, upon the decrease in the death-rates of
scarlatina and of enteric fever[1385]. Diphtheria is perhaps the most
obscure and complex of all the infective diseases in its causes and
favouring conditions. A certain explanation may seem to suit one outbreak
and be wholly irrelevant for another. More particularly there have been
innumerable cases for which insanitary surroundings cannot be alleged in
any ordinary meaning of the term.