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CONTRIBUTIONS TO THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF SCARLET FEVER.
694 This amount of necrosis of the femur
(Figs.
14 &
15)
was re-
incurable articular surfaces were taken away; in other words, excision of the knee was performed. Here is a cast (Fig. 16)
I
moved from each
commencement.
Soon afterwards the-
is the boy himself, with the leg that was preserved. stand upon it for houts, and walk miles daily. Of alls
still, here
I1I He
can
cases afterwards; unfortunately the lad got hip disease subsequently, but you will observe that my limb (the left) my feats of is the best; and this is the cast (Fig. 17) of the other; but, betterI
of one of these
as a
I’ prouder.
conservatism, I know of
none
of which I
an
-
the Saracens. The two former diseases were cerdescribed tainly by the Arabian physicians, Hali Abbas and TO THE Rhazes, and from certain passages in their writings it has been, ETIOLOGY, PATHOLOGY, AND TREATMENT fancied that scarlet fever was also included in their descriptions. The passages in question, however, are far from explicit. OF SCARLET FEVER. Scarlet fever was first distinguished from measles three cenBY CHARLES MURCHISON, M.D., F.R.C.P., turies ago by Phillip Ingrassias, of Naples, who pointed out PHYSICIAN TO THE LONDON FEVER HOSPITAL, ASSISTANT-PHYSICIAN TO THE that it was known at Naples by the designations Rossalia or MIDDLESEX HOSPITAL, VICE-PRESIDENT OF THE EPIDEMIOLOGICAL SOCIETY, ETC. Rossania, that it attacked an individual only once in his lifetime, and that it differed from measles (Morbilli) in the rash No. I. being attended by scarcely any tumefaction, and being diffuse Bi8tory-Fr8t notice of scarlet fever in B·itain-1 ts distinction like that of erysipelas, the whole skin looking as if it were on from measles-Increased prevalence of late years-Geogra- fire. He added : "Nonnulli suntqui morbillosidem cum rossalia phical distribution Etiology: A. Predisposing causes. existimant; nos autem soepe distinctos esse affectus nostrismet 1. Age. 2. Sex. 3. Monthsatd8easons. 4. Meteorological * conditions. 5. Locality ; overcrowding and bad drainage. oculis, non aliorum duntaxat relationi confidentes inspeximus." the sixteenth and seventeenth centuries numerous epi6. Social position. 7. Occupation. 8. -ldio8y?ic?,asy. 9. Other During demics of scarlet fever (including diphtheria) were described by diseases. Italian, Spanish, and German writers, under different designaHISTORY. tions, such as-Rossalia. Morbilli, Garrotillo, Morbus StranguTHE early history of scarlet fever is obscure, for the disease latorius, TonsiDse Pestilentes, Pestilential Affection of the was long confounded with measles and small-pox, in like manFauces, and Angina maligna. Scarlatina is said to have been for a long time the vernacular ner as typhus and enteric fever are still regarded as identical name for the disease on the shores of the Levant, before it was modern No reference to scarlet practitioners. by many precise this country ; but though the term may be objec. fever is contained in the works of Hippocrates, Paulus aegineta, importedininto a scientific point of view (so much so that the late tionable or of other Greek physicians. It has been surmised by his- Dr. Mason Goodt advocated the revival of the original name, torical writers that small-pox, measles, and scarlet fever came * Innrassias: DeTumnnbusprcetprnaturam, cp.i.,p.l9j:. Naples, 1S53,. originally from Africa, and that they were imported into t Study of Medicine, 4th ed. 133j., vol. ii., p. 317.
CONTRIBUTIONS
-
,
Europe by
695
all
the diseases included under the comprehensive head of there can be no doubt of its having been in common in this country since the disease was first observed two "Typhus."* centuries ago. TABLE I.-Moi-tality in 24 years. The first accounts of scarlet fever in Britain are contained in Wales. London. England and Wales. the works of Sydenham, and of Sir Robert Sibbald, physician Scarlet fever 53,663 England and for in of Scotland. Sydenham, to Charles II. 1676 spoke it as Continued fevers 403,193 occurring in London under the designation " scarlatina febris;"’ 208,672 48 432 on med fevers and in 1684, Sibbald,’ in his " Scotia Illustrata," remarked that Measles 181,868 diseases which 31,595 1 of f was one diseases which had made their scarlatina (sic) many Small-pox -pox 21,369 125,352 appearance in Scotland for the first time during the seventeenth At intervals of a few years scarlet fever spreads as an epiand the name was that derived the scarlet from colour century, of the skin.t The disease observed by both these authors was demic ; but its ordinary prevalence is greater than is generally There is indeed some ground for believing that, as very mild in its nature and very rarely fatal; and Sydenham imagined. has been diminishing under the influence of vaccinasmall-pox more it as than an effervescence of the blood nothing regarded scarlet fever has continued to increase. In the year 1838 produced by the heat of summer. Richard Morton, however, tion, described an epidemic of scarlet fever of a very fatal type,’ the deaths from small-pox in England and Wales amounted to 16,268, while those from scarlet fever did not exceed 5802. which prevailed in England from 1672 to 1686.1: In the former half of the eighteenth century many excellent But during the last fifteen years (1847 to 1861) the annual fromsmall-pox has never exceeded 7320 ; in five years descriptions of scarlet fever were published by observers in mortality different parts of Europe. Foremost among these writers rank it was under 3000, and in 1861 it did not exceed 1320, the average for the fifteen years being 4255 ; whilethe annual a Swedish physician, Rosen de Rosenstein, and our countrymen from scarlet fever has ranged from 13,111 to 30,317, Fothergilland Huxham.[[ In a dissertation entitled, "On mortality ’the Sore-throat attended with Ulcers," Fothergill described an the average being 17,495. Estimating the rate of mortality scarlet fever at 6 per cent., it followsthat during twentyThis essay epidemic which occurred in London in four years the disease attacked 6,250,150 of the population of acquired so great a reputation that the disease was long known England and Wales, and 894,383 of the inhabitants of London; as the Fothergillian sore-throat, while the author, still a young that the number of persons at present annually attacked and in London. man, was placed at once at the head of his profession 291,583 in England and Wales, and 43,200 in London alone. It is no less instructive than remarkable, that, the existence of clinical descriptions of scarlet fever which Some of the epidemics of scarlet fever in this country have rival any of modern times, and the assertion of a contrary epidemics of opinion so early as 1553 by Ingrassias of Naples, scarlet fever 1847-8, 1858-9, and 1863. That last mentioned, and was still regarded by the great body of the profession and by the best medical writers as a mere variety of measles, and It was often designated accordingly " morbilli confiuentes." was reserved for Dr. William Withering, of Birmingham, to to 4982, or to of the entire eradicate this error. He not only laid down correctly the in 1863 -clinical distinctions of the two maladies, but he remarked that mortality (70,312). Nor was this epidemic confined to London. a town or district of England escaped its ravages. "patients who had gone through the measles were equally Scarcely of the land there was uni.subject with others to scarlatina," although he had "never seen an instance of the same person having the scarlet fever obvious that we have much to twice," and believed " it to be as great an improbability as a a disease in the prevention and treatment of repetition of the small-pox.,,** In the first edition of his work ,(1779) Withering, like Sauvages and Cullen, drew a distinction which our art is still so powerless. between the anginosa of early writers and the angina GEOGRAPHICAL DISTRIBUTION. ’(scarlatina) maligna or ulcerous throat of Fothergill; but in the Scarlet fever is known to prevail over the whole of the confollowing year (1780) Dr. John Clark, of Newcastle, insisted tinents of Europe and America, but it is probably nowhere so that " they ought not to be considered as distinct affections, but only different species of the same disease." The latter common as in Britain. In France, according to Rilliet and view was also adopted by Withering in the second edition of Barthez, it is a rarer disease than either measles or small-pox.t his work (1792), in which he maintained that the affections in In Iceland it was epidemic in 1827, but since then, with the of a few cases in 1848, it has not been met with.t question "constitute but one species of disease, and that they exception The date of its first appearance in America is said to have been owe their existence to the same specific contagion," and its it now prevails alike in the tropical and temperate retruth has never since been called in It is only of late years that we have been to form an gions of that continent. In Asia and in Africa it appears to be and in many parts to be quite unknown. In -accurate idea of the prevalence of scarlatina ; but still there is a rare according to the testimony of Morehead and other no doubt that it has increased during the present century, and that it now occupies that pre eminence among the causes of writers, and the reports of the Army Medical Department, true fever is never met witn, but epidemics of a closely allied, mortality in childhood which was formerly held by small-pox. scarlet or scarlatina rheumaticanot identical, of the in if From the reports Registrar-General, it appears that -24 years (1838 to 1861 inclusive) 375,009 of the population of are observed from time to time. The absence of scarlatina from remarkable as measles is often very prevalent. England and Wales and 53,663 of the inhabitants of London Scarlet fevermore is said to be equally rare in Persia and in Egypt. have died of scarlet fever. About 1 in every 24 deaths which - occurred throughout England during these 24 years was due In New Zealand its existence was not noticed prior to 1848, to this disease. Iu Rome years the ratio was as low as 1 in 33, but since then it has been found to attack both the European and the in others as high as 1 in 14. During the ten years 1850-1861, . , ,. ,. whatever country the disease appears, it makes no dIstmcthe average annual mortality for every 100,000 of the populaIn between The natives of New Zealand and different races. - tion of England and Wales from all causes was 2217, and from American Indians, have suffered -scarlet fever alone 88. The mortality from scarlet fever ex- South America, and the ceeds the mortality of measles and small-pox taken together, equally with Europeans. ETIOLOGY. and almost equals (in London it exceeds) the gross mortality of
rossalia), use
......
... ...
.
/
had
made
Measles ...... ......
-
their
Small
1747-48.
50,751
... ...... ’"
... -.. ... ... ...
from
notwithstanding is
been fatality and remarkable mayfor betheirmentioned In particular the wide-spread character. 1801-4, 1833-4, therarely which the number number ofofits wevictims, regardhas extentif hasprevalence scarcely oryetthe of its its scarlet fever inLondon in 1863 amounted amounted to The deaths from onejfcurteenth
Throughout thelength andmourning. breadth Fromdesolation and From the above remarksitis learnrespecting
scarlatina
question..;$1735 ;§ enabled India,
disease,
affection--dengue,
India is the settlers
tion
natives.¶
North
A.-PREDISPOSING CAUSES.
-
* * Observ. Med. cirea Morbor. Acutor., Historiam et ed. ed. etCurationem, Curationem, Childhood’s isIS of the most powerful predeveloping ls7s. I676. 1. 1, Age 1. isone one of the most powerful predisposing Age.-Childhood t " Inter mtiltos autem morbos, qui huic seculo orininem debent. neperrim febris observata est, quœ scarlatina dicitur a eoccineo colore (nostratibus * scarlet linguâ. vernaculâ appellato), quo cutis fere universa tingitur."- (Scotia It is well known that deaths not only from typhus and enteric fever, bnt also from uraemia, asthenic pneumonia, cerebral diseases, and in short from Illustrata, auctoM Ituh. Sihbatd, Edinb. 1684, p. 65.) Pyretologia, seu Exercitationes de morbis universalibus acutis. Lond. 1692. any disease which assumes a typhoid character. are included under the § Maladies des Enfans. 1741. Registrar-General’s designation Typhus. The returns under this head afford An Account of the Sore-throat attended with Ulcers. 2nd ed., Ijond. 1748. no criterion whatever as to the prevalence of true typhus fever. On the on Fevers. 3rd ed., 1757, t Maladies des Enfans, 1843, it., 567. ¶ Malignant Ulcerous Sore-throat. Essay p. 266. t Hirsch : Handb. der Hist. Geog. Path., p. ?36. ** An Account of the Scarlet Fever and Sore-throat, Lond. 1779, pp. 47, 48. § It appeared first at an inland town 10 New England, and was not thought to have beeu imported.-Lond. Med. Obs. and Enquiries, 1776,,., tt Observations on Fevers, Lond. 180, p. 246. i.,210. (’]in. Res. on Dis. in India. Sec.ond Edit., 1860, i 199. tt Manv of the case’! towhich the term ’ angiiia maligna" was formerly and and For. Med. Chir. of as Brit. doubt Bretonneau has were without Rev., 1854; ( Thompson : Tuke, Edin. Med. examples diphtheria; but, applied 1861. pointed out, this was not the case with the ulcerous sore-throat of Fothergill Jotirn., ** Hirsch: and Huxham.-Memoirs on Diphtheria Syd. Soc. ed. 1859 p. 37. Op. cit., p. 239.
Observ.Med. circa Morbor.Acutor., Historiam
predisposing
———————————————————————————————
.
696 of scarlet fever. From the statistics of the London Fever it appears that out of 2402 patients admitted with scarlet fever during twenty years, 2124 (or 88’4 per cent.) have been under twenty-five years of age. causes
Hospital
years of age. The number of deaths, however, in the first year of life is less than one-half of that in the second, and constitutes less than one-ninetieth of the entire mortality, whereas the deaths from scarlatina in the second year of life amount to one-fifteenth of the entire mortality. Examples of scarlet fever in the fcetus have been recorded on good authority, although it might be sometimes difficult to distinguish a scarlet rash from the redness natural to newlyborn infants. On the 28th of April, 1839, the youngest son of the late Dr. George Gregory was born, "evidently suffering under some form of fever. The throat was affected on the fol. lowing day, obviously from angina maligna. Eruption was never developed. The child drooped, and died on the 1st of May."’ On two occasions I have known females, during an attack of scarlet fever, delivered of living and healthy children. Although scarlet fever is a rare disease after forty years of age, instances are not wanting of its occurrence at an advanced age. Out of 2402 cases admitted into the London Fever Hos. pital during twenty years, four were above fifty, and one above sixty. 18 Table III. four fatal cases are reported as having occurred in persons above eighty-five years. (To be continued.)
Hospital statistics, however, afford a fallacious test of the ages of scarlet fever patients, inasmuch as the majority of young children are treated at their own homes, and a large proportion of the hospital cases are servants in private families. More reliable information is furnished by the mortuary returns of the Registrar-General, subject to the correction that the mortality from scarlet fever under fifteen years is about double what TWO CASES OF SYPHILIS SHOWING A it is above that age. The subjoined table is constructed from PROLONGED INCUBATION PERIOD AND the death returns of England and Wales for the years 1847 and 1855 to 1861; and for London for 1845-46 and 1848 to 1854. COMMUNICATION OF THE DISEASE BY This gives us a total of 148,829 fatal cases : of which, 95,070, SECONDARY CONTAGION. or 63’87 per cent., were under 5 years; 133,661, or 89’8 per cent., were under 10 years; 142,337, or 95’63 per cent., were BY BERKELEY HILL, ESQ., F.R.C.S., under 15 years; and only 2615, or 1 75 per cent., exceeded 25 TO UNIVERSITY COLLEGE HOSPITAL. ASSISTANT-SURGEON fever years. From 1 to 5 years of age the deaths from scarlet were more than of the entire mortality during the same ON the 5th March, 1864, John J-,, aged thirty-three, period; between 10 and 15 they were betweenand 1-; from 10 to 15, less than ; and above 15 they constituted only 3½ of ostler, applied, among my out-patients, for relief for a painful the entire mortality. affection of the right eye. He said that about fourteen days before Christmas last, while fighting, he received a blow on the right eye and cheek, which drew blood; his antagonist sucked the wounds for him, after which they quickly healed, and, as far as he knew, the marks also disappeared. He experienced no further inconvenience until the latter end of January, when he observed some pimples appearing where he had been hit, and presently some scabs fell off, leaving a reddish pimple beneath each; but there was no ulcer, nor any discharge from these pimples. His eye next became troublesome, growing red and bloodshot, and smarting occasionally; and on Feb. lst he applied for some eye-water, with which he bathed his eye, but without improvement. Finding the eye-water of no service, on the 5th March he came to me, anxious for other treatment. I examined him, and found the following state of things :-At the outer corner of the right eye was an oval coppery patch, slightly elevated from the skin around it, especially so at the edges; it was smooth and dry. There was also about the middle of the margin of the lower eyelid another smaller patch, which desquamated freely, and whence the eyelashes It is therefore obvious that scarlet fever is most common in had dropped out. Two more similar patches existed on the the second, third, fourth, and fifth years of life, and that after cheek, over the malar bone. All these tubercles were induten years its frequency rapidly declines. From an analysis of rated, and surrounded by an areola of coppery tint. The conthe returns of the Registrar-General, extending over ten years, junctival membrane of the right eye was congested and the it appears that for every 100,000 children under five years of palpebral part thickened; whence the discomfort for which age, in England and Wales, 419 die annually of scarlet fever. relief was sought. The lymphatic glands beneath the jaw and It has been alleged that childhood does not predispose to in the neck on that side were severally enlarged, but painless. scarlet fever, but that adults merely escape in consequence of A coppery roseolous rash extended over the forehead and being protected by a previous attack; but the mere fact of such trunk. The penis was quite free from sores or cicatrices of any large numbers of infants being attacked shows a remarkable kind, and there was no history of any. The inguinal lymphatic aptitude for the disease in early life (not observed in small-pox glands were also quite normal ; likewise those of the body or typhus), while if we estimate the mortality of scarlet fever generally, with the above-mentioned exception of the subat only six per cent., the number of persons annually attacked maxillary ones. Though he complained of sore-throat when in England and Wales is considerably less than one-half of the questioned, the soft palate and uvula were only somewhat connumber of births, so that a large proportion of the adult popu- gested. He was ordered to take four grains of blue-pill witb lation must be unprotected. Daily experience shows that un- a little opium twice daily, and to attend frequently at the protected adults escape in families where all the children are hospital. On the 12th of March I saw him again. He was then under attacked. The above results show how erroneous is the opinion the influence of mercury. His gums were swollen, his breath originally expressed by Withering, and still by many believed was fetid, and he had a bad taste in his mouth. His throat was to be true, that scarlet fever does not often attack infants at not sore. The areolm round the hardened tubercles less spread the breast or under two years of age. No fewer than 30,974 and paler; the roseola much fainter; more of his eyelashes had (or more than one-fifth of the entire number) deaths from fallen. To continue his pill. scarlatina are noted in the above table as occurring under two * Gregory on Eruptive Fevers, p. 146, Lond., 1843.
(Figs.
14 &
15)
was re-
incurable articular surfaces were taken away; in other words, excision of the knee was performed. Here is a cast (Fig. 16)
I
moved from each
commencement.
Soon afterwards the-
is the boy himself, with the leg that was preserved. stand upon it for houts, and walk miles daily. Of alls
still, here
I1I He
can
cases afterwards; unfortunately the lad got hip disease subsequently, but you will observe that my limb (the left) my feats of is the best; and this is the cast (Fig. 17) of the other; but, betterI
of one of these
as a
I’ prouder.
conservatism, I know of
none
of which I
an
-
the Saracens. The two former diseases were cerdescribed tainly by the Arabian physicians, Hali Abbas and TO THE Rhazes, and from certain passages in their writings it has been, ETIOLOGY, PATHOLOGY, AND TREATMENT fancied that scarlet fever was also included in their descriptions. The passages in question, however, are far from explicit. OF SCARLET FEVER. Scarlet fever was first distinguished from measles three cenBY CHARLES MURCHISON, M.D., F.R.C.P., turies ago by Phillip Ingrassias, of Naples, who pointed out PHYSICIAN TO THE LONDON FEVER HOSPITAL, ASSISTANT-PHYSICIAN TO THE that it was known at Naples by the designations Rossalia or MIDDLESEX HOSPITAL, VICE-PRESIDENT OF THE EPIDEMIOLOGICAL SOCIETY, ETC. Rossania, that it attacked an individual only once in his lifetime, and that it differed from measles (Morbilli) in the rash No. I. being attended by scarcely any tumefaction, and being diffuse Bi8tory-Fr8t notice of scarlet fever in B·itain-1 ts distinction like that of erysipelas, the whole skin looking as if it were on from measles-Increased prevalence of late years-Geogra- fire. He added : "Nonnulli suntqui morbillosidem cum rossalia phical distribution Etiology: A. Predisposing causes. existimant; nos autem soepe distinctos esse affectus nostrismet 1. Age. 2. Sex. 3. Monthsatd8easons. 4. Meteorological * conditions. 5. Locality ; overcrowding and bad drainage. oculis, non aliorum duntaxat relationi confidentes inspeximus." the sixteenth and seventeenth centuries numerous epi6. Social position. 7. Occupation. 8. -ldio8y?ic?,asy. 9. Other During demics of scarlet fever (including diphtheria) were described by diseases. Italian, Spanish, and German writers, under different designaHISTORY. tions, such as-Rossalia. Morbilli, Garrotillo, Morbus StranguTHE early history of scarlet fever is obscure, for the disease latorius, TonsiDse Pestilentes, Pestilential Affection of the was long confounded with measles and small-pox, in like manFauces, and Angina maligna. Scarlatina is said to have been for a long time the vernacular ner as typhus and enteric fever are still regarded as identical name for the disease on the shores of the Levant, before it was modern No reference to scarlet practitioners. by many precise this country ; but though the term may be objec. fever is contained in the works of Hippocrates, Paulus aegineta, importedininto a scientific point of view (so much so that the late tionable or of other Greek physicians. It has been surmised by his- Dr. Mason Goodt advocated the revival of the original name, torical writers that small-pox, measles, and scarlet fever came * Innrassias: DeTumnnbusprcetprnaturam, cp.i.,p.l9j:. Naples, 1S53,. originally from Africa, and that they were imported into t Study of Medicine, 4th ed. 133j., vol. ii., p. 317.
CONTRIBUTIONS
-
,
Europe by
695
all
the diseases included under the comprehensive head of there can be no doubt of its having been in common in this country since the disease was first observed two "Typhus."* centuries ago. TABLE I.-Moi-tality in 24 years. The first accounts of scarlet fever in Britain are contained in Wales. London. England and Wales. the works of Sydenham, and of Sir Robert Sibbald, physician Scarlet fever 53,663 England and for in of Scotland. Sydenham, to Charles II. 1676 spoke it as Continued fevers 403,193 occurring in London under the designation " scarlatina febris;"’ 208,672 48 432 on med fevers and in 1684, Sibbald,’ in his " Scotia Illustrata," remarked that Measles 181,868 diseases which 31,595 1 of f was one diseases which had made their scarlatina (sic) many Small-pox -pox 21,369 125,352 appearance in Scotland for the first time during the seventeenth At intervals of a few years scarlet fever spreads as an epiand the name was that derived the scarlet from colour century, of the skin.t The disease observed by both these authors was demic ; but its ordinary prevalence is greater than is generally There is indeed some ground for believing that, as very mild in its nature and very rarely fatal; and Sydenham imagined. has been diminishing under the influence of vaccinasmall-pox more it as than an effervescence of the blood nothing regarded scarlet fever has continued to increase. In the year 1838 produced by the heat of summer. Richard Morton, however, tion, described an epidemic of scarlet fever of a very fatal type,’ the deaths from small-pox in England and Wales amounted to 16,268, while those from scarlet fever did not exceed 5802. which prevailed in England from 1672 to 1686.1: In the former half of the eighteenth century many excellent But during the last fifteen years (1847 to 1861) the annual fromsmall-pox has never exceeded 7320 ; in five years descriptions of scarlet fever were published by observers in mortality different parts of Europe. Foremost among these writers rank it was under 3000, and in 1861 it did not exceed 1320, the average for the fifteen years being 4255 ; whilethe annual a Swedish physician, Rosen de Rosenstein, and our countrymen from scarlet fever has ranged from 13,111 to 30,317, Fothergilland Huxham.[[ In a dissertation entitled, "On mortality ’the Sore-throat attended with Ulcers," Fothergill described an the average being 17,495. Estimating the rate of mortality scarlet fever at 6 per cent., it followsthat during twentyThis essay epidemic which occurred in London in four years the disease attacked 6,250,150 of the population of acquired so great a reputation that the disease was long known England and Wales, and 894,383 of the inhabitants of London; as the Fothergillian sore-throat, while the author, still a young that the number of persons at present annually attacked and in London. man, was placed at once at the head of his profession 291,583 in England and Wales, and 43,200 in London alone. It is no less instructive than remarkable, that, the existence of clinical descriptions of scarlet fever which Some of the epidemics of scarlet fever in this country have rival any of modern times, and the assertion of a contrary epidemics of opinion so early as 1553 by Ingrassias of Naples, scarlet fever 1847-8, 1858-9, and 1863. That last mentioned, and was still regarded by the great body of the profession and by the best medical writers as a mere variety of measles, and It was often designated accordingly " morbilli confiuentes." was reserved for Dr. William Withering, of Birmingham, to to 4982, or to of the entire eradicate this error. He not only laid down correctly the in 1863 -clinical distinctions of the two maladies, but he remarked that mortality (70,312). Nor was this epidemic confined to London. a town or district of England escaped its ravages. "patients who had gone through the measles were equally Scarcely of the land there was uni.subject with others to scarlatina," although he had "never seen an instance of the same person having the scarlet fever obvious that we have much to twice," and believed " it to be as great an improbability as a a disease in the prevention and treatment of repetition of the small-pox.,,** In the first edition of his work ,(1779) Withering, like Sauvages and Cullen, drew a distinction which our art is still so powerless. between the anginosa of early writers and the angina GEOGRAPHICAL DISTRIBUTION. ’(scarlatina) maligna or ulcerous throat of Fothergill; but in the Scarlet fever is known to prevail over the whole of the confollowing year (1780) Dr. John Clark, of Newcastle, insisted tinents of Europe and America, but it is probably nowhere so that " they ought not to be considered as distinct affections, but only different species of the same disease." The latter common as in Britain. In France, according to Rilliet and view was also adopted by Withering in the second edition of Barthez, it is a rarer disease than either measles or small-pox.t his work (1792), in which he maintained that the affections in In Iceland it was epidemic in 1827, but since then, with the of a few cases in 1848, it has not been met with.t question "constitute but one species of disease, and that they exception The date of its first appearance in America is said to have been owe their existence to the same specific contagion," and its it now prevails alike in the tropical and temperate retruth has never since been called in It is only of late years that we have been to form an gions of that continent. In Asia and in Africa it appears to be and in many parts to be quite unknown. In -accurate idea of the prevalence of scarlatina ; but still there is a rare according to the testimony of Morehead and other no doubt that it has increased during the present century, and that it now occupies that pre eminence among the causes of writers, and the reports of the Army Medical Department, true fever is never met witn, but epidemics of a closely allied, mortality in childhood which was formerly held by small-pox. scarlet or scarlatina rheumaticanot identical, of the in if From the reports Registrar-General, it appears that -24 years (1838 to 1861 inclusive) 375,009 of the population of are observed from time to time. The absence of scarlatina from remarkable as measles is often very prevalent. England and Wales and 53,663 of the inhabitants of London Scarlet fevermore is said to be equally rare in Persia and in Egypt. have died of scarlet fever. About 1 in every 24 deaths which - occurred throughout England during these 24 years was due In New Zealand its existence was not noticed prior to 1848, to this disease. Iu Rome years the ratio was as low as 1 in 33, but since then it has been found to attack both the European and the in others as high as 1 in 14. During the ten years 1850-1861, . , ,. ,. whatever country the disease appears, it makes no dIstmcthe average annual mortality for every 100,000 of the populaIn between The natives of New Zealand and different races. - tion of England and Wales from all causes was 2217, and from American Indians, have suffered -scarlet fever alone 88. The mortality from scarlet fever ex- South America, and the ceeds the mortality of measles and small-pox taken together, equally with Europeans. ETIOLOGY. and almost equals (in London it exceeds) the gross mortality of
rossalia), use
......
... ...
.
/
had
made
Measles ...... ......
-
their
Small
1747-48.
50,751
... ...... ’"
... -.. ... ... ...
from
notwithstanding is
been fatality and remarkable mayfor betheirmentioned In particular the wide-spread character. 1801-4, 1833-4, therarely which the number number ofofits wevictims, regardhas extentif hasprevalence scarcely oryetthe of its its scarlet fever inLondon in 1863 amounted amounted to The deaths from onejfcurteenth
Throughout thelength andmourning. breadth Fromdesolation and From the above remarksitis learnrespecting
scarlatina
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A.-PREDISPOSING CAUSES.
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* * Observ. Med. cirea Morbor. Acutor., Historiam et ed. ed. etCurationem, Curationem, Childhood’s isIS of the most powerful predeveloping ls7s. I676. 1. 1, Age 1. isone one of the most powerful predisposing Age.-Childhood t " Inter mtiltos autem morbos, qui huic seculo orininem debent. neperrim febris observata est, quœ scarlatina dicitur a eoccineo colore (nostratibus * scarlet linguâ. vernaculâ appellato), quo cutis fere universa tingitur."- (Scotia It is well known that deaths not only from typhus and enteric fever, bnt also from uraemia, asthenic pneumonia, cerebral diseases, and in short from Illustrata, auctoM Ituh. Sihbatd, Edinb. 1684, p. 65.) Pyretologia, seu Exercitationes de morbis universalibus acutis. Lond. 1692. any disease which assumes a typhoid character. are included under the § Maladies des Enfans. 1741. Registrar-General’s designation Typhus. The returns under this head afford An Account of the Sore-throat attended with Ulcers. 2nd ed., Ijond. 1748. no criterion whatever as to the prevalence of true typhus fever. On the on Fevers. 3rd ed., 1757, t Maladies des Enfans, 1843, it., 567. ¶ Malignant Ulcerous Sore-throat. Essay p. 266. t Hirsch : Handb. der Hist. Geog. Path., p. ?36. ** An Account of the Scarlet Fever and Sore-throat, Lond. 1779, pp. 47, 48. § It appeared first at an inland town 10 New England, and was not thought to have beeu imported.-Lond. Med. Obs. and Enquiries, 1776,,., tt Observations on Fevers, Lond. 180, p. 246. i.,210. (’]in. Res. on Dis. in India. Sec.ond Edit., 1860, i 199. tt Manv of the case’! towhich the term ’ angiiia maligna" was formerly and and For. Med. Chir. of as Brit. doubt Bretonneau has were without Rev., 1854; ( Thompson : Tuke, Edin. Med. examples diphtheria; but, applied 1861. pointed out, this was not the case with the ulcerous sore-throat of Fothergill Jotirn., ** Hirsch: and Huxham.-Memoirs on Diphtheria Syd. Soc. ed. 1859 p. 37. Op. cit., p. 239.
Observ.Med. circa Morbor.Acutor., Historiam
predisposing
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.
696 of scarlet fever. From the statistics of the London Fever it appears that out of 2402 patients admitted with scarlet fever during twenty years, 2124 (or 88’4 per cent.) have been under twenty-five years of age. causes
Hospital
years of age. The number of deaths, however, in the first year of life is less than one-half of that in the second, and constitutes less than one-ninetieth of the entire mortality, whereas the deaths from scarlatina in the second year of life amount to one-fifteenth of the entire mortality. Examples of scarlet fever in the fcetus have been recorded on good authority, although it might be sometimes difficult to distinguish a scarlet rash from the redness natural to newlyborn infants. On the 28th of April, 1839, the youngest son of the late Dr. George Gregory was born, "evidently suffering under some form of fever. The throat was affected on the fol. lowing day, obviously from angina maligna. Eruption was never developed. The child drooped, and died on the 1st of May."’ On two occasions I have known females, during an attack of scarlet fever, delivered of living and healthy children. Although scarlet fever is a rare disease after forty years of age, instances are not wanting of its occurrence at an advanced age. Out of 2402 cases admitted into the London Fever Hos. pital during twenty years, four were above fifty, and one above sixty. 18 Table III. four fatal cases are reported as having occurred in persons above eighty-five years. (To be continued.)
Hospital statistics, however, afford a fallacious test of the ages of scarlet fever patients, inasmuch as the majority of young children are treated at their own homes, and a large proportion of the hospital cases are servants in private families. More reliable information is furnished by the mortuary returns of the Registrar-General, subject to the correction that the mortality from scarlet fever under fifteen years is about double what TWO CASES OF SYPHILIS SHOWING A it is above that age. The subjoined table is constructed from PROLONGED INCUBATION PERIOD AND the death returns of England and Wales for the years 1847 and 1855 to 1861; and for London for 1845-46 and 1848 to 1854. COMMUNICATION OF THE DISEASE BY This gives us a total of 148,829 fatal cases : of which, 95,070, SECONDARY CONTAGION. or 63’87 per cent., were under 5 years; 133,661, or 89’8 per cent., were under 10 years; 142,337, or 95’63 per cent., were BY BERKELEY HILL, ESQ., F.R.C.S., under 15 years; and only 2615, or 1 75 per cent., exceeded 25 TO UNIVERSITY COLLEGE HOSPITAL. ASSISTANT-SURGEON fever years. From 1 to 5 years of age the deaths from scarlet were more than of the entire mortality during the same ON the 5th March, 1864, John J-,, aged thirty-three, period; between 10 and 15 they were betweenand 1-; from 10 to 15, less than ; and above 15 they constituted only 3½ of ostler, applied, among my out-patients, for relief for a painful the entire mortality. affection of the right eye. He said that about fourteen days before Christmas last, while fighting, he received a blow on the right eye and cheek, which drew blood; his antagonist sucked the wounds for him, after which they quickly healed, and, as far as he knew, the marks also disappeared. He experienced no further inconvenience until the latter end of January, when he observed some pimples appearing where he had been hit, and presently some scabs fell off, leaving a reddish pimple beneath each; but there was no ulcer, nor any discharge from these pimples. His eye next became troublesome, growing red and bloodshot, and smarting occasionally; and on Feb. lst he applied for some eye-water, with which he bathed his eye, but without improvement. Finding the eye-water of no service, on the 5th March he came to me, anxious for other treatment. I examined him, and found the following state of things :-At the outer corner of the right eye was an oval coppery patch, slightly elevated from the skin around it, especially so at the edges; it was smooth and dry. There was also about the middle of the margin of the lower eyelid another smaller patch, which desquamated freely, and whence the eyelashes It is therefore obvious that scarlet fever is most common in had dropped out. Two more similar patches existed on the the second, third, fourth, and fifth years of life, and that after cheek, over the malar bone. All these tubercles were induten years its frequency rapidly declines. From an analysis of rated, and surrounded by an areola of coppery tint. The conthe returns of the Registrar-General, extending over ten years, junctival membrane of the right eye was congested and the it appears that for every 100,000 children under five years of palpebral part thickened; whence the discomfort for which age, in England and Wales, 419 die annually of scarlet fever. relief was sought. The lymphatic glands beneath the jaw and It has been alleged that childhood does not predispose to in the neck on that side were severally enlarged, but painless. scarlet fever, but that adults merely escape in consequence of A coppery roseolous rash extended over the forehead and being protected by a previous attack; but the mere fact of such trunk. The penis was quite free from sores or cicatrices of any large numbers of infants being attacked shows a remarkable kind, and there was no history of any. The inguinal lymphatic aptitude for the disease in early life (not observed in small-pox glands were also quite normal ; likewise those of the body or typhus), while if we estimate the mortality of scarlet fever generally, with the above-mentioned exception of the subat only six per cent., the number of persons annually attacked maxillary ones. Though he complained of sore-throat when in England and Wales is considerably less than one-half of the questioned, the soft palate and uvula were only somewhat connumber of births, so that a large proportion of the adult popu- gested. He was ordered to take four grains of blue-pill witb lation must be unprotected. Daily experience shows that un- a little opium twice daily, and to attend frequently at the protected adults escape in families where all the children are hospital. On the 12th of March I saw him again. He was then under attacked. The above results show how erroneous is the opinion the influence of mercury. His gums were swollen, his breath originally expressed by Withering, and still by many believed was fetid, and he had a bad taste in his mouth. His throat was to be true, that scarlet fever does not often attack infants at not sore. The areolm round the hardened tubercles less spread the breast or under two years of age. No fewer than 30,974 and paler; the roseola much fainter; more of his eyelashes had (or more than one-fifth of the entire number) deaths from fallen. To continue his pill. scarlatina are noted in the above table as occurring under two * Gregory on Eruptive Fevers, p. 146, Lond., 1843.