“In the year 1801,” he says, “in the months of September, October, November and December, scarlet fever committed great ravages in Dublin, and continued its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character; and although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution. The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death (as appears by the notes of Dr Percival kindly communicated to me) so early as the second day. It thinned many families in the middle and upper classes of society, and even left not a few parents childless. Its characters seem to have answered to the definition of the scarlatina maligna of authors.”
The long immunity from malignant scarlatina which Graves asserts for Ireland after 1804, is made probable also for England and Scotland after 1805, by the fewness of the references to it in medical writings. Bateman in 1804 resumed the regular reports on the prevalent diseases of London, which Willan had left off at the end of 1800, and continued them until 1816[1335]; but he makes very few references to scarlatina compared with his predecessor. The two occasions when it is said to have been somewhat common were in 1807-8, during the severe epidemic of measles (and then it was “generally mild, presenting the eruption with a slight sore-throat”), and in 1814 when it was “very prevalent” along with measles. In Scotland during the same epidemic of malignant measles, in 1808, scarlatina was only occasional, and mild. It is heard of in its old malignant form from two localities of England, during the time of distress and typhus fever in 1810-11. At Nottingham it was “very prevalent, passing through whole families,” in September, 1810, and in October became more violent and often fatal[1336]. In the district around Debenham, in Suffolk, where it was last reported by the same observer in 1803, it made its appearance in February, 1810, in its very worst forms, causing deaths of children and adults in many houses, and destroying some children within forty-eight hours from the first attack. “All the surgeons for ten miles round have had to attend to scarlatina maligna in a variety of cases in all ages, from infants to fifty and sixty years.” It was still raging in October, 1810, and was breaking out “in different spots around this country, that appear to have had no communication with the afflicted[1337].”
It is not until 1831 that we begin to hear much of malignant scarlatina again. But it is clear that scarlet fever was common enough all through that interval, probably in its milder form. It was now the usual epidemic trouble of schools. In September and October, 1814, there were fifty-five cases, mostly mild, in children and two in adults in the Asylum for Female Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal Military College at Marlow, having been followed by anasarca in only one instance[1339]. Heysham, whose exact records of epidemics at Carlisle were made twenty or thirty years earlier, mentions casually in 1814 that scarlet fever had been “more frequent of late,” but that it did not spread as formerly[1340]. Other references to it in this interval are to show how seldom fatal it was under the cold water treatment or the lowering regimen[1341]. At the Newcastle Dispensary fully twice as many cases of scarlatina were attended in the twenty-five years 1803-27 (795 cases) as in the twenty-five years 1777-1802 (355 cases); but in the larger total, which an increasing population might account for, there were actually fewer fatalities (30) than in the smaller (33); the highest number in any one year was 71 in 1824, of which every one is entered as having recovered. This is the impression derived from various sources—that the scarlatina from about 1803 until about 1830 may have been frequent, but that it was mild, or easily treated, or not often fatal. Macmichael, writing in 1822, not only testified that the “scarlatina of last summer was very mild,” but argued that the malady in general was taken by many in those years in so mild a form that it was not recognized as scarlatina, “a name that sounds so fearfully in the ears of mothers,” and a rare disease in families compared with measles or even with smallpox. His point is that scarlet fever was in fact as nearly universal as measles, but that, as it was often extremely slight, it passed for rose rash or the like; at the same time he identified these slighter forms with true scarlatina by simply pointing to the oedema which might follow them[1342].
The testimony of Graves, of Dublin, who occupies many pages of his ‘Clinical Medicine’ with the disastrous scarlatina in various parts of Ireland about 1834, is conclusive that the severe type was new in the experience of that generation:
“I have already mentioned that the disease called scarlet fever assumed a very benign type in Dublin soon after the year 1804, and continued to be seldom attended with danger until the year 1831, when we began to perceive a notable alteration in its character, and remarked that the usual undisguised and inflammatory nature of the attack was replaced by a concealed and insidious form of fever, attended with great debility. We now began occasionally to hear of cases which proved unexpectedly fatal, and of families in which several children were carried off; still, it was not until the year 1834 that the disease spread far and wide, assuming the form of a destructive epidemic[1343].... Many parents lost three of their children, some four, and in one instance which came to my knowledge, five very fine children were carried off.” The severe cases were mixed with others of scarlatina simplex. The violence of the attack lay in the throat-affection, the congestion of the brain, or the irritability of the stomach and bowels, nausea, vomiting and diarrhoea being early symptoms, as in the malignant sore-throat with rash a century before.
Graves proceeds, with much candour, to show how mistaken had been the reasons assigned equally for the mild type of scarlatina between 1804 and 1831 and for the severe type of it previous to 1804:
“The long continuance of the period during which the character of scarlet fever was either so mild as to require little care, or so purely inflammatory as to yield readily to the judicious employment of antiphlogistic treatment, led many to believe that the fatality of the former epidemic was chiefly, if not altogether, owing to the erroneous method of cure then resorted to by the physicians of Dublin, who counted among their numbers not a few disciples of the Brunonian school; indeed, this opinion was so prevalent, that all those whose medical education commenced at a much later period, were taught to believe that the diminished mortality of scarlet fever was entirely attributable to the cooling regimen and to the timely use of the lancet and aperients, remedies interdicted by our predecessors. This was taught in the schools, and scarlet fever was every day quoted as exhibiting one of the most triumphant examples of the efficacy of the new doctrines. This I myself learned—this I taught: how erroneously will appear from the sequel. It was argued, that had the cases which proved fatal in 1801-2 been treated by copious depletion in their very commencement, the fatal debility would never have set in, for we all regarded this debility as a mere consequence of previous excessive reaction. The experience derived from the present [1834-35] epidemic has completely refuted this reasoning, and has proved that, in spite of our boasted improvements, we have not been more successful in 1834-5 than were our predecessors in 1801-2.”
From 1829 to 1833 there are numerous references to the scarlatina maligna in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in 1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346] in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348] in 1832-1833. It is in 1830 that scarlet fever begins to have a line to itself in the old and inadequate bills of the Parish Clerks of London, the deaths that year being 94; in the next seven years they are 143, 388, 481, 523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths from it in Glasgow[1349] for five years, during which they fell much below the deaths from either measles or smallpox.
Deaths from Scarlatina in Glasgow.
| Under one | 1-2 | 2-5 | 5-10 | 10-20 | 20-30 | 30-40 | 40 and up. | Total | ||||||||||
| 1835 | 27 | 50 | 89 | 73 | 23 | 7 | 2 | 2 | 273 | |||||||||
| 1836 | 34 | 57 | 136 | 86 | 25 | 9 | 5 | 3 | 355 | |||||||||
| 1837 | 4 | 9 | 34 | 22 | 5 | 3 | 1 | 1 | 79 | |||||||||
| 1838 | 3 | 15 | 42 | 17 | 7 | 1 | 1 | 1 | 87 | |||||||||
| 1839 | 29 | 45 | 104 | 74 | 10 | — | — | — | 262 |