■4

Glasgow
THniY>ersit£ Xtbrary

I

9

NEW VIEW

OF THE

INFECTION

OF

SCARLET FEVER,

TO

Sir HENRY HALFORD, Bart. M.D. F.R.S.

PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS
AND PHYSICIAN TO THE KING.

DEAR SIR,

I have ventured, in the fol-
lowing pages, to advance some opinions
of rather a novel nature, which will pro-
bably be open to many objections ; and I
am fully conscious how unworthy they
are of the sanction of a name which stands
deservedly at the head of the medical pro-
fession ; but I feel proud of the opportunity
they afford me of declaring publicly how

LONDON :

r HINTED BV THOMAS DAVISON, WHITEF1UAKS.

NEW VIEW

OF THE

INFECTION

OF

SCARLET FEVER,

ILLUSTRATED BY

REMARKS

ON OTHER

CONTAGIOUS DISORDERS.

BY WILLIAM MACMICHAEL, M.D. F.R.S.

FELLOW OF THE COLLEGE OF PHYSICIANS,
PHYSICIAN EXTRAORDINARY TO H. R. H. THE DUKE OF YORK,

AND

ONE OF THE PHYSICIANS OF THE MIDDLESEX HOSPITAL.

LONDON :

PUBLISHED BY THOMAS AND GEORGE UNDERWOOD,

FLEET-STREET.
1822.

2

very valuable statistical work * lately pub-
lished by order of the House of Commons,
that in 1820 the annual mortality was only
one in fifty-eight.

JlIJIMjqL yjiU mJlHULW J till J ,19V9WUll eD9889I

-od ovrnl aaibfikm smog fuo869i ^£otojagii£&
a This increase in the duration of human

life is attributable to various causes, among
which the most prominent are, the better
food and clothing of the poorer classes, the
more temperate habits that prevail pretty
generally throughout all orders of society,
the entire disappearance or mitigated se-
verity of many fatal diseases, the substitu-
tion of vaccination for the small-pox, and
t he improved state of the practice of physic.

It is obvious that whatever effect the last-
mentioned cause has produced, will be visi-
ble chiefly in the better treatment of those

* Population and Parish Registry .Returns

for 1821.-. )tniiro ,„i , •; uMavrin tfNn-urtriir

3

diseases which have been called epidemic,
and which attack great numbers of persons
at one and the same time. It must be con-
fessed, however, that without any apparent
satisfactory reason, some maladies have be-
come less common now than formerly, of
which rickets and scrofula are the most re-
markable ; on the other hand, gout, consump-
tion, palsy, and lunacy have increased in fa-
tality. Sudden elevations and depressions of
fortune, with the corresponding anxiety and
eagerness consequent on an excessive spirit
of mercantile speculation, may explain the
greater frequency of mental diseases ; while
sedentary trades and professions, nay, even
temporary fashions and customs in dress,
must necessarily affect the habits and cha-
racter of the constitution.

ltd iiiaaWttO't.i raited aifi pi ^ftaiifo old

The indulgences and vices of civilised life
naturally account for the greater preva-
il 2

4

lence of the gout : as to palsy, its increase
may probably be fairly enough attributed

to the less general use of blood-letting, a

/>m to 89ri688999n sAj to ooficDnudB lojtfyrg

practice that was formerly much more com-

tjfl 1 .B98JJJ3D 989111 TO $&fn 901 ^DBlSJniJOO

monly employed than it is at present.
Twice a year, at what was called the spring

and fall, persons of a certain period of life

t893£98ID 8uorgi>Jii09 OflJ io pia&Dinnoi isom
were in the habit of losing blood; and

even for the slightest ailment, as a pain

^I9j9iqai09 ^hm>fi9o bb blnow noilfiniDOjfv Io
in the finger, without any reference to a

threatened fit of apoplexy, bleeding was re-
sorted to.

Bnf moil noijqmsxo too toi snitiifn/iup izaioni?,

Jrarij 'io 90flfiiB9qqfi Qfh \6 bavoiq ex «9U3f;lq
The obvious causes of all those disorders

affecting great numbers of persons at the

same time, are bad or deficient diet, noxious

exhalations of the earth, contagion, and the

general influence of climate, or change of

seasons. Any controlling power which we

may be able to exercise over these causes,

will ameliorate the condition of society, and

5

93iB9*KDn£ 2li »Y&Ii»Cf Oi J2J5 * ^UO^B Sib 1{> £}f\fIoI

necessarily increase the value of life. Im-

D3

s

git

counteract the first of these causes. The
enforcement of a strict quarantine* has
entirely succeeded in banishing one of the
most formidable of the contagious diseases,
viz. the plague; and the universal practice
of vaccination would as certainly completely

* That we can rely on nothing but the
strictest quarantine for our exemption from the
plague, is proved by the appearance of that
calamity in the island of Malta, in the year
1813, when it was imported from Alexandria.
The improvements of modern civilised society
are at Malta in their full force, it is in the pos-
session of one of the most polished nations of
the world ; but all these advantages' were in-
sufficient to prevent the fatal and wide-spreading
ravages of the plague, when once introduced into
the island.

6

exterminate the small-pox. For it has been
well observed, with respect to inoculation
for the latter disease, that the partial benefit
derived by those who undergo the opera-
tion has been overbalanced by its favouring
the casual propagation of small-pox — an ob-
jection that cannot be made to vaccination.

Of the value of this discovery we may
form an opinion from the following state-
ments : — In 1818 only 421 persons died of
the small-pox in London, which is the
lowest number that has ever occurred since
the bills of mortality were kept ; but the
practice of vaccination is still by no means
universally adopted, and the report of the
National Vaccine Establishment of 1821
begins by regretting, " that the small-pox
has occasioned the loss of many lives in
various parts of the United Kingdom since
our last report, and that not less than 792

7

persons have died of that distemper within
the bills of mortality, in the course of last
year. This is about one-third of the average
number of those who perished annually in
the metropolis before the introduction of
vaccination; but so many deaths afford a
strong presumptive proof that great pre-
judices still prevail against vaccination, and
that the benevolent designs of the govern-
ment are still far from being accomplished."

The report of 1822 mentions, that 508
persons had died of small-pox within the
bills ; a diminution that may justly be at-
tributed to the wider diffusion of vaccina-
tion. That the pretensions of this discovery
were originally rated somewhat too high,
and that in some few instances small-pox
does occur in a peculiarly mild and modified
form, after the patient has undergone ge-
nuine and well characterised cow-pox, is

8

admitted now by every one : but that deep-
rooted prejudices should still exist against
the universal employment of vaccination,
cannot but excite surprise ; especially, as is
most ably urged in the candid report above
alluded to*, " we learn, from ample ex-
perience, that the number of cases of small-
pox in the safe form, which it is found to
assume after vaccination, is by no means
equal to the number of deaths by inocula^
tion,"

Jjh 1q ooiwhtd dim Jbaioanaoo yfouorr
If it be impossible to get rid of the other
contagious diseases, still much good has
been effected, by disarming them of their
violence. Ventilation, the free use of ex-
ternal cold, and the bold administration of
*fi Sud ^Hbihhib OTOI Jirodc ^mrn33

* Report to the Secretary of State for the
Home Department from the National Vaccine
Establishment, dated 31st January, 1822.

9

purgatives, have contributed much to lessen
the severity of typhus, the measles, and

In so mild a climate as England any very
great influence cannot be attributed to the
seasons. In the winter, pulmonary com-
plaints and dropsies are the most fatal ; in
the spring, inflammatory diseases ; and in
the autumn, bowel complaints predominate.
The latter, indeed, are diseases more ob-
viously connected with the influence of cli-
mate than any others. Dysentery has, how-
ever, gradually declined; the number of
deaths, recorded in the bills of mortality,
under the heads of bloody-flux, colic, and
gripes, being at the beginning of the 18th
century about 1070 annually; but at the
close of the same century they amounted to
only 20. This alteration in the health of
the people of England (for it is not confined

10

to the metropolis) Dr. Heberden* ascribes
to the improvements which have gradually
taken place, not only in London, but in all
great towns, and in the manner of living
throughout the kingdom, particularly with
respect to cleanliness and ventilation.
srti niffJiw vlteirh osxiBiBoqqB aii ohnm ?&d
Among the causes of epidemic, or rather
what would be called more technically en-
demic, diseases, I have enumerated bad diet,
in proof of which the Pellagra of Lombardy,
and the disorder called by the French Ergot,
may be cited as affording striking illustra-
tions of the baneful consequences of un-
wholesome or scanty nourishment.

* Observations on the Increase and Decrease
of different Diseases, by W. Heberden, jun.
M.D. &c— London, 1801.

11

«9dho8Xi *nobisd£>H .id (eiloqo-jJam orfi oJ

He ni tod <nobno J ai yiao ton <90£fcj nato
This is a disease which is described as
prevailing in the provinces of Italy, that lie
between the Alps and the Po, and which
has made its appearance chiefly within the
last fifty years. It is a cutaneous disorder,
confined to the peasants employed in the
cultivation of the soil, the principal objects
of which, in these plains, are, besides the
vineyards, maize, rice, and millet. In the
early stage of the complaint, red spots, with
slight elevations of the cuticle, resembling
lepra, are observable ; the skin becomes dry
and scaly; vague and irregular pains are felt ;
and in its inveterate form, the disease as-
sumes an appearance not unlike Icthyosis.
The malady then abates; but as the summer
of the following year approaches, it recurs
with increased violence; spasms, anxiety,

12

depression of spirits, cachexy, idiotcy, and
mania are the last symptoms. jK^BSfc
land* (from whom I have borrowed the
description of this disease) states, that in
the lunatic hospital at Milan, of 500 pa-
tients, more than one-third were Pellagrosi.

The disease is not contagious, but it has
an affinity both to leprosy and scurvy, and
has been called by some Scorbutus Alpinus.
The peasants of Lombardy, notwithstanding
the great fertility of these provinces, live in
extreme misery: they have little animal
food ; the quantity and quahty of their diet
are very bad ; their bread, which is princi-
pally made of maize, is ill fermented and
deficient in salt. The squalid wretched-
ness, in short, in which they live, which is

* Medico Chimrgical Transactions, vol. viii.
part 2.

13

the result of war, want of commerce, heavy
taxation, and every sort of privation, is
assigned, with all appearance of probability,
as the cause of that cachectic state of body,

-crP^S11!©11^?818 itself in the cutaneous
eruption, the muscular debility, and the

general affection of the nervous system,
that form the chief symptoms of this de-
plorable malady. It has indeed been at-
tnbuted, by some Italian physicians, to the
increasing use of maize ; by others, to that
of rice, as articles of food ; but both these
causes seem inadequate and fanciful. The
cure consists in generous diet, wine, tonics,
and the warm bath.

ERGOT. .

ay ii Jin tf jtjYii vanj uDinw m »jtqi!b 'to. j&R&n

Rye is subject to a disease called ergot ;
in English, horned rye. Bread made of it

14

has a nauseous, acid taste, and was thought
to be the cause of a spasmodic and gan-
grenous disorder. This epidemic, which
obtained, also, the name of Ignis saber, Feu
St. Antoine, and raged in Sologne about the
year 1650, was probably, however, the re-
sult of starvation, or deficient nourishment,
rather than of the use of diseased corn.
According to the description of this disease,
it commenced with lassitude and debility,
followed by torpor, swelling, and a sense of
burning heat, and excruciating pains in the
lower limbs, which then became shrivelled
and dark, and at length gangrenous, and
dropped off. The malady afflicted almost
exclusively the lowest classes of the people,
who, in order to avoid actual famine, were
compelled to live on a sort of bread, made
of the meal of acorns, of grape stones, of the
roots of fern, and of other crude and un-
nutritious substances. Another disorder,

15

which is said to have begun with an intense
heat, accompanied with a sense of the creep-
ing of insects over the skin, and followed
by acute pains of the limbs and general
convulsions of the muscles, by which the
patient was often carried off, was ascribed
to the ergot in rye, or to the mixture of
other unwholesome plants with the food.
The disease of the rye occurs when a very
hot summer succeeds a rainy spring.

odi ax 8nbfj grriJeroimzy bf«s JboA giuntiKf
bnc ,<i>--

The next general cause of disease which
I shall notice, is what the Italians call mal-
aria, known amongst ourselves by the term
marsh miasma. This is a name, however,
which conveys an erroneous idea ; for there
are many marshy districts where ague is
unknown, and others, again, where inter-

1()

mittents abound, though the soil is dry and
the ground elevated*.

* In the year 1812, I was detained several
days at Trichiri, a small seaport at the mouth
of the Gulf of Volo, in Thessaly. The town is
built on a dry limestone rock, but it is notorious
for malaria. During my stay here, I made an
excursion to visit the celebrated pass of Ther-
mopylae, and slept one night near the marshy
district in that neighbourhood. On my return,
the friends whom I had been waiting for arrived
from Athens, and we all embarked on board a
Greek vessel, to cruise in the Archipelago. On
the following day, I was seized with a most
severe fit of ague ; and, at the same time, a ser-
vant belonging to the party suffered a similar
attack. It might be said, that I had caught my
intermittent at Thermopylae : butthe servant had
not quitted the dry rock of Trichiri, upon which
he remained more than a week. My ague proved
a severe tertian ; and I did not entirely get rid
of it till two years after I had quitted Greece.

17

The nature of this invisible material,
called malaria, is quite unknown ; produced,
as it has been thought to be, from vegetating
soils, under peculiar circumstances of heat
and moisture, it has been variously pro-
nounced to be azote, carbonic acid gas, hy-
drogen, carburetted hydrogen, and sulphur-
etted hydrogen. All these suppositions
have been, in the end, proved to be false,
and we remain still utterly ignorant of the
essence of this pestilential substance.

The exciting cause of ague differs
from the matter of contagion, inasmuch
as it cannot be detained nor preserved in
dead substances. To suffer from it, the
human body must be exposed to its in-
fluence on the spot where it is produced.
In England, the aguish counties are Kent,
Essex, Cambridgeshire, and the East Hiding
of Yorkshire; but the country most re-

C

18

markable for the ravages of malaria, is that
part of Italy called the Maremma, a district
that stretches from Leghorn to Terracina.
It is a tract of country near the sea, varying
in breadth from thirty to forty miles, and
being in length about one hundred and
ninety-two geographical miles. The dis-
ease produced by the malaria of this ter-
ritory is the true Walcheren fever; but
it can by no means be said to be caused
by marsh miasmata, as the greater number
of places in which it exists are dry, airy,
and elevated. Nor is the approach of the
pestilence announced : the victim is warned
by no visible sign of the presence of the
destructive poison he is inhaling; for the
tranquillity of the air and the freshness of
the verdure around him, would lead him to
suppose he was in the most healthy region.
If the Pontine marshes are unhealthy from
stagnant water, that is not the cause in the

greater part of the Maremma, in the Tuscan
and the Roman territory for instance,
where the soil is dry, and the ground, in
many places, elevated above the plain. The
basis of the soil of the Campagna di Roma,
is a calcareous sand-stone, over which is a
covering of volcanic origin; and here the
unhealthy region extends from the foot of
the mountains of Viterbo to the walls of
the capital, within which the shepherds and
their flocks come to take shelter at night.
Nay, the city itself is not free from its at-
tacks ; and every year it reaches some part
of Rome, where it was before unknown.

Many reasons have been assigned for this
increase of malaria : the Italian writers as-
sert, that since the plague of the sixteenth
century, the population of the country has
never been great enough to resist the in-
fluence of the bad air, which augments

c 2

20

every year, in proportion as the number
of people and the labours of agriculture

diminish. A dense population, and the

"dJFWion tiK>dw ; aoffff f .tnobnu fli ha& vtoa
peculiar state of the atmosphere produced

by it, might retard its progress ; and this

supposition would seem to receive some

,D9gfe9inoo aid )?um il .YJii)j.qj?7 totg niiw
support from the curious fact mentioned by

the author of a very ingenious paper* on

this subject — that sleeping under a mos-

. . .
quito-net, in an infected place, will preserve

a person from the pernicious effects of the

malaria. The explanation given of this

singular protecting power is, that the heated

and compound gas, coming from the lungs,

and detained by the mechanical texture of

the net, may decompose the miasma.

Much ingenious speculation has been

* Edinburgh Review, No. 72. art. 9- Dello
Stato Fisico del Suolo di Roma, &c. Di G.
Brocchi,

21

exercised upon the cause of the difference

of salubrity of the country round Rome

9fii bnfi <noit£l|.rtroi:r s oactsb A .daini/fvb
now and in ancient times ; when, notwith-
standing the city was beset by marshes,

. f AOS BSty lUO!«\ r4l

lakes, and woods, its population increased
with great rapidity. It must be confessed,
that no very satisfactory explanation has
hitherto been advanced ; for it will hardly
be allowed, that the change of dress from
the woollen clothing of ancient Rome to
the use of the silk and linen of modern
days, can be received as an adequate cause.

The population of Rome in 1791 was
estimated at 166,000: it had decreased, in
1813, to 100,000: but the real nature of
malaria, whether it is to be considered as the
cause or the effect of this diminution, is not
at all understood, and still presents one of
the most curious problems to be found in
the natural history of any country.

22

While on the subject of ague, I may ob-
serve, that the contradictory opinions which
have been maintained on the infectious or
non-infectious nature of what has been
called yellow fever, may be reconciled by
admitting that two distinct kinds of fever
have received the same denomination. Dr.
Lind, speaking of a yellow fever in the island
of Jamaica, which was not contagious, and
of one brought from our American colonies,
that was highly infectious, observes : " We
can only reconcile the facts that may be
produced on both sides of the question, in
support of those opposite opinions, by sup-
posing, that the yellow fever, in the West
Indies, is sometimes of a mild nature, and
altogether free from infection, while, at
other times, it is more violent, and highly
infectious #." But, if we allow that the

* A Dissertation on Fevers and Infection,
p. 293. By James Lind, M. D.

23

name of yellow fever has been indiscrimi-
nately applied to the worst form of ague,
and to a fever which is infectious, and which
is, in fact, typhus, accompanied by great
derangement of the functions of the liver,
all ambiguity will vanish.
.iG .noitaaimon jb omm osti hyrieo&i ovmi

iMifi f8JJor«>r>7no> t< " aj;**' frjfdw ^orR fn.fi I. to
ni »noii83i/o 9fu to B'jJji-i ifjoci no fou^o'bo'jrir

oni hi ii .Bornit *.fo/l.to

24

"Sii wioioiiuxios tafioiJmo79*t Ifioijiloq tg}2f>jjp
CHAPTER II.

Contagion— Small-pox— Hydrophobia— Measles
— Epidemic Constitution — Origin of the In-

fection of Typhus Fever— The Plague.

ItiJg asuritiaoo hrtrt <te&q aogs omoa not iresd

But the most fatal of all the causes, pro-
ducing diseases that attack large classes of
the community, is contagion. The chief
diseases arising from this source are, the
plague, typhus, small-pox, measles, and
scarlet fever. How these several infections
first originated is a different question, and
foreign from the subject of my present in-
quiry. They seem to have existed anterior
to any tradition or historical record — to have
been perpetuated from age to age, and from
year to year — to have been confined, in the
first instance, to some remote district, and
to have been gradually disseminated over

the greatest part of the world by war, con-
quests, political revolutions, commercial in-
tercourse, or even by the accidental visits of
travellers.

89fejs9M — sidoriqoThYH— xoq-ltaraB — norguinoO

-ill aiifk* rirgr^.0- -iioxiu:liienoO wmsbiqSl
" Thus the small-pox," says Lind, " has

been for some ages past, and continues still
to be, the terror and destroyer of a great
part of mankind. But from what origin,
or how, was this infection first generated ?
Many opinions have been given on this
matter, equally incapable of proof or refuta-
tion. And the original causes of this, as well
as of several other contagions, continue still
among the hidden secrets of nature, not-
withstanding the many plausible conjectures
concerning them. The real existence of an
infection can only be ascertained -by its
visible effects ; many of which are also in-
explicable. Thus the Europeans have car-
ried the small-pox to almost all parts of the

26

world, where their ships have opened a
trade; though the seamen in those ships
might not have been afflicted with it in
that voyage. This venom has been con-
veyed, in an old blanket, to nations of In-
dians ; some of whom it has almost ex-
tirpated."—P. 295*

It is also more than probable that the
poison of hydrophobia is spread only by
communication from one rabid animal to
another ; for that it has no relation to the
heat of the weather is clearly proved by its
common appearance in Kussia during the
severest winters. Then it prevails amongst
the wolves, who venture during that incle-
ment season into the villages, and boldly
attack the peasants. Many parts of the
world are to this moment exempt from this

* A Dissertation on Fevers and Infection.

27

dreadful infection ; and I believe it has not
yet been known in the island of Jamaica,
or at Cairo, in Egypt ; and, if I am not mis-
taken, it has not appeared in India. If the
opinion that this poison, like the other in-
fections, is the result of an original unex-
tinguished contagion, be correct, does it not
point out a simple method of extinguishing
it in this country, viz. by adopting measures
similar to those of the strict quarantine, to
which we are indebted for our present ex-
emption from the horrors of the plague ?

Of the class of contagious diseases, some
may be considered, in the present state of
society, as almost inevitable, though they
generally affect the system only once in the
course of a life, while others, as typhus fever
for instance, may recur frequently, though
they may be avoided altogether by only
ordinary precaution.

28

One of the most remarkable of the con-
tagious diseases, which persons undergo
usually once only in their lives, is the small-
pox • and we have seen that vaccination has
disarmed it in a great measure of its alarm-
ing fatality, and might, indeed, by the uni-
versal employment of that great discovery,

- ililiiUIOO U>u(J'i' Kl 0 ill 03 ii> ^RiiiYTJBOO 39lLt>f(T

effect its complete extermination.

The small-pox occasionally recurs, but
certainly such an accident is rare, and the
assertion lately made in a treatise* on that
subject, must surely be hasty and inaccurate.
It is quite incredible that out of 836 cases
of small-pox, which Dr. Thomson saw in

* Historical Sketch of the Opinions enter-
tained by Medical Men respecting the Varieties
and the Secondary Occurrence of Small-pox,
&c. By John Thomson, M.D. p. 279.— London,
1822.

the interval from June, 1818, to the time

-flOi) 9X1J JO 9iU»2lxB.ff{3T JKOfTT. '3(1 J IO QifO

of the publication of his work, in 1822, se-
venty-one should have previously passed
through that disease. This proportion is
more than one in twelve: if such indeed

were the fact, we ought no longer to speak

~msj 9fij \a (D99iMn F$?\m ° r

of secondary small-pox, as one of those ano-
mahes observable in some peculiar constitu-
tions, which baffle the skill of the most ex-
perienced physician.

The inoculation of the measles by Dr.
Home of Edinburgh was an experiment,
which, though practicable, was not attended
with such advantage as to occasion its being
continued. Much, however, has been done
in mitigating the violence of this formida-
ble disease, by improved medical treatment,
and perhaps still more by the judicious ap-
plication of a remark that could not escape
the most careless observer, viz. that the

30

measles sometimes appear epidemically
under a very mild form.

.SiudJotn lo

The disease occasionally occurs without
any of the usual preparatory symptoms, and
after so very little fever, that patients can
hardly say they have been ill at all. Dr.
Heberden observes, that the longer the
preparatory symptoms, such as sickness,
quickness of pulse, cough, sneezing, pains
in the limbs, continue, and the worse they
are, so much the less mild has the distemper
proved.

Parents considering the measles as a dis-
ease almost inevitable, have wisely chosen
to expose their children to the contagion,
at such auspicious times ; so that the dis-
order may be once well over, and all further
anxiety at an end. It will be my present
purpose to prove that the same practice

31

should be followed as to scarlet fever, a
name that sounds so fearfully in the ears
of mothers.

iuodtbrr Sttuooo ylhuroigeooo oznwih f)rfT

Why contagious diseases at one time
assume a mild type, at another appear
under an alarming aspect, is a question
that may perhaps never admit of a very
satisfactory reply; but it is our duty to
note the fact, and to avail ourselves to the
utmost of the advantage to be derived from
a judicious application of so important a
truth.

In the absence of all other explanation,
it has generally been agreed to attribute
this difference of type to some occult quality
of the air ; for we are not more advanced
now in our knowledge of the subject, than
they were in the days of Sydenham. The
ronstitutio aeris is still appealed to as neces-

32

sary, if not to generate, at least to cause the
universal diffusion of contagious fever. But
if instead of employing so vague and un-
meaning a term, we were content to speak
of a constitutio epidemica, or that peculiar
state or condition of body, into which a
great number of people are brought by
having been subjected to the operation of
the same physical and moral causes, some-
thing more distinct and intelligible would
be expressed.

These causes are very numerous, and va-
rious is. their character ; as previous hot,
cold, or damp weather, deficient or bad diet,
fatigue, grief, anxiety, &c. Being all simi-
larly predisposed, it is not strange that if a
number of people should fall into the same
disease, they should have it in the same way,
whether mild or severe, in other words, that
an epidemic constitution should prevail.

33

When typhus fever is raging and com-
mitting great havock among the different
classes of society, or the small-pox, measles,
or scarlet fever, are very common, it is im-
mediately assumed that there is a peculiar
condition of the atmosphere favourable to
the propagation of these several complaints.
" It seems a well established fact," says Sir
G. Blane*, " that the same morbid effluvia
which produce typhus, give a susceptibility
or predisposition to the attacks of other dis-
eases." It might, perhaps, have been more
correct to have said, that when the body
has been debilitated by the long-continued
action of the above-mentioned moral and
physical causes, one or other of the conta-

* Observations on the comparative. Preva-
lence, Mortality, and Treatment of different
Diseases. — Medico - Chirurgical Transactions,
vol. iv.

D

34

gious diseases predominates, as accident
may determine.

I have stated that the constitutio epide-
mica is the result of the combined action of
various causes, which, during their almost
imperceptible and silent operation, may
have excited little or no observation ; hence
we have been led to attribute the appear-
ance and character of an epidemic to the
agency of some mysterious power, an arcana
constitutio aeris. Sydenham says, that the
character of diseases is the result of what he
called constitutiones annorum, which vary
not according to the degree of heat, cold,
moisture, or dryness, but depend upon some
occult and inexplicable change in the very
bowels of the earth*.

* Variae sunt nempe annorum constitutiones,
quae neque calori, neque frigori, non sicco hu-
midove ortum suum debent, sed ab occulta potius

35

Certain phenomena were observed, and
were referred to causes that were supposed
to be still acting, whereas the type of dis-
eases is modified by agencies that may have
ceased to operate, having already produced
their effect. An example of what I mean
is furnished by the bowel complaints so pre-
valent in the months of September and Oc-
tober, which ought to be referred rather to
the previous heat of summer, than to any
indulgence in the fruits of autumn. In all
hot countries these disorders are more com-
mon than they are with us, and here in
England they are most severe after the
hottest summers.

et inexplicabili quadam alteratione in ipsis terra
visceribus pendent, unde aer ejusmodi effluviis
contaminatur, quae humana corpora huic aut
illi morbo addicunt determinantque, &c. — Sy-
denham, Opera Universa, p. 6.

d 2

36

It may not always be so easy to assign
any one, or even any number of causes that
shall decidedly appear to have produced,
what I have called, the epidemic constitu-
tion ; but though we should still be incre-
dulous as to the theory, we ought not to
reject the application of the remark : if it
be really true that contagious diseases do
sometimes appear under an universally mild
form, we ought to profit by the observation,
though unable satisfactorily to explain it.

TYPHUS FEVER.

The contagion of typhus fever is an in-
visible ma tter exhaling from the body of the
patient, and radiating to the distance of two
or three feet only, provided the noxious va-
pour be not accumulated in a room for want
of ventilation. The poison adheres also to

37

the patient's wearing apparel and dirty linen,
to materials of wool, cotton, linen, beams of
wood, chairs, bedsteads, and other furniture ;
and also to various utensils used about the
sick ; and its virulence, so far from being
impaired by this lurking condition, has been
supposed to be more certain and con-
centrated than in the recently emitted
effluvia or excretions of the sick.

According to Lind, neither wholesome
air nor the severest frost appeared to miti-
gate the force of the contagion ; but he gives
a curious example of an unintentional fu-
migation that had the effect of entirely de-
stroying it on board a ship. " The Edgar,"
says he, " sailed soon after for the Medi-
terranean, where the contagion in a few
months acquiring great vigour, together
with a superadded scurvy, destroyed sixty
of her men. The manner in which the in-

38

fection was removed from the ship, though
not unusual, is worth relating. In the en-
gagement which happened that year with
the French fleet on the coast of Portugal,
twenty-five barrels of gunpowder were fired
on board of her during the action ; and to
the surprise of the officers, none of her men
were afterwards attacked with fevers*."

It has generally been maintained that
foul air, filth, putrid animal effluvia, cold,
wet, fatigue, or bad diet, will produce con-
tagion where none previously existed ; but
the probability is, that though these several
causes, acting for a long time, will pre-
dispose the body to yield to the influence
of infection, they are not able to generate
it ; in short, that typhus fever does not now

* A Dissertation on Fevers and Infection,
p. 191.

39

originate in any individual. I cannot better
endeavour to establish the truth of this
opinion, which will no doubt be questioned
by many, than by giving a few instances of
the first appearance of an infectious fever,
mentioned by that intelligent physician Dr.
Lind.

" During the month of October, the
squadron arrived from the West Indies,
after the reduction of Guadaloupe, so over-
run with the scurvy, that when in the Chan-
nel ten or a dozen persons usually died of it
every day. Out of three hundred and fifty
scorbutic patients, who were sent a-shore
from those ships, there was not one who
had a fever. This I mention for the sake
of the following remark.

" The surgeon of the Panther told me
that forty of her men had died of the scurvy

40

in their passage home; and, during that
time, there were usually ninety patients in
the sick apartment. The place appropriated
for the sick was in the bay of the ship, and
had no pipe from the ventilator, nor any
scuttles cut through its sides for the ad-
mission of the fresh air. A number of pa-
tients thus closely crowded together ren-
. dered the place so disagreeable and suf-
focating, that the sick were in a manner
stifled for want of air. The surgeon, when
visiting, could scarcely breathe in it, or re-
main for any length of time, without being
obliged to have recourse often to the fresh
air upon deck, and sometimes to the spirit
of hartshorn, or to a glass of wine, for his
immediate relief. He observed, that both
the virulence and mortality of the scurvy
were heightened by the unventilated air of
the place in which the sick for several weeks
had been confined; yet out of above an

41

hundred patients sent to the hospital by
this surgeon, not one was remarked to have
any symptom of contagion generated in that
apartment." — P. 195, 6. /

i£0fB icon .To&sliJflfiT - mofi oqiq on h&d
It would be impossible to conceive a
combination of circumstances more favour-
able to the production of contagion, than that
which ishere related ; numbers were crowded
together in a small space, and in a state of
extreme debility; in short, were in the very
condition to render them extremely sus-
ceptible of taking infection, if it had been
applied. To speak figuratively, it may be
said that the fuel existed, the combustible
materials were prepared, but the spark was
wanting. The place was so disagreeable and
suffocating*, that the surgeon could scarcely

* The cause of this sensation of suffocation
has never yet been satisfactorily made out; for
it appears by the most accurate chemical expc-

42

breathe in it, and was obliged to have re-
course to the fresh air upon deck, and still
no fever made its appearance.

riments that have yet been made, that the air
of a crowded assembly, for example, the heated
suffocating atmosphere of the gallery of a theatre,
contains precisely the same proportions of oxy-
gen and azote, which are to be found in the
ordinary atmosphere without doors. It is of
course loaded with aqueous vapour, and traces
of carbonic acid gas are to be detected in
it, but the essential constituent parts, oxygen
and azote, are there in their usual proportions.
We know that animals die before all the oxygen
of the air, in which they are confined, is ex-
pended ; and that if the carbonic acid, formed
by their breathing, be subtracted, they will live
the longer ; but in the situation above alluded
to, the loss of one portion of oxygen is imme-
diately supplied by the free communication with
the external air. What the cause of the dis-
tressing feeling of suffocation may be, of the

43

The very next paragraph of the same
treatise by Dr. Lind contains the exact con-
verse of the fact just related, and clearly
proves the importation of the fever, and its
appearance amongst a healthy crew, in con-
sequence of their communication with some
infected marines.

" The first ship," says he, " which arrived
towards the latter end of this year from the
fleet in North America was the LoestofFe.
On the 18th of October fourteen of her men
were sent to the hospital, and thirteen more
on the 21st of the same month. The scurvy,

desire to rush out and to breathe the fresh air,
is not discoverable on the application of chemi-
cal tests. Does the electrical state of such an
atmosphere differ from that of the pure external
air? This is a curious subject, which well me-
rits to be investigated.

44

the flux, and fevers were reported to be the
prevailing diseases in that ship.

" The account given of the fever was to
this effect. The company of the Loestoffe
were in perfect health during the eight
months they were in America, and until
a few days before their departure from
Quebec. At that time six recovered ma-
rines came on board from Poi?it Levi hos-
pital, and in forty-eight hours afterwards,
among her company of two hundred people,
fifty were seized with fevers and fluxes. In
some the sickness began with a flux, in
others with a fever; but the flux was ge-
nerally moderate and gentle. The fever
continued commonly from five to ten days ;
two patients were distressed with it for a
whole month. When the first attack was
from the fever, a supervening flux proved
salutary ; but where the contagion made its

45

first appearance with a flux, the accession
of the fever carried off the patient. This
ship was twenty-seven days in her passage
to England from Quebec, and during that
time, six of her men died." — P. 197.

Many other instances are given by Dr.
Lind of similar accidents ; and two cases
only noticed in which it might appear that
a seasoned sound crew became infected from
the closeness or damp below, occasioned by
the hatch-way being kept shut. Against
the numerous examples which prove the
contrary, it will scarcely be contended that
these two cases ought to have much weight,
particularly when it is by no means clear
that the infection was not previously on
board, and was not disengaged by the im-
prudent opening of some unsuspected pack-
ages, in which it had been lurking.

The liability to be affected by contagious

46

diseases differs greatly in different indivi-
duals ; some being acted upon by very small
doses, if I may so express it, of the poison,
while others resist even the strongest ; but
generally speaking, the causes that have
been before enumerated, such as depression
of mental energy from want of employment,
loss of bodily vigour from want of nourish-
ment, and the debility arising from previous
excessive hot weather, having similarly pre-
disposed the bodies of a great number of
persons, the infection is applied, and the
fever, whatever it may be, becomes general
or epidemic.

It has been said, that the contagion of
measles, scarlet fever, and hooping cough,
like that of typhus fever, is never wholly
extinct in any country ; yet that these dis-
eases prevail epidemically only during par-
ticular seasons : no one will deny the fact,
but to explain it, it is quite unnecessary to

47

have recourse to any peculiar constitution
of the air, which being once assumed, is then
styled an occult quality, having no relation
whatever to the thermometrical or baro-
metrical condition of the atmosphere.

This is an opinion, however, which, as I
have observed before, has been adopted by
the most intelligent writers on this subject,
and has prevailed from the days of Syden-
ham to the present time. Dr. W. Heber-
den# remarks, " that the presence of in-
fectious matter is not alone sufficient to
make the plague epidemical, but that some
concurrent state of the air, and of the hu-
man body, is likewise necessary."

There can be no question about the latter
condition, which, even in the opinion of the

* Increase and Decrease of Diseases, p. 95.

48

author just quoted, seems by far the most
essential ; for in another part of the same
treatise, he expresses himself in the follow-
ing manner, and does not seem to lay so much
stress on the necessity of the aerial change.

"But a proper state of the air is not
the only circumstance necessary to pro-
mote the operation of contagion. During
the epidemical constitution, it is highly
probable that good diet, and good spirits,
and cleanliness, and fresh air, and proper
clothing, and exercise, may all contribute
to render the body less susceptible of dis-
ease ; the seeds of which, like those of ve-
getables, will then only spring up and
thrive when they fall upon a soil convenient
for their growth*." In proof of this, he
mentions that the plague at Moscow at-

* Increase and Decrease of Diseases, p. 68.

49

tacked chiefly the poor, committing few
ravages among the nobles or the rich mer-
chants. Likewise at Marseilles, " la peste
fit ses plus grands ravages dans les quartiers
habites par le menu peuple*."

So much influence, indeed, does Dr.
Heberden attribute to our improved mode
of life, that he thinks " our long exemption
from the plague is not so much to be at-
tributed to any accidental absence of its
exciting causes, as to our own change of
manners, our love of cleanliness and venti-
lation, which have produced amongst us, I
do not say an incapability, but a great un-
aptness, any longer to receive itf."

Theseverity of our quarantine laws proves,
however, that we still think the absence of

* Traite de la Peste.

t Increase and Decrease of Diseases, p. 96.

E

50

the exciting cause, viz. the contagion itself,
is necessary to keep us quite free from the
fatal visitations of the plague.
$i ovig o) hfj^olqim vuiovsahaa t98XJ08ilj l&di
The opinion of Lind, whom I have so
often quoted, on this subject, is expressed
most clearly, and appears to be perfectly
correct. " An infectious disease," he says,
" is not, therefore, always such as the vulgar
imagine it to be, a calamity which spreads
itself to every person who approaches ; the
plague itself is not altogether of such a na-
ture. It comprehends only a disease, which,
in certain circumstances, may be communi-
cated to others ; there are certain constitu-
tions or habits of body which are peculiarly
susceptible of infection, and each species of
infection finds constitutions which more
strongly resist it*."

* On Fevers and Infection, p. 240.

51

In illustration of this, it has long been
known, that with respect to the small-pox,
during the utmost exertion of the force of
that disease, endeavours employed to give it
to some persons, by lying in the same apart-
ment with the infected, and other methods
of a free communication with them, often
proved ineffectual. Some of the constant
attendants about the sick in this disease
have never been infected.

To account for the disappearance and
cessation of infectious diseases, it has been
supposed that the contagion has exhausted
itself, abated by degrees in malignity, and
at length stopped. Of the plague, it has
been said, that when it was excited out of
its proper season, it has not spread; that
its chief force has always been felt in the
summer and autumn ; and that when it was
raging in Italy, the Neapolitans used no

e 2

52

artifice to purify either their goods or houses,
yet the disease ceased amongst them as en-
tirely as in the best-regulated towns. It is
also true, that the gaol distemper, or typhus
fever, after every method used to destroy it
has proved entirely ineffectual, will often of
itself gradually abate, and at length entirely
vanish.

May not all these several facts be explained
by supposing a change in what I have called
the epidemic constitution, which becoming no
longer favourable to the reception of the
infection, the contagious disease no longer
spreads amongst the community?

The degree and danger of a fever has
been imagined to depend, in a great measure,
on the quality or the specific nature of the
source from whence it has been derived;
but without supposing that the contagion

53

of one typhus fever, for example, is more
virulent than that of another, if we take into
account the state of the recipient, and re-
collect also that the quantity of contagious
matter, to the action of which the patient
has been exposed, may be, from want of
proper ventilation, greatly accumulated,
these duTerences are the more easily ex-
plained.

After these preliminary observations on
the nature of contagion, and on the ge-
neral causes of epidemical diseases, I shall
proceed to point out the great advantage
which would result from their practical ap-
plication to the treatment of a disorder with
which we are all familiarly acquainted.
tmwfti;;a tf&Xfg fi xxi Jjiiofpb oi bonigemi osad
adilo onisim oiliraqa 9iti 10 T(iilcup ^d J ao

>anodw moil ocrcwoa

54

tawoq gflitoad GHAPTESl 1 .noiguinoj)

-Iigm&lo aoiJosftcu oxijr. teiihs&i aoiimho&rlo

Scarlet Fever.

.xoq

One of the most remarkable circumstances
connected with contagious diseases, is the
property which some of them possess of at-
tacking each individual once only in the
course of his life. A change is thus wrought
in the system, which is not evident to the
senses, and it is remarkable that the same
change is produced, in however slight a de-
gree the morbid affection may have been
experienced.

In one instance we have recently found
that the change alluded to, is capable of being
brought about by the occurrence of a differ-
ent disease ; one morbid affection, in this
manner, being able permanently to alter

55

the condition of the body, so as to render
it insensible to the operation of another
contagion. I allude to the protecting power
of vaccination against the infection of small-
pox.

It has before been observed with regard
to measles, that there is a considerable range
of character in the disease : in one season it
will be slight, in another severe, and at other
times hold a middle course. It is usually
mildest in summer, and most severe in winter
and spring. In consequence, one of the ordi-
nary cautions about preparing children for
the reception of the measles, is in unfavour-
able weather to guard even strong children
against exposure to cold, and to keep their
bowels open, prior to infection. In other
words, we are to endeavour to bring about,
by artificial means, that state of body which
sometimes exists spontaneously in a large
portion of the community.

5()

Dr. Willan, speaking of scarlet fever, re-
marks, " that according to the state of the
air, the soil, climate, or season of the year,
one form predominates over all the rest, and
gives the general character to every epidemic
scarlatina*."

His attention seems to have been directed
chiefly to the state of the weather, and he
drew no inference from the above observa-
tion, but left it, as a simple matter of fact,
which afforded no practical deduction.

Small-pox and measles being found to be
diseases that are almost inevitable in the
present state of society, it is natural that
mothers should be anxious and desirous that
their children should have passed through
these formidable disorders. All anxiety
about the first of these complaints may be

* On Cutaneous Diseases, vol. i. p. 282.

*

57

considered now as nearly set at rest by the
practice of vaccination ; to receive the other,
children are prepared by medicine, and ex-
posed to the infection at favourable times,
and when a mild sort of measles is prevailing.
But as to a scarlet fever, the very name of
it inspires so much dread, and so many
people pass through a long life without ever
having experienced, as they assert, the
disease, that it is avoided with every ima-
ginable precaution.

The symptoms of the small-pox, as well
as those of the measles, are so obvious, and
so decided in their external appearance,
that little or no doubt can exist as to
the fact, whether a person has undergone
these diseases or not ; but scarlet fever is so
various in its character, and there is one
form of it so extremely mild, that it does
most certainly sometimes pass through the

58

system unobserved, and in many more in-
stances under the name of a rash, exciting
no alarm, and requiring no medical treat-
ment.

m nerbliHD .noiaicfo yja 1o taoqqua ni
No satisfactory reason has hitherto been
given why a disease, so contagious as scarlet
fever is well known to be, should not be as
general in its attacks as the measles.

The discerning Sydenham says, speaking
of this disease, " Infantes vero prae ceteris
infestat*." And it is a common observa-
tion, that old people are not so liable to
catch the scarlet fever as young persons.
But the most natural and most obvious ex-
planation of this fact is, that persons ad-
vanced in life have already had the disease ;
for this immunity from contagion is not ob-

* Opera Uni versa, p. 287.

59

served to hold good with respect to typhus
fever, but only to be true of those diseases
which are experienced once only during
life. The very use of the word infantes is
in support of my opinion. Children in
arms are most liable to catch the infection,
for the simple reason, that many boys and
girls eight or ten years of age may, like older
people, have undergone it before, but in so
slight a manner as to escape observation.

It is upon the truth and accuracy of
these remarks that the whole value of what
I would wish to inculcate, in the following
pages, must entirely rest.

There is sometimes in schools what is
called a rash, a redness of the skin, of va-
rious extent and brightness, occasioned by
an unusual quantity of blood distributed to
that part. Nothing else, perhaps, is taken

60

notice of ; the rash passes off without ob-
servation, or if it should happen to be
for a moment imagined to resemble, in the
smallest degree, that alarming disease, scar-
let fever, the suspicion is instantly checked,
and the whole matter hushed up as quietly
and discreetly as possible. Now I am
anxious to direct the attention of the public
to this point ; from a judicious practical ap-
plication of which, I think, much advantage
may be derived.

It has long been indisputably established,
that the slightest of all eruptive fevers, viz.
the simple scarlet fever, and that most fatal
disease, the malignant sore throat, are va-
rieties only of the same disease, and proceed
from the same contagion. That the scarlet
fever, like the small-pox, is in some rare cases
to be had twice, will not be denied, though
the proportion of such instances, which is

61

assigned by Dr. Willan, is perhaps unusu-
ally small ; for he asserts that in 2000 pa-
tients, he had never seen a repetition of the
disease ; that is, that those who have once
had the mildest form of scarlatina, have not
afterwards suffered the malignant sore
throat. It may, however, be safely affirmed,
that scarlet fever does not occur twice, more
frequently than the other specific conta-
gions, consequently no argument can be
founded on such an anomaly.

Dr. Heberden observes*, "According to
my experience, some children have, beyond
all doubt, been afflicted a second time with
this disease ; but it is evident that this hap-
pens very seldom ; for otherwise, in such a
common distemper, there could be no more
8988!) 9X61 5X«ti3 m&^oq-Iifiraa odi Q&l<i3vdH

* Commentaries on the History and Cure of
Diseases, p, 28, 29.

question about the possibility of a second
infection than there is in the itch, or in ve-
nereal disorders. I have met with several
grown persons who have had frequent re-
turns of a slight sore throat, which, at these
times, was beset with little ulcers, similar to
those of the malignant sore throat, but with-
out any, or at most, without much fever,
and without any discolouring of the skin.
If this slight angina bear any relation to
the malignant one, it is not more than sub-
sists between the small-pox and those erup-
tions which are sometimes observable in
such as have already had that disease, while
they are nursing and attending others who
are ill of it."

There are, it is now universally admitted
by all practitioners, some rare instances in
which these contagious distempers do at-
tack a person twice; but it seems quite

63

established, with respect to one of the most
formidable of them, viz. the small-pox, that
the very mild disease, produced by vaccina-
tion, if indeed it merit the name of a dis-
ease, is quite as good a preservative against
the small-pox, as the most severe small-pox
is itself against the recurrence of that dis-
order.

On the contrary, it has been maintained,
that the mild measles, unattended by fever
and catarrhal symptoms, does not destroy
the susceptibility of receiving the febrile
disorder afterwards. An interval of many
months, or even of two years, it is asserted,
has elapsed between the attack of this va-
riety and the other ; but the latter, or true
genuine measles, usually occur about three
or four days after the appearance of the
non-febrile eruption. This is the opinion
of Dr. Willan, who attempts, even by an

64

engraving, to represent this singular disease,
which he has denominated rubeola sine ca-
tarrho. That such a variety ever exists is
very questionable; and when it is recollected
that the measles and scarlet fever are ge-
nerally epidemical at the same time, it is
much more probable that in the cases de-
scribed by him, the eruption was that of
mild scarlet fever, which, of course, affords
no protection against the attack of measles.

It is very difficult, in some cases, to di-
stinguish, with certainty, the two eruptions.
That they were formerly often mistaken for
one another, there is no doubt. Morton
distinctly avowed his conviction of their
identity*.

* Hunc morbum prorstis eundem esse cum
morbillis censeo, et solo efflorescentise modo ab
illis distare. — De Febre Scarlatina, cap. 5.

65

In his " Observations on the Increase and
Decrease of Diseases," Dr. W. Heberden,
endeavouring to account for the striking
differences, in the bills of mortality, of
the number of deaths imputed to measles,
which amount, in some years, to one-
thirtieth of the whole number of deaths ;
whereas at other times they fall short of
one in four thousand, thinks that the mea-
sles and scarlet, fever must have often been
confounded together ; nay, he himself does
not appear to have made up his mind on
the subject, for he expresses himself in the
following manner : " If so, those two formi-
dable distempers (if indeed they are two
distinct distempers, and not one and the same)
being disguised under the name of measles,
may have been older and more general than
is usually imagined." — P. 38.

There is also another opinion advanced

F

66

by Dr. Willan, which I should be much
disposed to call in question ; viz. that scar-
latina is sometimes not completely formed,
but appears with some of its symptoms only;
as a pulse rather flurried, the uvula slightly
inflamed, the tonsils a little swelled, the
pain and inflammation varying, and the dis-
order going entirely off, without ever gain-
ing a greater ground. In some persons,
therefore, he thinks, the effects of contagion
seem to cease, or perhaps have been re-
moved by early applications. In these
cases, persons are said to be not less liable
to take the disease in its fullest form, when
again exposed to its influence. It cannot
be denied that people are not at all times
equally liable to take an infectious disease,
but it is much more probable, that in the
cases above described, the patients resisted
it altogether, and had some other ailment,
than that they should have experienced a

67

sort of half-formed scarlatina. Such an
occurrence is contrary to what we observe
in other similar diseases, and is, perhaps,
quite fanciful ; for we know from observa-
tion, that in contagious disorders, the same
change is wrought in the system, in however
slight a degree the morbid affection may
have been experienced.

As little confidence should I place in the
assertion, that when persons have once
decidedly had scarlet fever, they are liable,
on being again exposed to its contagion, to
suffer one of its symptoms, a slight sore
throat, for example. It is true, that those
who have once suffered cynanche maligna,
are, during the remainder of their lives,
subject to have a specked sore throat ; but
this arises from accidental causes, such as
exposure to cold, acting on a part previ-
ously much weakened by a violent disease,

f 2

08

and has no sort of connexion whatever with
contagion.

I cannot better illustrate what I would
inculcate on the subject of scarlet fever, than
by making a few extracts from a paper of
Dr. Maton's, published in the fifth volume
of the Transactions of the College of Phy-
sicians. Hence, will appear the occasional
extreme mildness of that disease, and the
propriety of attempting its diffusion under
that mitigated form, when, indeed, it is as
contagious as at any other time ; instead of
adopting measures to check its progress.

Dr. Maton begins his paper with ob-
serving, that there is probably no class of
diseases, in which inaccurate diagnosis is
more frequently made than in those of the
skin ; nor is error more likely to be fol-
lowed with danger, than in that division of

69

cutaneous complaints which have been de-
nominated exanthemata or rashes. The ex-
ternal characters of rubeola and scarlatina,
for instance, do, on some occasions, assume
so ambiguous an aspect, as to mislead even
intelligent practitioners, if their examina-
tion be not made with due nicety and
caution. Dr. Maton then proceeds to de-
scribe a disease, which bears so much re-
semblance to scarlatina, that he has no
doubt of the one having been often con-
founded with the other, especially as no ac-
count of the former is to be found in noso-
logical writers.

" My attention was first called," he ob-
serves, " to this subject some years ago,
when scarlatina was stated to be prevalent
in one of our great public schools, and when
the different practitioners, whose attend-
ance was called for on the occasion, ex-

70

pressed much surprise to one another at
what was considered the slightness of the
symptoms of that fever. I certainly did
not at that time see reason for referring
those symptoms to a different species of
disease, for the eruption was precisely the
same in its appearance ; but the shortness
of its duration, and the absence of all
symptoms which could deserve to be de-
nominated those of debility, made me re-
solve to keep a scrutinizing eye on all
similar cases which came under my co-
gnizance at future periods of my prac-
tice*."

An attentive unbiassed perusal of this
paper will, I think, convince any one, that

ton bib tsUiqm ,,. , j u Ik

* Medical Transactions, published by the

College of Physicians in London, vol. v. p.

151.

71

the complaint which Dr. Maton met with,
was really no other than a very mild scar-
latina, and not a non-descript disease, whose
history had been hitherto confounded with
one sufficiently familiar to all medical men
in this great metropolis.

The symptoms of the first patient, a
young lady aged thirteen, were general in-
disposition, a scarlet rash suffused over the
greater part of her skin, causing considera-
ble irritation, especially after the patient
had been exposed to a cooler air. The
efflorescence was most vivid on the face and
neck, where it appeared in innumerable
points, which bore as strong a resemblance
as possible to scarlatina. There was no
inflammation of the fauces, the tongue wras
slightly furred, but the papillae did not
protrude through the fur; its edges and
apex were perfectly moist and natural.

72

The pulse could scarcely be said to be
affected. She had no pain whatever, and
except an itching of the skin, she felt only
a general disordered state of her system.
The eruption had been ushered in by none
of the usual symptoms of fever, or if there
were any such, they had not excited any
attention. The day after, an elder sister
of the young lady was attacked with the
same kind of eruption, preceded by rigors,
and some of the other concomitants of in-
cipient and febrile diseases. On the third
day of Dr. Maton's attendance, without
any medical treatment, except the exhibi-
tion of a dose of calomel and rhubarb, and
some saline draughts, both patients de-
scribed themselves perfectly cured of all
indisposition. Four other children of the
same family had been sitting with the in-
valids, so that even upon the supposition
of the disease being scarlatina, it seemed too

73

late to prevent its further progress, by sepa-
rating the latter from the former.

But the almost natural appearance of
the tongue, which did not exhibit the bright
red and elongated papillae, the absence of
unusual heat of skin, and the presence of
an almost intolerable itching or tingling,
which is not an ordinary concomitant of
scarlatina, and the circumstance that it did
not appear that any of the family had been
exposed to the infection of that disease,
induced the physician to hesitate in giving
it that denomination, and to consider it
rather as a cutaneous affection, arising from
some disorder in the digestive functions.
After an interval of about seventeen days
three other members of the same family
were attacked with the same disease, slightly
varying only in the mildness or severity of
its symptoms ; and soon after two others,

74

making in all eight persons who had been
exposed to the same contagion, and in whom
the complaint required little or no medical
treatment.

Dr. Maton lays some stress upon the
great length of interval after exposure to
contagion, as affording an additional reason
why he would deny the name of scarlatina
to this disease. Willan has asserted, that
the sixth day is the latest period intervening
between the application of the infection and
the commencement of the disease ; here the
interval was seventeen days. But there
are well authenticated cases of an interval
of fourteen days elapsing, and this when
the patient has been exposed to the in-
fection of the most decided and well charac-
terized scarlatina. Besides, nothing can be
less conclusive than this point of the length
of interval, for we know that in the instance

75

of the poison, the moment of insertion of
which can be ascertained with the most
perfect accuracy, I mean the poison of hy-
drophobia, the interval varies from forty
days to six months*.
•

Perhaps there is less uncertainty with
regard to the small-pox than any other
similar disease; the fever of the former
most commonly appearing on the seventh
day after inoculation ; but the contagion
of typhus fever lies dormant sometimes, ac-
cording to the testimony of Dr. Haygarth,

* Six weeks, or about forty days, is the most
usual period. In a case which occurred a few
months ago, in the Middlesex Hospital, under
the care of my friend and colleague Dr. P. M.
Latham, the interval was six weeks. The dis^
order was hopeless, as all such cases unfor-
tunately are ; and the patient died on the fifth
day after the first appearance of the symptoms.

76

seventy-two days; and Dr. Bancroft has
even asserted that it may lurk in the system
so long as five or six months.

Speaking of the measles, Dr. Heberden
observes, that the preparatory symptoms of
that disease have appeared thirteen days
after the infection had probably been re-
ceived ; in two others there was the greatest
reason to judge, that they began to come
on fourteen davs after the time of infection.
In four others, the infection seemed not to
have lain dormant above ten days*.

It is well known also, that there is great
irregularity in the appearance of some of
the symptoms attendant upon the measles ;
for instance, the cough usually comes on
two or three days before the eruption, but

* Heberden's Commentaries, p. 32'2.

77

it has been known to precede the measles
seven or eight days.

To return to the cases of Dr. Maton ;
he mentions, that small tubercles or tubero-
sities, varying in size from a pea to a hazel-
nut, made their appearance in three of the
cases; and these he is disposed to con-
sider as characteristic, and differing from
scarlatina ; but in the eldest patient there
was no itching, so that the absence of the
irritation of the skin, as well as the presence
of the tubercles, can be considered as ac-
cidental circumstances only in a disease
that evidently sprung from one and the
same contagion. From the extreme mild-
ness of the symptoms, Dr. Maton was in-
clined to think the disorder more allied to
roseola or urticaria, which it resembled in
the distressing tingling of the skin; but

78

then it was obviously infectious, which these
two diseases are not.

It is with great deference I would venture
to consider the cases above quoted to be
rather a proof of extreme refinement on the
part of that intelligent physician, and that
it is hardly necessary to form any new de-
nomination for the complaint he describes.

The scarlatina of Sydenham is precisely
the disorder mentioned by Dr. Maton,
agreeing with it in all its essential sym-
ptoms. Rigent horrentque sub initio, ut in
aliis febribus, qui hac afficiuntur, neque ve-
hementer admodum aegrotant : postea cutis
universa maculis parvis rubris interstingui-
tur, crebrioribus certe et multo latioribus,
magisque rubentibus, at non perinde uni-
formibus, ac sunt illae quae Morbillos con-

79

stituunt. Ad duos tresve dies persistant
hae maculae, quibus demum evanescentibus,
decedenteque subjecta cuticula, restant fur-
furaceae quaedam squammulae ad instar fa-
rinas corpori inspersae, quae ad secundam
aut tertiam vicem se promunt, conduntque
vicissim*.

Sydenham considers the disease as no-
thing else than a moderate effervescence of
the blood, occasioned by the heat of the
preceding summer ; or, as I should say, the
preceding heat of summer had predisposed
the body to receive the influence of a con-
tagion, that had before been somewhere
lying dormant. He judged it sufficient for
the patient to keep his room, without lying
always in bed, and to abstain from animal
food and spirituous liquors. When de-

* Opera Universa, p. 287.

80

squamation had taken place, he gave a mild
aperient, suited to the age and strength of
the patient.

Simplici hac et naturali plane methodo,
hoc morbi nomen (vix enim altius assurgit,)
sine molestia aut periculo quovis facillime
abigitur#.

If more be done, he says, the disease is
immediately increased, and the patient falls
a victim to the over-officiousness of the
physician.

Should any doubt still exist about this
mild form being the true and genuine scar-
let fever, it may be further removed by
the observation, that the oedema of the
ankles and wrists, which appears a fortnight

* Opera Universa. Febris Scarlatina, p. 288.

81

after the rash has vanished, and which is
considered so characteristic of the disease,
occurs after this mild form as well as after
an attack of the most violent disorder.

An objection will doubtless be started,
arising from the fact, that sometimes in a
numerous family one child will have scar-
latina, without communicating it to the
rest, and yet at a succeeding period, several
of them will be infected by a much slighter
exposure to the contagion. This is certainly
true, as well as that occasionally in the same
family, every degree of the disease, from its
mildest form to one that is very severe, will
be seen.

These are exceptions, which do not
always admit of any very satisfactory ex-
planation; but still it is no less true, as
has before been remarked, that one form or

G

82

type of contagious diseases is always ob-
served to predominate over all the rest, and
to give the general character to every epi-
demic.

The scarlatina of last summer was very
mild ; we had several cases of it in the
Middlesex Hospital, and some were brought
as out-patients, covered with the eruption,
but otherwise suffering little or no indis-
position. On one occasion a mother who
brought her child with the complaint
seemed alarmed, and anxious about the
numerous family she had at home, who all
ran the greatest risk of infection. I advised
her to take no means to prevent their free
communication with the patient, but rather
to insure, if possible, their catching the
disease.

Before I conclude, I will just enumerate

83

the leading symptoms of the more aggra-
vated forms of the same disease. In the
scarlatina anginosa, in addition to the fever
and efflorescence, a considerable swelling
of the tonsils takes place, beginning some-
times with the febrile accession, at others
not perceptible till the scarlet eruption is
at its acme. A stiffness in the muscles of the
neck and lower jaw is felt at the very be-
ginning of the attack. On the second day
of the fever the throat feels rough and
straitened, the voice becomes hoarse, and
deglutition is not performed without pain
and difficulty. On the two following days,
headache, vomiting, delirium, great heat of
skin, quick respiration, a small pulse, ex-
treme languor and faintness, come on. Upon
examination a considerable enlargement of
the tonsils is discoverable, with a florid red-
ness, which extends over the neighbouring
parts. The colour of the tongue is deeply

g 2

84

red, and the papillae over the whole of its
surface are greatly elongated.

All these symptoms are much aggravated
in the other or most malignant form of the
disease. Aphthous ulcers in the throat are
visible sometimes on the very first day of
the fever; the sores are numerous, deep,
and sordid. The patient becomes hoarse
and almost dumb. Sometimes the whole
skin is intensely red at the commencement
of the distemper ; at other times only the
breast and arms have this colour. On other
occasions the efflorescence has not been ob-
servable before the fourth day of the fever,
and in many patients it is scarcely or never
perceived at all. The condition of the sores
is to be considered as indicating the danger
of the disease, which must be judged to be
greater, in proportion as these ulcers oc-
cupy a larger space, are deeper, more firmly

85

fixed, and of a more gangrenous hue. In
fatal cases the patient becomes, on the second
day, comatose, breathes with great difficulty,
bending back his head as far as possible:
at the same time a purulent and highly of-
fensive matter flows from his nostrils ; the
throat, on inspection, is found to be gan-
grenous, and death soon follows.

87

CHAPTER IV.

Treatment of the different Forms of Scarlatina —
Recapitulation.

On the subject of the treatment of scarlet
fever, I have nothing novel to propose ; the
mild sort requires little or no medical aid,
and the practice in the severer forms of the
disease appears now to be well understood,
and pretty generally agreed upon.

In the scarlatina simplex, the principal
attention of the physician should be di-
rected to counteract the mischief likely to
result from the mistaken zeal and officious-
ness of the patient's friends and attendants ;
to keep his apartment cool, and to remove
all unnecessary weight and warmth of bed

88

clothes. The lightest diet and coolest
drinks, with moderate laxatives, are to be
recommended.

The two great improvements of modern
days, in the management of febrile diseases,
consist in the discovery of the powerful in-
fluence of diminished temperature, and the
beneficial effects of purgative medicines ;
and in none are the advantages resulting
from the use of these remedies more evident
than in their application to the treatment
of scarlatina anginosa.

The great heat of surface, the anxiety,
restlessness, and general distress, which
accompany the efflorescence, are all sur-
prisingly abated by sponging the body with
cold water, or water and vinegar, more or
less frequently as the morbid heat recurs.
A sudden change of countenance, and an

89

almost instantaneous improvement in the
symptoms of the patient are observable, in a
diminution of thirst, a more moist condition
of the tongue, a cooler and less arid feel of
the skin, and, almost uniformly, a disposi-
tion to quiet and refreshing sleep.

The washing or sponging may be more
or less general over the surface of the body,
according to the state of the symptoms ; in
moderate cases, the application of the cold
water to the hands and arms, the face and
neck, may be quite sufficient. The use of
a remedy so simple, and yet so powerful
in its effects, may be intrusted to the dis-
cretion of the least experienced attendant
upon the sick, with the single precaution,
to employ it only when the skin is hot and
dry.

The dread of the employment of purga-

90

tive medicines has now in a great measure
subsided, and their cautious use, even in
the worst form of cynanche maligna, has
been recommended by some of our most
popular medical writers. Formerly it was
laid down as a rule of practice in the ma-
lignant sore throat, to avoid all purgatives
till towards the end of the fever ; and if a
spontaneous diarrhoea came on, to check it
as soon as possible.

It was supposed that purgatives served
to diffuse the acrid matter, descending from
the throat into the stomach, over the whole
surface of the intestines, and thus increased
the source of contagion, and aggravated the
irritation which arose from the presence of
this deleterious matter.

But the moderate and free evacuation of
the bowels, by a few grains of calomel, com-

91

bined with rhubarb or jalap, so far from
causing the mischievous effects here enume-
rated, will expel the offensive and acrimo-
nious mass, and instead of increasing the
debility, will relieve the symptoms of ge-
neral fever, and, united with the cool treat-
ment above insisted upon, most materially
expedite the cure of the disease.

No premature fading or disappearing of
the efflorescence on the skin follows their
employment, and they have the additional
advantage either of preventing the dropsical
swellings that frequently succeed an attack
of scarlatina, or of removing them if per-
sisted in, after convalescence from the fever.

Acidulated drinks are extremely grate-
ful; a few drops of oxygenated muriatic
acid diluted in water form perhaps as agree-
able a refrigerant as can be contrived.

92

Blisters are very much approved of by Dr.
Heberden, who says, the patient should
never be without one or more, until he be
out of danger ; but acidulated gargles ge-
nerally afford sufficient relief, and by pre-
venting the acrid mucus, secreted by the
inflamed tonsils, from being swallowed, may
probably contribute to obviate the diarrhoea,
which frequently follows the fever.

It has been thought that the free, and, at
the same time, judicious employment of the
cool washing, not only serves to moderate
the violence of the febrile symptoms, and
prevent their running into a state of pu-
trescency, but also checks the tendency to
dropsical effusion.

When the rash has quite disappeared, and
the febrile excitement of the system has
entirely abated, recourse may be had to the

93

use of cinchona, combined with the mineral
acids. To remove the anasarca, if it su-
pervenes, small doses of calomel, united to
the remedies which have the reputation of
being diuretic, may be administered.

The symptoms of rapid debility, and of
malignant putrescency indicated by the
livid and dark sloughy hue of the ulcers in
the throat, and occasionally by the appear-
ance of petechia? and vibices on the skin,
with hemorrhage from the mouth or ali-
mentary canal, which characterise the cy-
nanche maligna, necessarily point out a much
more cautious use of the remedies before
mentioned.

The viscid offensive matter that besets
the internal fauces should be frequently
removed by the gargle of capsicum, or the
acidulated decoction of cinchona. As the

94

strength of the patient fails, it should be
supported by wine, opium, and light nourish-
ment.

I have mentioned, that scarlatina was
formerly confounded with some other dis-
orders, more particularly with measles ; but
in the present state of physic, when the
distinguishing marks of diseases are so
much better understood, and the accuracy
of diagnosis carried to a much greater ex-
tent than it has ever attained before, it
does not often happen that such mistakes
are committed. The disposition, however,
to refine too much, and to turn away from
the evidence of the most natural and pal-
pable appearances, in pursuit of some fa-
vourite speculation, may sometimes produce
the same mischief, which would result from
an utter want of the powers of discrimina-
tion.

95

It is well known that some errors in diet,
some derangements of the functions of the
stomach, and perhaps of the other digestive
organs, do' occasionally produce a sympa-
thetic affection of the skin.

The nettle-rash, for instance, is fre-
quently connected with teething or dis-
ordered bowels in children, and is often
produced also by certain articles of food, as
lobsters, crabs, shrimps, and more especially
by muscles. In some individuals, the ker-
nels of stone fruit, mushrooms, oatmeal,
almonds, raspberries, or strawberries, will
have the same effect.

The eruption produced by these various
substances appears sometimes immediately
after they have been eaten, and is not always
accompanied by wheals, but is a mere ef-
florescence resembling that of scarlet fever.

96

The disordered state of the stomach, the
sickness, langour, fainting, together with the
heat, itching, stiffness and swelling of the
skin are extremely violent for a few hours,
but usually cease altogether in a day or two.
The disorder scarcely requires the aid of
medicine; at all events, a gentle emetic is
all that is necessary.

I think that I have seen lately a case of
genuine and well-marked scarlet fever, with
slight sore throat, great heat and redness of
skin, followed by desquamation of the cu-
ticle, treated by copious bleeding, as well
local as general, and considered as an in-
flammatory disease, arising from a disor-
dered state of the digestive organs.

To recapitulate the substance of the fore-

97

going observations I have to remark, that
if they are founded in truth and warranted
by daily experience, we must come to the
following conclusions.

As the causes producing epidemic diseases
are not very numerous, and are much subject
to our own control, the means of lengthening
the duration and increasing the comforts of
life are to a great extent placed in our own
hands.

It has been seen that by a strict enforce-
ment of the laws of quarantine, we have
been able to banish the plague, and by the
employment of vaccination, we have it in
our power (if we choose to avail ourselves
to the utmost of the benefits of that great
discovery) to exterminate the small-pox ; a
contagion still more fatal than the plague
itself. For the latter disease has never yet

H

98

been known in India, China, North or
South America, nor in the arctic or tropical
regions ; while the small-pox has spared no
nation, but has made its appearance in all
seasons, and extended its ravages over every
climate of the earth.

Till we are happily enabled (and the hope
ought not to be treated as wild and chime-
rical, for who would, a few years ago, have
believed in the possibility of a discovery so
beneficial as vaccination?) to extinguish the
other contagions, we should watch the fa-
vourable types of these disorders, and court
rather than avoid their infection at such
auspicious periods. For though it be true
that some few persons pass through the vi-
cissitudes of a long life, without ever catch-
ing the scarlet fever, such an occurrence is
by no means common. I have endeavoured
to show that its frequency has been, from

99

carelessness and inattention, greatly over -
rated.

The chance, therefore, of such an escape,
ought to have no weight in the calcula-
tions of prudence and sound reasoning, as
in the course of their lives, it is probable,
that nine persons out of ten have undergone
scarlet fever, in various degrees and shades
of violence, from the unnoticed rash to the
virulent form of putrid sore throat.

There is one other remark which occurs
to me before I conclude, from which much
practical benefit may occasionally be de-
rived. Whenever it happens that a person
infected with typhus fever, or any other
contagious disease of a malignant character,
is necessarily confined in a house occupied
by a numerous family, he should be re-
moved to the upper story. The current of

100

heated air is naturally upwards, and the
atmosphere loaded with the contagious
steams, emanating from the patient's body,
will (if he be in a lower apartment) diffuse
themselves over the whole house, whereas,
if he be placed above, they will have a
ready and immediate vent.

THE END.

LONDON :

PRINTED RY THOMAS DAVISON, WMITEFRIAIIS.