Since early March 1877, 29 infants and children in Loughton have been
attacked by, and 13 have died of, a peculiar affection of the skin, that
had been regarded as an anomalous kind of erysipelas. The disease was
described to me by the mothers or others nursing the cases as presenting
the following appearances:—
In fatal cases, a generally blackened condition of the skin of the groins
and pudenda, which quickly became somewhat swollen and hard; this was
frequently the first change observed. Occasionally there was a like
condition of the abdomen about and below the umbilicus. The skin of the
axillæ and folds of the neck was another part in which blackening and
swelling was commonly observed. Invasion of these several parts, when it
occurred, was simultaneous. In some instances vesication, variously
described as “little white blisters,” “yellowish bladders” or “bags of
water” preceded or appeared about the same time as the blackness; in
others, blackness with, or without, vesication was preceded by a short
interval by a bluish red condition of the parts affected. The vesicles
breaking discharged clear fluid, and left raw black surfaces, which did
not, it would seem, take on suppurative or sloughing action. In no
instance was a tense shining appearance of the skin spoken of; nor was
there, except in one case, any tendency of the blackened condition of the
surface to extend over the limbs or trunk. The constitutional symptoms
seem to have been great restlessness, with fits of crying or screaming in
the first instance, passing soon into a condition apparently of collapse
in which the infant quietly died. The average duration of illness in
these cases was four to five days.
In non-fatal cases, the symptoms varied much in severity. In almost all,
blisters or bladders like those already spoken of formed between the
folds of the groins, in the armpits, and in the neck. In some cases
these vesications broke and formed black excavated sores, in the
neighbourhood of which the skin became more or less indurated and
discoloured. From some of the sores “cores came out,” and all discharged
yellowish matter. In milder cases minute vesicles burst and left shallow
sores that were little if at all discoloured, and that quickly healed
under appropriate treatment. The constitutional symptoms do not seem to
have been in any instance out of proportion to the local malady. In few,
if indeed in any, cases were vomiting or purging prominent symptoms.
There has now to be considered—What has been the nature of the disease,
and how did it come about? Has it been erysipelas as it was at first
thought to be; or, has it been, as recently alleged, skin-poisoning?
I. _As to erysipelas_. From the above account it appears by no means
surprising that the malady in its graver cases (many of the slighter ones
did not come under medical treatment) should have been regarded as a
disease of the nature of erysipelas. It resembled that disease in
several important features, and the constitutional symptoms, particularly
of the fatal cases, might well have belonged to erysipelas itself. On
the other hand it may be remarked that the malady in question seems to
have differed from erysipelas as ordinarily observed in certain not
unimportant particulars. There was not, so far as I can ascertain, any
of that marked, tense, glistening or shining appearance of the skin,
almost invariably present in erysipelas of infants; moreover, the
affection had commonly no tendency to wander over the trunk and limbs in
the manner customary with such erysipelas; but instead remained localised
almost from the first, in each instance, in the parts of the body
primarily affected by it. This appears to have been specially notable as
regards those slighter cases not medically treated; in such the
vesication and subsequent abrasion and induration of the skin was
observed only in the folds of the neck, armpits, and genital organs.
Nevertheless, before discarding the hypothesis of erysipelas, I thought
it well to inquire whether there had been any typical erysipelas among
infants or others in the parish; and whether the facts of the
distribution of the malady in question could be explained on the
supposition that those attacked had had conveyed to them erysipelatous
infection. In this sense inquiry has result as follows:—
(1.) As to typical erysipelas. Except two cases, occurring in adults,
one in October the other in December 1877 (both it will be observed long
after the earlier cases of the infantile malady), I cannot hear of any
occurrence whatever in Loughton of ordinary erysipelas in persons of any
age. Vaccination proceeded as usual and no erysipelas or other disease
was observed in connexion with it.
(2.) As to likely channels for erysipelas propagation, one kind only
seems of importance as being in any degree probable, viz., the baby linen
clubs of the parish. These, the church club and the chapel club, have
been instituted for the purpose of affording their subscribers body and
baby linen during the month subsequent to confinement. One rule common
to both clubs provides that clothing thus acquired shall be returned
properly cleansed and got up within five weeks from the date of loan; and
hence it might have happened that, assuming the disease to have been
erysipelas, babies’ napkins imbued with specific contagion might have
been returned to the club imperfectly cleansed or not properly
disinfected, and have thus, on reissue, conveyed to other infants the
infection of that disease. Examination of the operations of these two
clubs shows that during the last 15 months there have been ten boxes or
bags of baby linen in circulation, and that of the 29 sufferers by the
malady 17 have received club linen, while 12 have not. On the other hand
33 other infants have during the same period had baby linen from one or
other of the clubs without ill result. The 17 sufferers, with 19 others,
were all of them members of the church club, the total operations of
which during the period referred to are shown in detail in Table I.