The one thing that connects the scarlatina of surgical wards in children’s hospitals and the scarlatina of the milk-pail is putrefying blood or pus: the disease is a septic effect of blood, just as a scarlet rash is known to be a toxic effect of very various drugs in peculiarly susceptible subjects. The obviously septic varieties of scarlatina make but an insignificant part of the whole; but they may be finger-post instances. Thus, if we assume that the infection may be miasmatic from the ground as well as contagious from the person, there are certain facts, or suspicions, that will fit the hypothesis of putrefying blood. A theory of scarlatina was put forward in 1871, on the basis of observations near Croydon, that its virus came from the blood and offal of slaughter-houses collected at particular spots to be used as manure[1361]. The first death in a recent small epidemic within the writer’s knowledge was of a school-girl who lived just across the road from a slaughter-house. The septic hypothesis of scarlatina might be made to include other corrupting animal matters. Some practitioners have a suspicion that scarlet fever is bred in the atmosphere of a horse-mews. On the greater scale, others have traced a connexion between the more signal outbreaks of angina maligna and preceding murrains of cattle[1362]. The animal matters which may become toxic to man, in miasmatic or other form, are indeed many. If scarlatinal drug-eruptions are any clue to the mystery of scarlet fever, we need not be surprised to find a somewhat uniform disease-effect produced by a variety of septic agents[1363]. But, in that hypothesis, the refuse of the shambles will merit most attention. This was thought the one great nuisance of London in the sanitary ordinances of Edward III., Richard II. and Henry VII.; it was then considered a danger to health in the measure of its offensiveness to sight and smell, but there may still be dangers from it which are subtle and unperceived.
Reappearance of Diphtheria in 1856-59.
The memorable outburst of epidemic throat-disease in Britain about the years 1858-59 was part of a sudden uprising of the malady all over the globe—in Europe, America, North Africa, India, China, and the Pacific[1364]. It was only in some parts of France, and of Norway and Denmark, that “diphtheria” had been epidemic in the generation before. Of its novelty to nearly the whole British profession in 1858, familiar as they were with the angina of scarlet fever, there can be no question. Its appearance among diseases coincided with the publication of Darwin’s hypothesis of the origin of species by natural selection; and it was in the terms of that hypothesis that Farr, of the Registration Department, spoke of the phenomenon of diphtheria. New diseases, he said, “are only recognized as distinct species when they have existed for some time. Diphtheria is an example. It obtains a distinct line in the Tables of this year [1859] for the first time”—with a total of 9587 deaths. For four years before that, it had been in a “provisional table” under the names of “diphtheria” and “cynanche maligna”; but in the general table, the deaths under these names had been merged with the scarlatinal deaths. This inclusion for a time of diphtheria under scarlatina could not have been because practitioners had any difficulty in diagnosing the one from the other, but probably because scarlatina anginosa seemed the nearest affinity in the nosological system. Diphtheria in 1858 had no scarlet rash, and yet it was supposed to be the same disease that had made so much commotion in England about the middle of the 18th century: “In Fothergill’s account,” says Farr, “the symptoms are confused by the introduction of the eruption of scarlatina into his description”—as if his description had been a patchwork of his fancy, with some characters taken from “diphtheria” and some from scarlet fever. The greatest of our nosologists, Cullen, had long before that separated “cynanche maligna” from “scarlatina anginosa,” but the separation was not made on the ground of absent or present rash. Both had the rash, the cynanche having, besides a general exanthem, very distinctively the peculiar scarlet redness, with swelling and stiffness, of the fingers which Fothergill described, while the scarlatina rash was “commonly more considerable and universal.” Both also might have a discharge from the nose; but when the coryza did occur in scarlatina, “it is less acrid, and has not the foetid smell which it has in the other disease.” It was really on the ground of malignancy or fatality that Cullen separated them. In forty years he had seen scarlatina anginosa six or seven times prevailing as an epidemic in Scotland, and he had seen two or three epidemics of cynanche maligna. He had seen mild cases in the latter, as well as in the former; but whereas there would be only one or two malignant cases in a hundred of scarlatina anginosa, the malignant or putrid cases in an epidemic of cynanche were four-fifths of the whole[1365]. On the other hand Willan, writing just fifty years before the modern diphtheria made its appearance, maintained that “no British author has yet described any epidemical and contagious sore-throat except that which attends the scarlet fever,” not even Starr, whose “morbus strangulatorius” he held to be “the most virulent form of scarlatina[1366].”
The name diphtheria, which appeared for the first time among the classified causes of death in England in the report for the year 1855 (published two years after), had been given originally in 1826, with the termination itis according to the then Broussaisian fashion, by Bretonneau in his account of epidemics at Tours in 1818-21 and at La Ferrière in 1824-25[1367]. It was in January, 1855, or just before the disease became general in Europe, that he changed the termination to diphtherie[1368]. This name was taken from διφθέρα, a prepared skin or hide, suggesting in strict correctness, a certain toughness and texture which were actually found in only a small proportion of all the diphtheritic deposits or exudations or sloughing infiltrations in the first great epidemic and subsequently.
The interval between 1793-94, the date of Rumsey’s diphtheria or “croup” at Chesham, and the outbreak of diphtheria in England in 1856-59, affords several instances of the disease, some of which were contemporaneous with Bretonneau’s in France, but were still called “croup” in this country. These I shall merely enumerate in a note, passing at once to the beginnings of the great outbreak[1369].
The first public notice of the reappearance of a fatal throat epidemic in England appears to have been in the Registrar-General’s third quarterly report of the year 1857, when attention was drawn to the remarks by various local registrars (Thame, Billericay, Maldon, Liskeard, Truro and Chesterfield) as to fatalities from “inflammation of the throat,” “putrid sore throat,” “malignant sore throat,” “disease in the throat,” and “throat-fever.” About this time it was also called the “Boulogne sore throat.” There had been an epidemic at Launceston from 30 September, 1855, which had come to a height in August, 1856; several deaths had occurred near Spalding, in Lincolnshire, in July, 1856, and the disease had been seen at Ash, in Kent, in November, 1856. When the registered causes of death during the year 1855 were classified (in 1857), “diphtheria” was credited with 186 deaths, in the Supplementary Table then first introduced, “cynanche maligna” having 199 deaths. The following shows the progress of the epidemic during the four first years, and the mode of entry:
| Year | Cynanche maligna | Diphtheria | Scarlatina (inclusive of columns 1 and 2 in the general table) | |||
| 1855 | 199 | 186 | 17,314 | |||
| 1856 | 374 | 229 | 14,160 | |||
| 1857 | 1273 | 310 | 14,229 | |||
| 1858 | 1770 | 4836 | 30,317 |
In 1857 and 1858 the deaths from croup were above the average, and probably included some of the new disease.
Accounts of the epidemic began to come into the medical journals[1370] from various localities in the course of 1858,—from Lincolnshire, Essex, Kent, Sussex, etc. A systematic inquiry, conducted by Greenhow and Sanderson for the Medical Department, under the direction of Simon, gave an exact picture of the several degrees of throat-distemper that constituted the epidemic in the year 1858, in certain of the more severely visited centres of Lincolnshire, South Staffordshire, Cornwall, Kent, and other counties[1371]. The numerous cases of throat disease occurred often in the midst of scarlatina, but sometimes also where there was no scarlatina. One of the worst centres was in and around Spalding, a market town situated in a flat grazing country within the fen district of Lincolnshire. A thousand cases were counted in and near Spalding, many of them mild, a small ratio of them gangrenous and mortal; one practitioner had 200 cases with 5 deaths, another 200 cases with 2 deaths, another 160 cases with 17 deaths (of 65 tabulated with 9 deaths, which occurred in 35 houses, the first four all died from gangrene in June, 1858). The doctor at Pinchbeck, in the same district, had some 500 cases of which 300 occurred in the space of about six weeks; most of the 19 deaths in his extensive series happened in the first cases (this was observed also in the New Hampshire epidemic of 1735). At Launceston, in Cornwall, there were about a thousand cases known, the height of the epidemic having been in the summer and autumn of 1856; among 126 taken as they came in 98 families, 18 died. The mildest and the most severe cases were equally parts of the epidemic constitution, and occurred side by side in the same households; many of them were quinsies, ulcerated sore-throats, or the like, others were gangrenous. In this great variety, only a part could be reckoned “true diphtheria.” From the first, the remarkable sequel of paralysis, not only of deglutition but of the motor powers generally, was remarked here and there. Sometimes an eruption of the skin was seen, but desquamation did not occur[1372]. Albumen in the urine was somewhat constant. It is noteworthy, the more so that the coincidence was not remarked at the time, that the true diphtheritic pellicle,—tough, leathery, elastic,—was found most distinctively, if not exclusively, where it was found in 1748, namely in Cornwall[1373].
Although the epidemic was not confined to low and damp situations, yet there was no mistaking the severity of it in Lincolnshire; and although it fell upon both clean and filthy houses, yet it is probable that the cases with most pronounced gangrene or foetor happened amidst the most unwholesome surroundings. The disease was very general in England in 1858. When the deaths from it in 1859 (9587) were tabulated for the first time according to counties, it was found that they came from every part of England and Wales. The highest death-rate was in Lincolnshire, 1·2 per 1000 on the annual average of 1859 and 1860 (995 deaths in the two years). Sussex, Kent, Essex and Norfolk had also high death-rates, the agricultural counties in general having somewhat more than their usual share of an infective mortality as compared with the industrial centres. But it would be erroneous to suppose that diphtheria was at all specially a country disease. The mining districts of Staffordshire, Durham and South Wales had considerable mortalities, and so had Lancashire and the West Riding. But the North Riding and East Riding had their full share or even more than their share; whereas, if it had been scarlatina or enteric fever, they would have been far behind the great industrial division of Yorkshire in ratio of their populations. In the more recent prevalence of diphtheria the country districts have lost their preeminence, according to the following table of death-rates per million living in registration districts classified roughly as sparse, dense and medium[1374]: