V. MEASLES
In the earliest English writings on medicine, measles is the inseparable companion of smallpox; so closely are they joined in pathology and treatment that even the statements as to the pustules and scars of the eruption are in some compends made to apply to both without distinction. This singular conjunction of two diseases came originally from the Arabian teaching, which was everywhere authoritative in the medieval period, and especially authoritative in all that related to smallpox. In the Latin compends based upon Avicenna or other Arabic writers, the two names were variolae and morbilli, the former being as it were the morbus proper and the latter its diminutive. It can hardly be doubted that we owe the English name of measles as the equivalent of morbilli to John of Gaddesden. Originally the English word meant the leprous, first in the Latin form miselli and misellae (diminutive of miser), as in the histories of Matthew Paris, and later in the Norman-French form of mesles, as in the Acts of Parliament of Edward I. and in the ‘Vision of Piers the Ploughman.’ In the 15th century the leper-houses in the suburbs of London were called the “lazarcotes” or “meselcotes.”
Gaddesden, by some unaccountable stretch of similarity, coupled the sores or tubercular nodules on the legs of “pauperes vel consumptivi,” who were called “anglicé mesles,” with the spotted rash of the Arabian “morbilli”; and it was doubtless this haphazard bracketting of two unlike diseases that led in course of time to the name of mesles being disjoined from its original sense of the leprous and restricted to the second member of Gaddesden’s strangely assorted couple. In the time of Henry VIII. smallpox and mezils are familiarly named together just as variolae et morbilli are an inseparable pair in the treatises of the Arabistic writers. A still more singular usurpation by “mezils” or “maysilles” or “measles” is met with in the Elizabethan period. In the vocabulary of Levins, a schoolmaster who was also a medical graduate of Oxford, the word variolae is rendered by “ye maysilles,” while morbilli is omitted altogether among the Latin names and smallpox among the English; and in the English translation of Latin aphorisms appended to one of the works of William Clowes, surgeon to St Bartholomew’s Hospital, variolae is in like manner translated “measles” on every occasion. In the English dictionary by Baret, belonging to the same period, measles is defined as “a disease with many reddish spottes or speckles in the face and bodie, much like freckles in colour”--which seems to exclude the possibility of a pustular disease having been part of the Elizabethan notion of measles.
Notwithstanding this singular usage of the vocabularies and dictionaries, the name of smallpox occurs by itself in letters or other memorials of the Elizabethan period, having been doubtless correctly applied to the true pustular variola. In the short essay on smallpox by Kellwaye, appended to his book on the plague (1593), measles and smallpox are distinguished on the whole clearly, according to the definitions of Fracastori or other foreign writers of the 16th century. The association between measles and smallpox that survived longest was a peculiar and somewhat uncommon one; certain cases of smallpox, in which the pustules were wholly or partially represented by, or changed into, broad spots level with the skin, red or livid in colour, and in which haemorrhages occurred from the nose, lungs, bowels or kidneys, that is to say, cases of haemorrhagic smallpox, were apt to be called, from the time of James I. until as late as the case of Queen Mary in 1694, by the name of “smallpox and measles mingled.”
From the date of the annual bills of mortality by the Parish Clerks of London, the year 1629, it is improbable that there was any real confusion between smallpox and measles; there was certainly some ambiguity in the entry of measles long after, but that later confusion, especially in the second half of the 18th century, was with scarlatina[1184]. The entry of measles is in the bills from the first, apart from that of “flox and smallpox:”
Measles Smallpox Year deaths deaths
1629 42 72 1630 2 40 1631 3 58 1632 80 531 1633 21 72 1634 33 1354 1635 27 293 1636 12 127 1647 5 139 1648 92 401 1649 3 1190 1650 33 184 1651 33 525 1652 62 1279 1653 8 139 1654 52 832 1655 11 1294 1656 153 823 1657 15 835 1658 80 409 1659 6 1523 1660 74 354
In the great epidemic of smallpox in 1628, the year before the bills begin, Thomas Alured wrote to Sir John Coke that his house in London had been visited “once with the measles and twice with the smallpox, though I thank God we are now free; and I know not how many households have run the same hazard[1185].” In the year 1656, which has the highest total in the above table, two cases of measles are mentioned in a letter of 31st May: “Young Sir Charles Sedley is at this time very sick of a feaver and the meazells, of which Sir William dyed”--Charles Sedley being then in his seventeenth year[1186]. An instance parallel to that of 1628, of measles and smallpox co-existing in the same household, occurred in the royal palace at Whitehall in December, 1660. The princess of Orange, sister of the king, died of smallpox on the 23rd; on that day, or a day or two before, her sister the princess Henrietta, who had come from France on a visit with the queen-mother, Henrietta Maria, removed from Whitehall to St James’s, “for fear of infection.” After a few days she embarked on board the ‘London’ at Portsmouth to return to France, but the ship had to come to anchor again owing to the princess being attacked with “the measles.” Her illness, which delayed the sailing of the vessel until the 24th of January, 1661, is uniformly spoken of as the measles in the various letters which make mention of it[1187]. In that year, and in several of the next ten years, the measles deaths in London reached a considerable total:
Measles Year deaths
1661 188 1662 20 1663 42 1664 311 1665 7 1666 3 1667 83 1668 200 1669 15 1670 295
The epidemic of 1670 is the subject of a description by Sydenham, the diagnostic points of which were doubtless those current at the time.
Sydenham’s description of Measles in London, 1670 and 1674.
Sydenham’s account of the epidemic of 1670 is full enough to leave no doubt that it was measles of the ordinary kind; the details, indeed, are as minute for all essential points as they would be in a modern text-book[1188]:
Measles, he says, is a disease mainly of young children (infantes), and is apt to run through all that are under one roof. It begins with a rigor, followed by heats and chills during the first day. On the second day there is fever, with intense malaise, thirst, loss of appetite, white tongue (not actually dry), slight cough, heaviness of the head and eyes, and constant drowsiness. In most cases a humour distils from the nose and eyes, the effusion or suffusion of tears being the most certain sign of sickening for measles, more certain indeed than the exanthem. The child sneezes as if it had taken cold, the eyelids swell, there may be vomiting, more usually there are loose green stools (especially during dentition), and there is excessive fretfulness. On the fourth or fifth day small red maculae, like fleabites, begin to appear on the forehead and the rest of the face, which coalesce, as they continue to come out in increasing numbers, so as to form racemose clusters. These maculae will be found by the touch to be slightly elevated, although they seem level to the eye. On the trunk and limbs, to which they gradually extend, they are not elevated. About the sixth day the maculae begin to roughen and scale, from the face downwards, and by the eighth day are scarcely discernible anywhere. On the ninth day the whole body is as if dusted with bran. The common people say that the spots had “turned inwards,” by which they mean that, if it had been smallpox, they would have remained out longer, and have proceeded to suppuration or maturation. The rash having thus “gone in,” there is an access of fever, attended with laboured breathing and cough, the latter being so incessant as to keep the children from sleep day or night. If they had been treated by the heating regimen, they are apt to have the chest troubles pass into peripneumonia, by which complication measles becomes more destructive than smallpox itself, although there is no danger in it if it be rightly treated. When peripneumonia threatens, the patient should be bled, even if it be a tender infant. Diarrhoea, which sometimes continues for weeks after an attack of measles, may be cut short by blood-letting, and so also may whooping-cough.
This epidemic, says Sydenham, began in January, and was almost ended in July, which agrees exactly with the rise and decline of measles deaths in the weekly bills of the Parish Clerks.
His account of the epidemic of 1674 is still more important to be set beside the figures in the bills; for the type, according to Sydenham, was anomalous, and the total of deaths entered by the Parish Clerks (795) is exceptionally large. Like the epidemic four years before, it began in January, came to a height about the vernal equinox, and was nearly over at the summer solstice[1189].
Weekly Deaths in London in the first six months of 1674. (Epidemic of Measles.)
1674
Week Griping in Convulsions Consumption All ending Fever Smallpox the guts Measles Teeth causes
Jan. 6 35 13 35 0 37 15 78 332 13 35 19 32 1 32 22 65 369 20 37 12 29 0 39 18 65 327 27 34 15 38 0 38 17 68 354 Feb. 3 32 23 39 7 45 26 75 418 10 47 18 35 4 48 35 86 430 17 55 21 46 15 70 38 98 537 24 62 17 45 28 54 44 97 510 March 3 58 31 28 59 48 49 87 547 10 55 22 31 87 85 58 122 688 17 63 15 46 95 79 57 113 695 24 59 23 44 65 57 39 96 568 31 51 19 49 60 77 51 105 622 April 7 44 13 40 43 65 48 118 547 14 53 20 32 31 60 50 98 535 21 40 17 43 38 55 42 106 517 28 50 17 44 53 67 34 87 520 May 5 51 31 28 30 56 24 75 452 12 38 26 47 30 54 37 79 479 19 50 35 33 26 47 28 82 461 26 67 27 33 13 45 28 63 415 June 2 48 24 28 14 41 26 77 365 9 35 26 38 15 48 27 66 369 16 64 34 38 19 38 22 70 419 23 34 33 34 9 52 15 71 368 30 37 39 30 9 30 21 59 343
It will be seen that the highest weekly mortality from measles is only 95, in the week ending 17th May. But in that week the deaths from all causes reached the enormous total of 695, which was nearly three hundred above the weekly average of the time. This appears to have been the epidemic of measles which Morton declares to have destroyed three hundred in a week, a mode of reckoning which would claim for measles, directly or indirectly, the excess of mortality from all causes during the height of the epidemic[1190].
These high weekly mortalities in February, March, April and May are remarkable for the season of the year. Usually when the weekly figures reach six or seven hundred, it is in a hot autumn, and the cause is infantile diarrhoea, represented in the bills by the excessive number of deaths from “griping in the guts” and “convulsions;” more rarely, and then only for three or four weeks, correspondingly high figures are reached in a season of influenza. But in this case the epidemic measles is the only relevant thing. The measles deaths by themselves do by no means account for the enormous weekly totals; but two of the three columns of figures which help them, and indeed keep pace with the rise of the measles deaths, namely, “convulsions” and “teeth,” are infantile deaths obviously related to the prevailing epidemic; while the third column, “consumption,” which contributes most of all, did not in the London bills mean pulmonary consumption exclusively, but also the wasting or marasmus which followed or attended acute fevers in general, and was specially apt to follow or attend measles[1191].
Sydenham gives no indication that the spring of 1674 was unusually productive of pneumonia or pleurisy among adults; the winter, he says, was unusually warm, the weather in spring turning colder. But, as to the measles, he does say that the epidemic was anomalous or irregular; while both he and Morton refer the fatalities more especially to the sequelae of measles,--to the “suffocation” of infants and children by the bronchitis or peripneumonia, or to “angina,” as Morton says, meaning perhaps the same as in Scotland was understood by “closing” in infants. Measles itself was a milder disease than smallpox, according to the experience of all times; and yet, by its sequelae (bronchitis, capillary bronchitis and pneumonia, including what Morton calls “angina,” and excluding, for the present, whooping-cough), it raised the weekly mortalities of February, March, April and May, 1674, to far above the average. Sydenham said, with reference to the much milder epidemic of 1670, that these after-effects of measles “destroyed more than even smallpox itself” (quae [peripneumonia] plures jugulat quam aut variolae ipsae). We shall not correctly understand the part played by measles among the infective maladies of children unless we keep that grand character of it in mind--that its effects upon the mortality of infancy and childhood are only in part expressed by the deaths actually appearing under its name.
The London bills for 1674 afford us the opportunity of testing Sydenham’s paradox that measles, by its after-effects, destroyed more than smallpox itself. The epidemic of measles was nearly over in June; and immediately thereafter an epidemic of smallpox began (not of course from zero but from the usual level of the disease), which reached a maximum of 122 deaths in the week ending 20th October. The second half of the year was thus marked by a sharp outburst of smallpox, as the first half was marked by a sharp outburst of measles; and those two diseases were the only epidemic maladies that gave character to the respective seasons, each being in its proper season, according to Sydenham--measles in the spring, smallpox in the autumn. Although the measles deaths were only 795 for the whole year, the smallpox deaths being 2507, yet the former epidemic was attended by so great an excess of deaths under various other heads that the half of the year in which it fell was far more unhealthy than the succeeding half in which the smallpox mainly fell, the weekly average of the first six months having been 468 deaths, and of the second six months 349 deaths. The following table shows the weekly mortalities for the second half of the year; it will be observed that no column of figures keeps pace with the rise of the smallpox deaths, as three columns had kept pace with the rise of the measles deaths in the first six months of the year.
Weekly Deaths in London in the last six months of 1674. (Epidemic of Smallpox.)
1674
Week Griping in Convulsions Consumption All ending Fever Smallpox the guts Measles Teeth causes
July 7 31 44 35 9 44 24 69 351 14 38 55 34 5 37 17 54 353 21 40 71 47 6 42 25 56 395 28 43 71 37 3 49 18 48 367 Aug. 4 38 68 39 6 31 23 47 347 11 33 66 48 -- 18 8 45 324 18 49 86 41 1 26 20 48 374 25 35 85 23 3 32 10 46 328 Sept. 1 60 96 41 -- 32 18 57 414 8 32 99 48 3 22 16 32 374 15 28 102 38 2 30 19 55 362 22 27 72 32 3 29 11 57 327 29 39 81 34 2 41 9 53 358 Oct. 6 37 98 29 -- 34 10 63 391 13 36 75 25 -- 35 17 49 311 20 42 122 35 1 34 10 68 402 27 24 75 36 -- 38 15 45 294 Nov. 3 34 83 21 -- 30 11 41 322 10 30 81 15 -- 31 12 49 321 17 31 70 16 -- 24 10 58 304 24 35 70 28 -- 38 14 57 344 Dec. 1 33 85 29 -- 32 14 68 378 8 33 66 28 -- 36 11 53 327 15 29 61 26 -- 39 16 49 339 22 34 68 21 -- 32 11 52 335 29 41 41 19 -- 33 7 74 337
The total of deaths by smallpox for the year, 2507 was the highest since the bills began, and remained the highest until 1681. It is open to us to suppose that it would not have been so high but for the epidemic of measles preceding. The measles not only made the first half of the year far more deadly than the second, within which most of the smallpox fell, but its effects may have aided the high mortality of smallpox itself, according to the experience of later times that infants and young children recovering from measles in a greatly weakened condition fell an easier prey to smallpox coming after[1192].
Morton passes from the fatal epidemic of 1674 (or, as he says, 1672), with the remark that the malady had not been epidemic again in London from that time until the date of his writing, 1692-94, a period of nearly twenty years; and that is on the whole borne out by the London bills and by Sydenham’s records so far as they extend. From 1687 to 1700, inclusive, the London bills grouped the measles deaths along with the deaths from smallpox, under the heading, “Flox, Smallpox and Measles”; in 1701 the total of measles, 4 deaths, is given as a separate item in the same bracket with smallpox; and in 1702 the heading of “Measles,” is restored to the place in the alphabetical list which it had held, except for that unaccountable break, from the beginning of the published bills in 1629. The following are the annual totals from and including the great epidemic of 1674:
Death from Year measles
1674 795 1675 1 1676 83 1677 87 1678 93 1679 117 1680 49 1681 121 1682 50 1683 39 1684 6 1685 197 1686 25
Thus for a good many years after the general prevalence of measles in 1674 the deaths from it in London averaged only about one and a half in the week, while in no year until 1705-6 is there an epidemic comparable to that of 1674. It is clear that the severe epidemics of measles came at first at very long intervals, and that the years between had a very moderate mortality from that disease.
Measles in the 18th century.
There is hardly a reference to be found to measles in medical or other writings until the annual accounts of the public health at Ripon, York, Plymouth, etc. in the third decade of the 18th century. The annual deaths from it in London, according to the bills, were as follows, from 1701, when the disease was restored to its separate place in the classification:
Year Measles deaths
1701 4 1702 27 1703 51 1704 12 1705 319 1706 361 1707 37 1708 126 1709 89 1710 181 1711 97 1712 77 1713 61 1714 139 1715 30 1716 270 1717 35 1718 492 1719 243 1720 213 1721 238 1722 114 1723 231 1724 118 1725 70 1726 256 1727 72 1728 82 1729 41 1730 311 1731 102 1732 30 1733 605 1734 20 1735 10 1736 169 1737 127 1738 216 1739 326 1740 46
The high mortalities of 1705 and 1706 belonged to one continuous epidemic from October, 1705, to April, 1706 (Sir David Hamilton says that smallpox was common in London in July, 1705, but the deaths in the bills are not excessive). The epidemic followed a great prevalence of the autumnal diarrhoea of infants, so that it is probable the high mortality was due as much to a greater fatality of cases from the antecedent weakening, as to an unusual number of cases[1193]. The following were the weekly deaths in a population about one-sixth that of London now:
1705-1706
Week Measles ending deaths
Oct. 16 9 23 9 30 12 Nov. 6 10 13 30 20 34 27 29 Dec. 4 37 11 46 18 44 25 22 Jan. 1 35 8 33 15 28 22 20 29 18 Feb. 5 27 12 11 19 26 26 28 Mar. 5 10 12 10 19 9 26 13 Apr. 2 9 9 9
The unusually large mortalities from measles in 1718-19 and in 1733 were again associated with a “constitution” otherwise sickly. The epidemic in the latter year, from the middle of March to the end of July, which had a maximum of 47 deaths in each of the two middle weeks of May, followed close upon a severe influenza. Like the epidemic of 1674, it was attended by a high mortality from other causes, especially “convulsions” and “consumption”; and, as the bills had now begun to give the ages at death, it is no longer doubtful, or merely conjectural, that the great excess of deaths under these and other heads was really among infants, or that a rise in “consumption” at that time of the year meant an increase in the wasting diseases of infancy. This was a period when any epidemic malady among London children was sure to go hard with many of them, the period, namely, when spirit drinking, besides ruining the health of the parents, rendered them, in the opinion of the College of Physicians, “too often the cause of weak, feeble and distempered children[1194].”
The intervals between epidemics of measles in London having been so considerable as the table shows, it is not surprising to find but casual mention of the disease in the chronicles of Wintringham, Hillary, and Huxham for England, of Rogers, O’Connell and Rutty for Ireland, and of the Edinburgh annalists. Wintringham, of York, whose annals extend from 1715 to 1730, records an epidemic of measles in 1721, which began in April and lasted all the summer, being for the most part of a bad type, attended with continual cough and inflammation of the lungs. Hillary, of Ripon, enters measles in 1726, “very common but mild,” autumn and winter being the season of it. Wintringham briefly mentions the same epidemic. Huxham of Plymouth has an entry of measles in the first year of his annals, 1727, in the month of July, followed by whooping-cough in December. Wintringham again enters measles at York in 1730 in the company of smallpox. In the annual accounts of the disease at Edinburgh, for a series of years beginning with 1731, measles is first mentioned in 1735[1195]. The epidemic began in June and became universal in December: “The progress of these measles along the west road of England towards Edinburgh was very remarkable, for they could be traced from village to village; and it was singular that the first person in Edinburgh who was seized with them was a lady in childbed, who saw nobody but her nurse and a friend who lived in the house with her”--an argument, apparently, for the doctrine of an epidemic “morbillous” constitution of the air. Five years after, we obtain the mortality statistics of Edinburgh, in the two great years of scarcity, typhus fever and sicknesses of all kinds, the years 1740 and 1741: in those two years measles must have been as general as smallpox if it were half as mortal, for the deaths set down to it in each year are 110 and 112, as compared with 274 and 206 from the more usual infantile infection. In like manner the second year of the disastrous epidemic of typhus in 1741-42, had the highest total of measles deaths in London until the great epidemic of 1808. While the high mortality of that year was due to special causes, it is at the same time clear from the following table that measles had not yet become a steady or perennial cause of death to the infancy of the capital:
Year Measles deaths
1741 42 1742 981 1743 17 1744 5 1745 14 1746 250 1747 81 1748 10 1749 106 1750 321 1751 21 1752 111 1753 253 1754 12 1755 423 1756 156 1757 24 1758 696 1759 316 1760 175 1761 394 1762 122 1763 610 1764 65 1765 54 1766 482 1767 80 1768 409 1769 90 1770 325 1771 115 1772 211 1773 199 1774 121 1775 283 1776 153 1777 145 1778 388 1779 99 1780 272 1781 201 1782 170 1783 185 1784 29 1785 20 1786 793[1196] 1787 84 1788 55 1789 534 1790 119 1791 156 1792 450 1793 248 1794 172 1795 328 1796 307 1797 222 1798 196 1799 223 1800 395
The considerable epidemic of 1755 is thus referred to by Fothergill in his monthly notes:
May: the measles more common than for some years, adults, who had not before had it, rarely escaping. June: measles common, smallpox rare. September and October: no epidemic disease but measles; few perished in proportion to all who took it[1197]. The epidemic of 1758 was more fatal, but Fothergill’s notes are not continued to that year. The elder Heberden says that measles was remarkably epidemical (in London) in 1753, which year has only 253 deaths in the bills, whereas the year 1755 has 423 deaths and the year 1758 has 696; but, as he implies that the type was mild, there would have been a multitude of cases to produce that number of deaths. It was a peculiarity of that epidemic, he says, that the cough preceded the outbreak of measles by seven or eight days, whereas it was usually but two or three days in advance of the eruption[1198].
At that period there would have been an epidemic of measles in London every other year, or once in three years, with a fatality from the direct effects seldom more than a sixth part that of an epidemic of smallpox. A London writer some twenty years after said that few escaped measles in infancy or childhood, while the deaths put down to it were only a tenth part of those due to smallpox on an average of years[1199]. The proportion of measles deaths to smallpox deaths was nearly the same in Manchester for twenty years from 1754 to 1774, according to Percival’s table of the burials in the register of the Collegiate Church where most of the poorer class were buried[1200]:
Annual averages of Burials from Measles etc. at the Collegiate Church, Manchester.
All deaths Deaths at Period Measles Smallpox under two all ages Baptisms
1754-58 21 64 209 651 678 1759-63[1201] 10·6 95 213 639 731 1764-69 9·6 98 229 659 827 1770-74 21·6 102 242 651 1062
The ages of those who died of measles “in six years from 1768 to 1774,” to the number of 91, were as follows:
Total 3 mo. -6 mo. -12 mo. -2 years -3 -4 -5 -10 -20 -30
91 2 3 10 31 25 7 9 2 1 1
Fifty were males, forty-one females--a preponderance of males which is according to rule. Of the whole ninety-one, no fewer than fifty-one died in June of the several years.
In the smaller and more healthy towns, such as Northampton, the epidemics of measles came at long intervals and caused but few deaths:
Infantile Causes of Death, All Saints, Northampton[1202].
Year Measles Whooping-cough Convulsions Teething
1742 3 1 10 8 1743 -- -- 21 2 1744 -- 3 14 4 1745 -- -- 22 7 1746 -- 3 19 3 1747 7 -- 29 -- 1748 -- -- 24 4 1749 -- 6 15 4 1750 1 -- 17 1 1751 -- -- 14 6 1752 -- 1 13 6 1753} not published 1754} 1755 -- 1 8 1 1756 -- 2 10 2 1757 1 1 28 4
In the parish of Holy Cross, a suburb of Shrewsbury, there were 4 deaths from measles in the ten years 1750-60, and 15 in the ten years 1760-70, the smallpox deaths having been respectively 33 and 46. Ackworth, in Yorkshire, may represent the country parishes. It had no deaths from measles from 1747 to 1757, two deaths from 1757 to 1767. At Kilmarnock during thirty-six years from 1728 to 1764, there were 93 deaths from measles, 52 of them in the period 1747-52, and only 11 in the next twelve years. Sims, of Tyrone, having described an epidemic of smallpox which desolated the close of 1766 and spring of 1767 with unheard of havoc (it had been out of the country for some years), mentions farther that an epidemic of measles followed immediately: “Before the close of the summer solstice the measles sprang up with a most luxuriant growth,” and was followed in harvest by whooping-cough.
Wherever we have the means of comparison by figures, it appears that measles caused by its direct fatality not more than a sixth part of the deaths by smallpox in Britain generally. But in the colonies, where an epidemic of smallpox was a rare event of the great seaports, and as much an affair of adults as of children, measles seems to have been more fatal, dividing with diphtheria or scarlatina the great bulk of the infectious mortality of childhood. Thus Webster enters under 1772: “In this year the measles appeared in all parts of America with unusual mortality. In Charleston died 800 or 900 children”; and under 1773: “In America the measles finished its course and was followed by disorders in the throat”--especially in 1775[1203]. It is only among the children of public institutions in England that we find in the corresponding period a similar predominance of measles and scarlatina over smallpox. In the Infirmary Books of the Foundling Hospital the more general outbreaks of smallpox cease after 1765, while epidemics of measles, extending to perhaps a third or more of the inmates, as well as great epidemics of scarlatina, begin after that date to be common[1204].
In the Infirmary Book from which the following extracts are taken, the number of deaths is not stated. The number of children in the Hospital was 312 in 1763, 368 in 1766 and 438 in 1768.
1763. Before the date of the Infirmary Book, Watson records an epidemic of putrid measles from 21 April to 9 June, 1763, which attacked 180 and caused 19 immediate deaths.
Nov. 19. Nine in the infirmary with “morbillous fever”; many cases of “fever” until the 17th December.
1766. May to July. Many entries in the book; Watson says: “Seventy-four had benign measles, and all recovered.”
1768. Great epidemic, May to July; one hundred and twelve in the infirmary with measles on June 4th; Watson gives the total cases at 139, of which 6 were fatal.
1773. Nov. and Dec. Great epidemic: maximum of 130 cases of measles in the infirmary on 27th November. Next week there were 40 with measles, and 90 convalescing therefrom.
1774. May. A slight outbreak (8 cases at one time).
(Records from 1776-1782 not seen.)
1783. March and April. Great epidemic: maximum number of cases in the infirmary with measles 94, on March 22nd.
1784. June. Eleven cases of measles at once.
1786. March and April. Maximum on April 5th--measles 47, recovering from measles 19.
The records from 1789 to 1805 have not been seen, but Willan gives the following dates and numbers, on the information of Dr Stanger, physician to the charity[1205].
1794. 28 had measles, all recovered.
1798. 69 had measles, 6 girls died.
1800. 66 had measles, 4 boys died.
1802. 8 had measles, one died.
The general testimony in the last quarter of the 18th century is that measles, if a common affection, was not usually a severe one. Heysham, of Carlisle, says that measles came thither in 1786 from the south-west of Northumberland, “where, I am informed, they proved very fatal”; the epidemic began at Carlisle in August, and continued very general until January, 1787, but extremely mild and favourable, only 28 having died (26 under five years, 2 from five to ten), out of “some six or seven hundred, I suppose.” The previous epidemic of measles at Carlisle in 1780 (mortality not stated), had followed a most fatal epidemic of smallpox in 1779; and although the epidemic of mild measles in 1786 did not follow a great epidemic of smallpox, it followed a high and steady annual average of deaths of infants and young children from that cause year after year[1206]. In both years of the measles at Carlisle, there were no deaths from smallpox. In like manner at Leeds, in 1790, measles followed smallpox, and was extremely mild; Lucas wrote of it, “I have not seen one instance of a fatal termination[1207].” This was the time (1785) when Heberden said of the disease in London, just as Willis, Harris and others had said of it and of smallpox together a century before: “The measles being usually attended with very little danger, it is not often that a physician is employed in this distemper.”
Increasing mortality from Measles at the end of the 18th century.
There were epidemics of measles with high mortality in the 17th and 18th centuries, occurring in special circumstances of time and place, of which instances have been given. But in general the position of measles was not then so high among the causes of death in infancy and childhood as it afterwards became. It is not easy to demonstrate the exact proportions by figures, even for London; the bills of the Parish Clerks are less trustworthy for measles than for smallpox, for the reason that deaths from scarlatina were probably included among the former (see under Scarlatina). For example, the ratio of 1·10 per cent. measles deaths for the ten years 1781-90 in the following table should be only 0·70 if the 793 deaths in 1786, supposed scarlatinal, be left out. But, taking the bills as they stand, they show an increasing ratio of measles (as well as of whooping-cough) among the deaths from all causes towards the end of the 18th century.
Percentage of Measles and Whooping-cough in all London deaths, 1731-1830.
Ten-year Share of Share of periods measles whooping-cough
1731-40 0·70 0·41 1741-50 0·68 0·40 1751-60 1·15 1·03 1761-70 1·11 1·12 1771-80 0·93 1·66 1781-90 1·10 1·32 1791-1800 1·34 1·97 1801-10 3·11 3·14 1811-20 3·52 3·49 1821-30 3·17 3·13
During the same period, the ratio of deaths from all causes under two years of age had decreased, while the ratio of deaths from two to five, and at all ages above five, had increased as in the following table, also compiled from the London bills beginning with the year 1728 when the ages at death were first published.
Ratios of Deaths from all causes under two years, from two to five, and above five, London, 1728-1830.
Ratio Ratio Ratio of Total under from all ages Period deaths Two years Two to Five above Five
1728-30 (3 yrs.) 84,293 36·7 8·7 54·6 1731-40 246,925 38·6 8·9 52·5 1741-50 254,717 33·6 7·9 58·5 1751-60 204,617 30·9 9·3 59·8 1761-70 234,412 34·1 9·1 56·8 1771-80 214,605 34·4 9·6 56·0 1781-90 192,690 32·5 9·5 58·0 1791-1800 196,801 31·8 10·9 57·3 1801-10 185,823 29·3 11·5 59·2 1811-20 190,768 27·7 9·8 62·5 1821-30 209,094 28·0 9·7 62·3
Thus, while measles (with whooping-cough) was usurping, so to speak, a larger share of all the deaths, the two first years of life were claiming a smaller share of the deaths from all causes as the probability of life was improving. The saving of infant life was due to various things, but especially due to the decline of smallpox, as described in another chapter. We may now turn to consider, by a less abstract method, the increase of measles mortality from the last years of the 18th century.
In Willan’s periodical reports of the prevailing diseases of London[1208], scarlatina declined in 1795 and became sporadic, after having been extremely fatal for a long period, while measles and smallpox began to extend about the end of that year, the former being for the most part mild in its symptoms and favourable in its termination, the latter often confluent, and fatal to children. The report for March and April, 1796, is that measles had become more severe, and had been followed by obstinate coughs; for May, that “smallpox and measles have prevailed more during this spring than has been known for many years past.” However, it was smallpox that occasioned the larger share of the deaths among infants and children. The next general view that Willan gives us of the relative importance of measles among the infectious diseases is under Oct.-Nov. 1799: “The measles, though extensively diffused, have continued mild and moderate. The scarlet fever has increased, since the last report, both in extent and in the violence of its symptoms; but the contagious malignant fever [typhus] has been the most frequent, as well as the most fatal, of all acute diseases.” There is little sign of fatal measles in the London bills during the years of distress, 1799-1801; but we hear of it in Scotland and Ireland, where there was probably less scarlatina. An Edinburgh observer of the prevailing diseases says that “several hundreds” died of measles there in the winter of 1799[1209]. In the Irish emigration to America, which took one of its periodic starts owing to the repressive measures following the rebellion of 1798 and the union with England, measles appears to have been the fatal form of infection among the children on board ship. A medical letter from Philadelphia, 10 December, 1801, says that measles had been imported to Newcastle and Wilmington in the summer of 1801 by some vessels from Ireland, on board which a great many children died during the voyage; the epidemic at length reached Philadelphia and had become general throughout the city[1210]. At Whitehaven large numbers of infants were attended in measles from the Dispensary in 1796 and 1799, but the deaths (2 in 202 cases, and 2 in 266 cases) are probably only a few that came to the knowledge of the visiting physician. An epidemic at Uxbridge, Middlesex, in the winter of 1801-2 was certainly malignant or fatal more than ordinary, whatever its anomalous type may have meant.
The epidemic began in September, and was at first of so mild a type as to need no medical assistance. Towards November the cases increased in number and severity, but still, says the narrator, “I believe every case terminated favourably, not in my practice only, but in that of other gentlemen also.” Towards the middle of November, the attacks were more sudden and more violent while they lasted, and were soon over either in death or recovery. In some the eyes became all at once as red as blood, the pulse full, quick and hard, the cough incessant, with a rattling noise in the throat and quick laboured breathing, the skin hot and parched. “Another peculiarity in this epidemic was that the cuticle in many children did not separate after the disappearance of the eruption, and in several others that I particularly noticed, it came off in large flakes instead of branny scales; and the appearance of the rash in others assumed so striking a resemblance to the scarlet fever that, had it not been for the violent cough and other measly symptoms, many such cases occurring singly might, upon a superficial view, have been considered and treated as that disorder.” The various forms occurred in the same family; thus, of four children, one had typical measles, ending in a branny scurf, two others had the sneezing and the watery inflamed eyes, but the eruption in the form of an universal red fiery rash, after which the skin peeled in large flakes, while the fourth had the disease of a low typhoid type and recovered with difficulty. The epidemic “continued its destructive career” through December and January, after which the type became as mild as it had been at first. If the author had not discussed the diagnosis as between measles and scarlatina, deciding in favour of the former, one might have suspected that there were cases of both. But even the sphacelation that followed the application of blisters, the pemphigus-like eruption turning gangrenous, and the petechiae, were signs of malignancy in more than one of the exanthematous fevers. The sequelae of this epidemic of measles were as anomalous as the symptoms themselves; instead of the inflamed eyes, and the distressing cough (sometimes ending in consumption) there were aphthous fever and dysenteric purging[1211].
The deaths in the London bills for the first twelve years of the century will be found in the table on p. 655. We find the measles deaths for the first time equalling the smallpox deaths in 1804, and in 1808 surpassing them, and we may take it that the deaths so entered were almost wholly of measles proper. The epidemic of measles in 1807-8 was, in fact, a great and clearly defined event in British epidemiology, the first of a series of epidemics in which that disease established not only its equality with smallpox as a cause of infantile deaths but even its supremacy over the latter. It would appear, also, to have been more malignant than the scarlatina that coexisted with it. Thus, Bateman, of London, at the outset of the great measles epidemic of 1807-8, says: “The most prominent acute disorders have been eruptive fevers and particularly the measles, which during October and November have been very prevalent, and, when occurring in young children, have proved very fatal by terminating in violent inflammation of the organs of respiration.... The scarlatina was generally mild, presenting the eruption with a slight sore-throat[1212].”
Other accounts of the epidemic in London show it to have been of the type which Sydenham, in 1674, called anomalous or malignant.
The epidemic began in October-November, 1807, and was remarked as unusually fatal[1213].
Several children in the same family had fallen victims to it. Some cases were fatal in a few days, either from the intensity of the fever or from pneumonic complication. “But when these symptoms have been less violent, and the patient has passed without much alarm through the different stages of the disorder, and even after all apprehension of danger in the mind of parents or friends has been dismissed, a continuance or recurrence of pneumonic symptoms has laid a foundation for phthisis pulmonalis.” In some cases attended from the Westminster Dispensary, death followed from effusion into the chest or from membranous inflammation of the trachea. Numbers who recovered from the measles were afterwards affected with debility, cough, emaciation and oedematous swellings of the face and extremities which proved very difficult to remove. These particulars are given mostly for the end of 1807, but it is under the year 1808 that the great rise in the measles deaths appears in the London bills of mortality.
Besides these accounts for London, we have some details of the same epidemic at Edinburgh and Aberdeen and exact figures for Glasgow. It began at Edinburgh in the winter of 1807, and at Aberdeen (as at Glasgow) in the spring of 1808. At both places it was remarked as unusually fatal, chiefly from a complication of bowel complaint in children and from pulmonary affections in adults.
The Aberdeen observer says that in town (the disease being milder in the country) there were troublesome symptoms in almost every case--a violent pain in the belly, frequently accompanied with diarrhoea (and even with vomiting), and with the dysenteric symptoms of tenesmus and mucus in the stools. This bowel complaint usually lasted three or four days, and wasted the patients remarkably. There was also the usual catarrh with violent tickling cough, and, after the acute attack, a tendency to sudden dyspnoea and “fatal coughs.” In some the convalescence was lingering and very distressing to the patient: “it consists in a slow kind of fever, with evening exacerbations[1214].”
The observers at Edinburgh and Aberdeen agree that the epidemic was the worst that had been seen for many years. Says the former[1215]: “I believe that the present epidemic has been more general in this place and its vicinity than ever happened within the remembrance of any medical man at present living, and I am sorry to say it has been very fatal.” The Aberdeen chronicler says the mortality was “greater than we have witnessed for a long period,” and that the epidemic was general throughout the whole of England and Scotland. But, besides this direct testimony, there is a not less indirectly significant fact of the epidemic. It affected many adults--“persons of all ages, who had never had them,” says the Aberdeen writer: few persons escaped, says the Edinburgh observer, “who had been previously unaffected by this disease.” The deaths from pulmonic complaints did not often happen among children, but among people somewhat advanced in life. Significant also was the outbreak in the Invernessshire Militia, which marched into Edinburgh in March while the epidemic was raging. Fifty men, all young recruits newly joined, were attacked in the course of a few days, the others escaping the disease though equally exposed to it; in some of those who died in the regiment there were found, on opening the thorax, fibrinous pleurisy and pericarditis, with effusion of fluid, as well as evidences of bronchial catarrh[1216]. The Aberdeen writer says: “I always observed that in full-grown persons the eruptions were more numerous, quicker in appearing, and longer in going off than in young subjects.... Many full-grown persons were very ill, yet the measles were more fatal to the young.” The implication of so many adults in the severe epidemic of 1808 would of itself show that measles had not been for some time before a steady and universal affection of infancy and childhood[1217].
Measles in Glasgow in 1808 and 1811-12: Researches of Watt.
The measles epidemic of 1808, which appears to have been somewhat general in England and Scotland, made an extraordinary impression in Glasgow. That disease had never before been nearly so mortal there, nor had any infection since the time of the plague, not even smallpox itself, engrossed the burial registers so much as measles did in the months of May and June, 1808. Glasgow had been the worst city in the kingdom for smallpox; by a somewhat sudden transition the infancy of the city died for a few months in larger numbers by the new disease than by the old. The highest monthly mortalities from smallpox had been 114 in October and 113 in November, 1791, the population being 66,578; but in 1808, the population having increased to 100,749 by the census of 1811, measles carried off 259 children in May and 260 in June, and in the months before and after as follows:
Measles in Glasgow, 1808.
Month Deaths
Jan. 2 Feb. 2 March 5 April 71 May 259 June 260 July 118 Aug. 32 Sept. 22 Oct. 10 Nov. 4 Dec. 2
The figures were not known at the time; but every doctor in Glasgow, as well as the whole populace, knew that measles was cutting off the infants, while smallpox had fallen to insignificance. So dramatic was this turn in the public health that the common people set it down to the new practice of inoculating children with cowpox: ready to believe anything of vaccination, they concluded that, if it kept off smallpox, it brought on measles. Dr Robert Watt took the trouble to refute this singular notion; he found in his own practice that three children in one family, and in another two, had died of measles who had neither been vaccinated nor had smallpox before. Another great epidemic of measles arose in Glasgow three years after, in the winter of 1811-12:
Measles 1811 deaths
October 12 November 76 December 161
1812
January 130 February 61 March 30 April 19 May 15 June 18
Those two great epidemics of measles in Glasgow, in 1808 and 1811-12, were the occasion of one of the earliest and most memorable inquiries in vital statistics in this country, the research by Dr Robert Watt on “the Relative Mortality of the Principal Diseases of Children, and the numbers who have died under ten years of age in Glasgow during the last thirty years[1218].” Having begun with a search of the principal Glasgow burial-registers for deaths by whooping-cough, he extended it to sixteen folio volumes of the registers of all the burial-grounds, old and new, and included the mortalities from all causes with the ages at death, and from fevers and the principal diseases of infancy and childhood. The increase of population from 1783, when his figures begin, to 1812, the date of his writing, was known to him; but as the numbers living at the respective periods of life were not known, he was obliged to state the change in the mortalities at the various ages, and from the various diseases, in ratios of the annual deaths from all causes,--a perfectly scientific comparison so long as the nature of the ratios compared was clearly stated. It would have been more satisfactory, of course, if the comparison could have been made in terms of the annual death-rate, which was much lower (for reasons already explained), in the second half of his period than in the first; but, in the circumstances, that was impracticable, and Watt did the next best thing. The following is the principal part of his table of ratios in five successive periods of six years each:
Vital Statistics of Glasgow in sexennial periods, 1783-1812. (Watt.)
Per Per Per cent. cent. Per Per Sum cent. from from cent. cent. of all under Two to Five of of Period deaths Two Five to Ten Smallpox Measles
1783-88 9994 39·40 10·66 3·42 19·55 0·93 1789-94 11103 42·38 11·90 3·79 18·22 1·17 1795-1800 9991 38·82 12·21 3·45 18·70 2·10 1801-06 10304 33·50 13·43 5·10 8·90 3·92 1807-12 13354 35·89 14·22 5·58 3·90 10·76
Per cent. of Per cent. of Period Whooping-cough “Bowel-hive”
1783-88 4·51 6·72 1789-94 5·13 6·43 1795-1800 5·36 6·47 1801-06 6·12 7·27 1807-12 5·57 9·26
The actual deaths from smallpox, measles and whooping-cough are shown in the next table, which includes for comparison the corresponding figures from the London bills of mortality:
Smallpox, Measles and Whooping-cough in London and Glasgow, 1783-1812.
London /----------------------------------\ Year Smallpox Measles Whooping-cough
1783 1550 185 268 1784 1759 29 457 1785 1999 20 194 1786 1210 793 200 1787 2418 84 228 1788 1101 55 298 1789 2077 534 374 1790 1617 119 391 1791 1747 156 279 1792 1568 450 311 1793 2382 248 352 1794 1913 172 469 1795 1040 328 311 1796 3548 307 536 1797 522 222 567 1798 2237 196 418 1799 1111 223 451 1800 2409 395 380 1801 1461 136 428 1802 1579 559 1004 1803 1202 438 586 1804 622 619 697 1805 1685 523 703 1806 1158 530 623 1807 1297 452 439 1808 1169 1386 326 1809 1163 106 591 1810 1198 1031 449 1811 751 235 486 1812 1287 427 508
Glasgow /----------------------------------\ Year Smallpox Measles Whooping-cough
1783 155 66 153 1784 425 1 41 1785 218 0 34 1786 348 2 173 1787 410 23 57 1788 399 1 17 1789 366 23 45 1790 336 33 177 1791 607 4 117 1792 202 58 68 1793 389 5 112 1794 235 7 51 1795 402 46 180 1796 177 92 60 1797 354 5 76 1798 309 3 98 1799 370 43 95 1800 257 21 27 1801 245 8 125 1802 156 168 90 1803 194 45 60 1804 213 27 52 1805 56 90 129 1806 28 56 162 1807 97 16 85 1808 51 787 92 1809 159 44 259 1810 28 19 147 1811 109 267 62 1812 78 304 103
The ratio of deaths under the age of two had decreased greatly in Glasgow, while the ratios from two to five and from five to ten had increased. At the same time smallpox had almost ceased (but only temporarily, as it appeared) to be the great infectious scourge of infancy, while measles had come in its place. “Now that the smallpox are in great measure expelled,” (Watt believed that cowpox inoculation had done this), “the measles are gradually coming to occupy the same ground which they formerly occupied. I am sorry to make this statement, but the facts, at least with regard to Glasgow, are too strong to admit of doubt.”
In order to explain the enormous increase of deaths by measles, he had recourse to the following argument. Formerly nearly all children, say nine-tenths, had both smallpox and measles, the attack of smallpox in most cases coming first. Children who had survived smallpox were fortified by that ordeal, not merely as selected lives, but positively fortified, so that measles, when it assailed them in due time afterwards, was taken mildly or was “modified,” not one in a hundred cases proving fatal. But now (1813), when so few children have been through the smallpox, measles has become ten times more fatal to them, although it could hardly be more common than it used to be. Having found it necessary to assume that children in former times took smallpox before they took measles, nine-tenths of them taking both, he qualifies this in another passage: “Still, however, as the measles came round now and then, as a very general epidemic, they must occasionally have had the precedence, and it was perhaps chiefly among such patients that the disease proved fatal.”
The measles which came round now and then as a general epidemic was nearly the whole of it; even in London there were intervals of several years with only a few annual deaths, and in smaller towns or country districts the clear intervals were longer. The prevalence of measles on the great scale being more casual than that of smallpox, it is likely that most children had taken smallpox before they incurred measles. But it is clear from such instances as the London epidemic of 1674, and the epidemic in the Foundling Hospital in 1763, that measles might attack children just before smallpox, and by its weakening effects, increase the number of victims of the latter. As to the fatality of measles itself in the 17th and 18th centuries, the statement of Watt that it did not amount to one death in a hundred attacks, while it can neither be proved nor disproved by an array of figures, can be shown to be inconsistent with the language of annalists. The epidemics of measles varied in severity then as afterwards: that of 1670 in London was regular and mild, that of 1674 in the very same months of the year was anomalous and fatal; Huxham characterizes the measles at Plymouth in the winter of 1749-50 as “maximé epidemici, imo et saepe pestiferi”; at Kidderminster, in 1756, after fevers had been very fatal to adults, the measles went through the town so that an immense number of children “died tabid”; in the West of England about 1760 a disease called measles made “a melancholy carnage amongst children.”
While Watt’s theory of the working of this principle of substitution is open to criticism on some points of detail, the law itself, as enunciated by him, remains to the present time one of the soundest and most instructive generalities in epidemiology. He based it upon a laborious search of the burial registers, such as no one before him in this country had undertaken. Next he saw correctly that a great rise in the deaths of infants by such a disease as measles could only be accounted for by a great increase in the rate of fatality. Thirdly, he connected the loss from measles with the saving from smallpox. Adopting an old opinion, which may be discovered in Willis[1219], he argued that smallpox, when taken first, served to fortify children so that they passed easily through the measles afterwards; but in the following passage he indicated a better reason why the absence of smallpox gave measles the chance of proving more fatal: “In this point of view we are not to consider the smallpox as so peculiarly fatal in their nature. They perhaps prove so fatal merely by having the start of other diseases. The measles, the chincough, the croup, the scarlet fever, and perhaps many others, would have proved equally fatal had they occurred first.” The principle is true to this extent, that a certain proportion of weakly infants, or children of poor stamina, will succumb to almost any disease--if not to smallpox, then to measles, and if not to measles directly, then to the sequelae of measles. This was perceived in the form of a necessary truth by Haygarth in 1793: “A considerable number of those who now die of the smallpox would die in childhood of other diseases if this distemper were exterminated[1220].” It was commonly believed that smallpox had at length found its real artificial check, not in the inoculation of itself, but in the inoculation of cowpox. At all events it had declined greatly in Glasgow. During the three years before the measles epidemic of 1808, there could hardly have been more than a thousand children attacked by smallpox, or not one in ten of all the children born. During several years the infancy of the city had been spared any great ordeal of infectious disease; the first epidemic that came along happened to be measles, so that it fell to that infection to take off the weaklings. In the economy of nature it is impossible to rear all the young of a species, nor would it be good for the species if it were possible. It is among the birds that the principle of population, or of the survival of the fittest, is seen working in the most admirable way: the annual migration of many species to breed in a remote country brings with it an ordeal for the birds of the year in finding their way to the winter feeding-grounds--an ordeal which only the strongest come through. For some unexplained reason, the young of the human species are peculiarly tried by infectious diseases, which multitudes pass through safely, while many of poor stamina or of ill tending are cut off.
Dr Watt’s teaching, as to the displacement of one infectious cause of death by another was resisted at the time as being of “evil tendency” for the pretensions of vaccination, although Watt believed as firmly in the virtues of cowpox as Jenner himself did. Writing to James Moore on 6 Dec. 1813, Jenner says of Watt’s essay (Baron, II. 392): “There is nothing in its title that developes its purport or evil tendency.... Is not this very shocking? Here is a new and unexpected twig shot forth for the sinking anti-vaccinist to cling to.” Sir Gilbert Blane, who was then president of the Medical and Chirurgical Society, having a natural fondness for ideas of all kinds expressed in a paper to that society rather more approval of Watt’s view than was thought prudent: “An ingenious friend of mine has remarked to me in conversation that some light is thrown on this subject by considering that whichever of the epidemic maladies attack children first, it will be the most fatal, inasmuch as all feeble constitutions will fall in its way while the stronger will be left to encounter the attacks of the others; and that the smallpox, owing probably to the greater abundance and rankness of their effluvia, are generally caught in a casual way before measles, hooping cough and scarlet fever, and are therefore reckoned more fatal than any of these. But, a new field of research being opened,” etc. Efforts were made to correct the effect of this, by showing that measles in some parts of the country had not been more fatal than usual. Holland, of Knutsford, attributed the fatality of the epidemic in 1808 to a change of the wind to the east. Writers in the Edinburgh Med. and Surg. Journal, pointed out that Watt had compared the absolute deaths by smallpox at one time and by measles at another without taking account of the increase of population, and the rates of mortality from each disease. The best criticism of Watt was by Roberton in his Mortality of Children, 1827, p. 49. He offers the following considerations, without seeming to know that they were really to be found in Watt’s own essay: Smallpox used to be caught first; it swept off the feeble and sickly, leaving the strong and vigorous only to encounter the attacks of other diseases. “That infectious febrile disease to which in early infancy there is the strongest predisposition will of course in general make the first attack and prove the most fatal of any.” There were reasons why measles used to have comparatively few victims, “and why, when they now prevail epidemically, they, as was the case with smallpox, are caught at an earlier age than other diseases in general and prove so very fatal: which happens not more from their priority in attack than from being in their nature what they were ever considered--a severe and dangerous disease. We are to recollect, however, that measles do not in general attack at so early an age as smallpox; nor ever, like the latter, destroy eight or nine-tenths of all the children that die in the place where they happen to prevail, as was the case in the variolous epidemics of Chester and Warrington [this is an error, vide supra, p. 554]; consequently we have reason to hope that neither measles nor any other infantile disease will, as Dr Watt imagined, ‘come to occupy the place which smallpox once occupied,’” (p. 58). A feeble echo of Roberton’s criticism, with all its scientific candour left out and its points against Watt emphasized in a spirit of paltry cavilling, was heard next year in the Goulstonian Lectures of Bisset Hawkins on Elements of Medical Statistics, 1829.
Many years after, when the enormous increase of deaths by scarlatina was illustrating the doctrine of displacement in a new way, Dr Farr gave a full analysis of Watt’s essay in his annual Letter to the Registrar-General for the year 1867, and endorsed the Glasgow teaching of 1813 with more heartiness than it had hitherto received. Although Farr did not take the Malthusian view that the loss of weakly children by one means or another was inevitable, yet he could not help seeing, in his work upon the registration returns from 1837 onwards, that one infection had been taking what another spared. He recurred to Watt’s doctrine time after time in his annual reports, and in that of 1872 (p. 224), expressed his belief thus plainly: “The zymotic diseases replace each other; and when one is rooted out, it is apt to be replaced by others which ravage the human race indifferently whenever the conditions of healthy life are wanting. They have this property in common with weeds and other forms of life: as one species recedes, another advances.”
Two remarks remain to be made under the doctrine of displacement. The first is that the substitution of measles for smallpox was one of a series of such changes in the public health of Britain. The great infective scourge of medieval and early modern periods had been plague, which destroyed at times immense numbers of the valuable or mature lives. Its successor was typhus fever, which also cut off the parents more than the children, but did not retard population as the plague had done. The saving of life by the extinction of plague was in great part balanced by the loss from smallpox, which fell, however, more and more upon the earliest years of life until at length it was almost confined to them. The first great decline of smallpox itself corresponded to a great decline of typhus fever during the second half of the French war; but while there was no great infectious disease in those years to thin the ranks of the adults, measles took the place of the more loathsome smallpox in cutting off a certain number of young lives. While the older types of infection have disappeared, the incidence has shifted from mature lives to children, so much so that at the present time enteric fever, and occasional choleras and influenzas, are almost the only infections that correspond to the old plague and to typhus fever in their age-incidence.
The other remark is that the greater prevalence or fatality of measles, as if in lieu of smallpox, meant a good deal more for the bills of mortality than actually appeared under the name of measles. Smallpox was not an infection that did much constitutional damage to those that came through it, although it sometimes destroyed the vision and spoiled the beauty of the face. On the contrary, it was held by many that the general health was better after an attack of smallpox than before; and, if personal experience can justify an opinion, that ought to be my own view of the matter[1221]. But measles is an infection peculiarly apt to leave mischief behind. The bronchial catarrh, which is an integral part of the malady, and is often the cause of death in the second stage of the attack, may so affect weakly children that the respiratory organs are permanently damaged. Tuberculosis of the lungs is apt to follow measles. Some children, again, fall into mesenteric disease after measles, and die tabid, the intestinal catarrh being as dangerous in one way as the bronchial is in another. Another large proportion of the subjects of measles take whooping-cough[1222]. While smallpox did its work summarily, the full effects of measles were longer in being realized. This may in part explain the fact brought out by Watt, that while fewer children died under two years of age, measles being the dominant epidemic disease, there was an increase in the ratio of deaths from all causes between the years of two and five and from five to ten.
Measles in the Period of Statistics.
The history of measles for nearly a generation after the great epidemics of 1808 and 1811-12 is little known. No one in Glasgow continued Watt’s laborious tabulation of the causes of deaths in the numerous burial registers[1223]; nor was any regular account kept elsewhere except by the Parish Clerks of London. The following deaths by measles in their bills from 1813 to 1837, when the modern registration began, were probably no more than from a third to a half of the deaths in all London:
Measles Year deaths
1813 550 1814 817 1815 711 1816 1106 1817 725 1818 728 1819 695 1820 720 1821 547 1822 712 1823 573 1824 966 1825 743 1826 774 1827 525 1828 736 1829 578 1830 479 1831 750 1832 675 1833 524 1834 528 1835 734 1836 404 1837 577
The inadequacy of these figures to the whole of London will appear from the fact that the registration returns under the new Act gave for the last six months of 1837 the measles deaths at 1354, while the bills of the Parish Clerks gave them at 577 for the whole year. But the old bills enable us to compare the deaths from different diseases within the same area and under the same system of collection, and to compare the deaths “within the bills” in a series of years since the last of the new parishes were taken in about the middle of the 18th century. Using the bills so far legitimately, we find that measles at length came to be of equal importance with smallpox itself as a cause of death in childhood, and that it had become a larger and steadier total from year to year.
So far as concerns Glasgow, the high mortality from 1807 to 1812, making 10·76 on an annual average of the deaths from all causes, was not maintained. When the tabulation of the causes of death was resumed from 1835, the annual average of measles for the five years ending 1839 was found to be only 6 per cent. of the deaths from all causes, the average of smallpox having come back to 5·3 per cent. During that unwholesome period, in which there was much distress among the working class and a great epidemic of typhus, measles and smallpox were dividing the infectious mortality of childhood somewhat equally, the age-incidence of measles being only a little lower than that of smallpox:
Ages of the Fatal Cases of Measles in Glasgow, 1835-39[1224].
Under one 1-2 2-5 5-10 10-20 20-30 30-40 40-50 Total
1835 116 141 121 34 10 4 - - 426 1836 86 209 183 38 1 1 - - 518 1837 77 133 122 16 2 1 350 1838 76 124 161 39 3 1 1 405 1839 165 259 275 73 7 2 1 783 -------------------------------------------------------- 520 866 863 200 23 9 1 1 2482
In Limerick, which may stand for a typically unhealthy Irish city in the worst period of over-population, there were many more deaths from smallpox among children than from measles, the age-incidence being nearly the same, according to the following dispensary statistics for a number of years before 1840[1225]:
Limerick Dispensary Deaths.
Age 0-5 5-10 10-15 15-20 Total
Smallpox 333 55 5 0 393 Measles 187 32 6 1 226 Scarlatina 8 2 10
Although it is impossible to prove it, yet the indications all point to measles having kept for a whole generation after 1808 the leading place among infantile causes of death which it then for the first time definitely took[1226]. Almost the only direct references to the subject were made by way of controverting the doctrine of Watt; but these are too meagre, or too general in their terms, to be of any use[1227]. The epidemics of measles seem to have travelled then, as they do now, from county to county in successive years. Thus in 1818, while most parts of England were or had recently been suffering from smallpox, the Eastern counties were suffering from measles “very frequent and fatal.” Smallpox at length reached Norwich in 1819, and became the reigning epidemic in the place of measles, which was “hardly met with” so long as the enormous mortality of the other disease proceeded[1228]. At Exeter in the spring of 1824 measles became epidemic after a long interval; many susceptible children had accumulated, and of these few escaped. The mortality was very great, and was caused by severe pulmonary inflammation, the catarrhal symptoms being mild. In one day seventeen children were buried in one of the five parish churchyards of the city; but that high mortality, according to the parochial surgeon, did not on an average stand for more than four deaths in one hundred cases[1229].
When the curtain rises, in the summer of 1837, upon the prevalence and distribution of diseases in England, as ascertained by the new system of registration of the causes of death, measles is found in the first place among the infectious maladies of childhood, thereafter yielding its place to smallpox for a year or more, and taking the lead again until it was passed by scarlatina.
Deaths by Measles and Smallpox in London, 1837-39.
1837 1838 1839 3rd Qr. 4th Qr. 1st Qr. 2nd Qr. 3rd Qr. 4th Qr. (four quarters)
Measles 822 532 173 96 94 225 2036 Smallpox 257 506 753 1145 1061 858 634
The epidemic of smallpox hardly touched the Eastern counties until 1839; so that while the home counties in that year had far more deaths by measles than by smallpox, Norfolk had only 72 deaths by the former against 820 deaths by the latter. In the same year measles took the lead in four out of six great English towns, scarlatina being the dominant infection in one (Sheffield), and smallpox in one (Bradford):
Deaths in 1839 by the three chief infections of Childhood.
Liverpool Manchester Leeds Birmingham Sheffield Bradford
Measles 401 773 383 170 33 70 Scarlatina 374 264 35 133 419 7 Smallpox 259 237 171 56 16 208
In all England and Wales during fully half-a-century of registration, measles has fluctuated somewhat from year to year but has not experienced a notable decline among the causes of infantile mortality (see the table at p. 614). In the decennial period 1871-80, its annual average death-rate was 377 per million living; in the next decennium it rose to 441, the previously high rates of scarlatina having fallen greatly. Among the highest rates for the ten years 1871-80, were those of Plymouth, 1·13 per 1000, East Stonehouse 1·79, and Devonport 1·19 (owing to a great epidemic in 1879-80), Exeter, 0·82, Liverpool ·91, Bedwelty (Tredegar and Aberystruth collieries) 0·88, Wigan 0·74, Whitehaven 0·71, Alverstoke 0·81. In the most recent period there have been some very high death-rates; thus at Jarrow the annual rate, which was only ·27 per 1000 from 1871 to 1880, rose in the nine years 1881 to 1889 to an annual average of ·94, having been made up almost wholly by great epidemics every other year--in 1883 (2·9), 1885 (2·4), 1887 (1·4), and 1889 (·9)[1230]. In the year 1888, an epidemic at Stoke-on-Trent, Hanley, &c. with 342 deaths, made a rate of 2·8 for the year; in Wolstanton, Burslem, &c., 221 deaths were equivalent to a rate of 2·6.
The latest reports of the Registrar-General have traced a progression of the epidemic of measles from county to county or from district to district in successive years, such as was remarked, both for smallpox and measles, by some of the 18th century epidemiologists in England, Scotland and Ireland.
Thus in 1890, measles was epidemic in Cheshire, South Lancashire and North Staffordshire; in 1891 it ceased in these, but became epidemic in North Lancashire, South Staffordshire and the West Riding; in 1892 it ceased in its last-mentioned area, and became epidemic in Warwickshire, Leicestershire, Derbyshire, the East and North Ridings, Westmoreland and Durham. During the same three years a similar progression or cycle was observable (on looking over the tables) in the South-west of England. The epidemic year of measles in Devonshire was 1889. It ceased there, and became epidemic in 1890 in Cornwall on the one side and in Somerset on the other, sparing Dorset. In 1891 it ceased to be epidemic in those parts of Cornwall and Somerset which it occupied in 1890, and became prevalent in the extreme west of Cornwall, in parts of Somerset, in Wiltshire and in Gloucestershire. In 1892 it ceased in all the last-mentioned excepting Gloucestershire, and became epidemic in Dorset, where there had been no severe prevalence of measles since 1888[1231].
Measles has no such decided preference for a season of the year as scarlatina and enteric fever have for autumn or infantile diarrhoea has for summer. But it often happens that most deaths are recorded from May to July, owing, doubtless, to the greater number of attacks in summer and not to any excessive fatality of that season. In London and the great industrial towns the deaths are spread somewhat uniformly over the year; or, in the language of statisticians, the maxima do not rise far above the mean of the year. In a tabulation of the weekly deaths in London from 1845 to 1874[1232], it appears that they touch a higher point in mid-winter (Nov.-Jan.) than in summer, a fact which may be readily accounted for by the injurious effects of the London air in winter upon a disease which is largely a trouble of the respiratory organs. In the great industrial populations of Lancashire, which resemble London in their high death-rate from measles, the rise of the deaths in mid-winter is almost the same as the summer increase[1233].
Most of the deaths from measles fall at present upon the ages from six months to three years, just as they did when the deaths were comparatively few, as at Manchester from 1768 to 1774. Deaths of adults, which were not altogether rare in the first great epidemic of modern times in 1808, are seldom heard of at present, for the same reason that adult deaths used to be uncommon in smallpox, namely, that the disease is passed by almost everyone in infancy or childhood. Although the deaths from measles sometimes reach large totals--in London during the spring of 1894 they were in some weeks as high as one hundred and fifty--yet it is the common experience of practitioners that a strong or healthy child rarely dies of measles, that the fatalities occur among the infants of weakly constitution, and especially in the numerous families of the working class in the most populous centres of mining, manufactures and shipping.
To bring these various characteristics of measles together in a concrete instance, I shall give briefly the facts of a recent epidemic in a town in Scotland of some twelve thousand inhabitants. There had been only five deaths from measles for two years. There had not been a case of smallpox for at least ten years. The measles epidemic, when its triennial opportunity came, reached a height in July, on a certain day of which month there were seven or eight burials from measles or its direct sequelae. Nearly all the children in the place who had not been through the measles in the corresponding epidemics of 1889 or 1887 suffered from it on this occasion, excepting the class of very young infants. The deaths in the whole epidemic numbered about fifty, which would not all be registered, however, as from measles. Yet this high mortality was not due to any unusual malignancy of the disease, but to the feeble stamina of a certain number of infants, or to the indifferent housing and tending of the poorer class. One did not hear of a death in the well-to-do families (probably there was none), although they had their full share of attacks. The frequency of the burials for a short time, and the effects of the epidemic on the mortality from first to last, must have been very nearly the same as in an epidemic of smallpox a century before, when the population was only a third or fourth part as large. But in the period when smallpox was in the ascendant, having few rivals among the infective causes of death in childhood, the general conditions of health in this town were altogether different. One or two specimens of the thatched huts of the poorer class had been left standing into the era of photography, so that we could compare past with present, in externals at least; also, of the houses of the richer class some still remained, perhaps turned into tenement-houses, with small windows, low doorways, and crow steps on their gables; and it was on record by the parish minister at the end of the 18th century, that within the memory of that generation there had been peat stacks and dunghills before the doors on the High Street of the burgh.
VI. WHOOPING-COUGH
It is singular that a malady so distinctively marked as whooping-cough is should figure so little in the records of disease from former times. Astruc could find no traces of it in the medical writings of antiquity or of the Arabian period. In modern times the first known account of an epidemic of it is under the year 1578, when Baillou of Paris included a prevalent convulsive cough as part of the epidemic constitution of that year, remarking in the same context that he knew of no author who had hitherto written of the malady[1234]. Yet, if whooping-cough had been as common in former times as it has been in quite recent times, it deserved a high place among the causes of infantile mortality. Doubtless it occurred in former times in the same circumstances in which it occurs now. Baillou in 1578 speaks of it as a familiar thing; and it can be shown from an English prescription-book of the medieval period that remedies were in request for a malady called “the kink,” a name which survives in Scotland (like other obsolete English words of the 15th century) in the form of “kink host[1235].”
In Phaer’s Booke of Children (1553) chincough is not named. It is perhaps more singular that the disease should be omitted from the list in Sir Thomas Elyot’s Castel of Health (1541), of maladies proper to three periods of childhood; for that list has every appearance of being an exhaustive enumeration[1236]. Still, it would be erroneous to suppose that the convulsive cough of children which is so common an epidemic incident in our time, and in some impressionable subjects is the almost necessary sequel of a coryza or catarrh, did not then occur in the same circumstances as now. When Willis, in his Pharmaceutice Rationalis of 1674, remarks that pertussis was left to the management of old women and empirics, he suggests the real reason why so little is said of it in the medical compends. Sydenham mentions it twice, and on both occasions in a significant context. Under the name of pertussis, “quem nostrates vocant Hooping Cough,” he brings it in at the end of his account of the measles epidemic of 1670, without actually saying that it was a sequel of the measles. His other reference to it, under the name of the convulsive cough of children, comes in his account of the influenza of 1679. In both contexts it is adduced as an instance of a malady much more amenable to bloodletting than to pectoral remedies, the depletion being a sure means of cutting short an attack that was else very apt to be protracted, if not altogether uncontrollable[1237]. One glimpse of it we get among the children of a squire’s family in Rutlandshire in the summer of 1661. On the 26th of May the mother of the children writes to her husband then on a visit to London[1238]:
“I am in a sad condition for my pore children, who are all so trobled with the chincofe that I am afraid it will kill them. There is many dy out in this town, and many abroad that we heare of. I am fane to have a candell stand by me to goo in too them when the fitt comes.” On 2 June, the children are still “all sadly trobeled with the chincofe. Moll is much the worst. They have such fits that it stopes theare wind, and puts me to such frits and feares that I am not myselfe.” In a third letter, the children “are getting over the chincofe. I desire a paper of lozenges for them”; and on 30 June, the children are better, but the smallpox is still in the village. It was probably from the latter disease that many were dying.
In Dr Walter Harris’s Acute Diseases of Infants[1239], the convulsive or suffocative coughs are mentioned in one place without being identified as chincough, while in two or three other places the malady is briefly referred to under its name. Thus, “corpulent and fat infants troubled with defluxions, and having an open mould, are most subject to the rickets, chincough, king’s evil, and almost incurable thrushes.” Again, chincough of infants is one of the inflammatory diseases that are “not altogether free from contagion”; and again: “Albeit that any notable translation of the subject matter of the fever into the lungs, and chincoughs, do advise bloodletting for the youngest infants, yet it is most evident that it is not a remedy naturally convenient for them.... And therefore its help is not to be invoked for all the diseases of infants except in the chincough or any other coughs that do attend and are concomitants of fevers that do suddenly begin”--showing his deference to Sydenham, his master.
Probably the “any other coughs” are those that he thus describes in another place (p. 26):
“Moreover he is often troubled with a slight, dry cough, though sometimes it is strangling and suffocative: with a dry cough because of the sharpness and acrimony of the humours that continually prickle the most sensible branches of the windpipe; but the choaking doth proceed from the abundance of serous and watry humours that so fill up and burden the small vesicles of the lungs that it cannot be cast off and discharged. But also they being endued with a great debility and weakness of nerves, and a superlative softness and delicacy of constitution, they are not able to subsist with that violent trouble of coughing, but do succumb under that unnatural and excessive motion of their breast, and their face is blackish as that of strangled people.”
These were cases of whooping-cough, although they are not so called. Among his eleven cases, Harris gives two in infants of the Marquis of Worcester; one had been “very often troubled with an acute fever,” and was found to be much weakened by a chincough when the physician was called to him; the other, an infant of eleven months, had at the same time an acute fever “and a cough almost convulsive.”
This inclusion, under the generic name of cough, of cases that had all the signs of whooping-cough, namely, the paroxysmal seizures, choking fits, and blackness of the face, is found also in the London bills of mortality. Although “coughs” are entered as the cause of a not very large number of deaths in the earlier annual bills, with an occasional special mention of whooping-cough among them, it is not until 1701 that “hooping cough and chincough” becomes a separate item, with six deaths in the year; next year the entry is “hooping cough” alone, with a single death, and so on for a number of years in which the deaths are counted by units; in 1716 they rise to eleven, and continue to be counted by tens until 1730, when 152 deaths are set down to “cough, chincough, and whooping-cough.” It would be a mistake to suppose that these figures during the first thirty years of the 18th century are anything like a correct measure of the number of infants in London who suffered from whooping-cough, or are at all near the number who might have reasonably been returned as dying from it. It was in that generation that the entries of the Parish Clerks became most indefinite as to the causes of death in infants, five-sixths of the enormous total of deaths under two years being entered under the generic head of “convulsions” and “teeth,” while the item “chrysoms” received the deaths under one month old.
The increase of whooping-cough in the following table, from units to tens, from tens to hundreds, and thereafter to a somewhat steady total of hundreds year after year, can hardly be explained except on the hypothesis of more exact classification of infantile deaths, corresponding to the actual decline of the article “convulsions” in the second half of the century.
Years Whooping-cough
1701 6 1702 1 1703 5 1704 0 1705 0 1706 2 1707 3 1708 3 1709 1 1710 5 1711 7 1712 3 1713 6 1714 6 1715 7 1716 11 1717 15 1718 24 1719 17 1720 33 1721 20 1722 21 1723 38 1724 25 1725 53 1726 37 1727 67 1728 21 1729 35 1730 152 1731 33 1732 65 1733 97 1734 139 1735 81 1736 130 1737 160 1738 69 1739 72 1740 280 1741 109 1742 122 1743 92 1744 46 1745 135 1746 95 1747 151 1748 150 1749 82 1750 55 1751 275 1752 188 1753 65 1754 336 1755 93 1756 199 1757 239 1758 84 1759 227 1760 414 1761 197 1762 300 1763 291 1764 251 1765 225 1766 213 1767 364 1768 262 1769 318 1770 218 1771 249 1772 385 1773 235 1774 554 1775 206 1776 181 1777 529 1778 379 1779 268 1780 573 1781 165 1782 78
(Continued in the table of measles deaths, p. 655)
It is not without significance that the vital statistics of Sweden were the first to give whooping-cough something like its rightful place among infantile causes of death: from 1749 to 1764 the deaths set down to that cause were 42,393, or an annual average of 2600, the epidemic year 1755 having 5832. In this we should find merely the influence of systematic nomenclature. Nosology, or the scientific classification of diseases, may be said to have begun under Linnaeus, who was for many years professor of medicine at Upsala before he became professor of botany, and was teaching a somewhat rudimentary nosology to the Swedish students of medicine before the great work of his friend and correspondent Sauvages made classifications general.
Concerning the year 1751, which has 275 deaths from whooping-cough in the London bills, Fothergill writes in May: “Great numbers of children had the hooping cough, both in London and several adjacent villages, in a violent degree. Strong, sanguine, healthy children seemed to suffer most by it; and to some of them it proved fatal where it was neglected or improperly managed”--the deaths having become more numerous towards the end of the year[1240]. At Edinburgh, during the second year of high mortalities in the famine-period 1740-41, whooping-cough has 101 deaths to 112 from measles, having had only a fourth part as many the year before (see p. 523). In the Kilmarnock register from 1728 to 1763, “kinkhost” is credited with a total of 116 deaths, about 3 on an annual average, measles having a total of 93 during the same thirty-six years. In Holy Cross parish, a suburb of Shrewsbury, chincough has 9 deaths in the ten years 1750-60, and 6 in the next ten years, measles having 4 and 15 in the respective periods, and convulsions 9 and 31. In Ackworth parish, chincough has no deaths in the ten years 1747-57, and 2 in the next ten years, “infancy” having 13 in each decade, “convulsions” and measles none in the first, 6 and 2 respectively in the second. Warrington, in the disastrous smallpox year, 1773, had 16 deaths from chincough and 34 from convulsions. In the two years 1772 and 1773, Chester had 33 and 10 deaths from chincough, 70 and 69 from convulsions, 17 and 13 from “weakness of infancy.”
Watt’s researches in the registers of all the Glasgow burial-grounds brought out the fact that whooping-cough during a period of thirty years, 1783 to 1812, had been a common and somewhat steady cause of death among infants, having made 4·51 per cent. of the annual total of deaths at all ages in the first six years of the period, and 5·57 per cent. in the last six years[1241]. This was a higher annual average ratio than in the London bills for the same period (see the tables at p. 647 and p. 655), and was probably the maximum in Britain, inasmuch as the Glasgow death-rate of infants was the worst from all causes.
Whooping-Cough in Modern Times.
When the causes of death began to be registered, in July, 1837, whooping-cough was found to have the following relative place among the principal maladies of children during the latter six months of the year in London and in all England and Wales.
Mortality by diseases of Children, last six months of 1837.
London England and Wales
Convulsions 1717 10729 Measles 1354 4732 Whooping-Cough 1066 3044 Smallpox 763 5811 Scarlatina 418 2550
Throughout the whole registration period, whooping-cough has kept its place steadily among the chief causes of infant mortality, neither decreasing nor increasing notably in the successive periods from 1837 to the present time. Its mortality has varied a good deal from year to year, owing to occasional great epidemic years such as 1866 and 1878; but on the mean annual average of decennial periods, it has varied little:
Annual Deaths by Whooping-cough per million living at all ages.
Males Females Both sexes
1851-60 460 545 503 1861-70 487 566 527 1871-80 474 547 512 1881-90 -- -- 451
No other epidemic malady has shown the same excess of female deaths in proportion to the numbers of the sex living, diphtheria being the only other that shows an excess at all.
The excess of deaths by whooping-cough among female infants was roughly shown by Watt in 1813, viz. 975 females to 842 males in the registers of the Glasgow High Church, College Church and the North-Western Cemetery, the relative numbers of the sexes living at the respective ages being then unknown. In all Scotland in 1889 the ratio was 1043 male deaths to 1225 female. The singular difference between the sexes in this respect is almost certainly related to the corresponding differences in the formation and development of the larynx, the organ which gives character, at least, to the convulsive cough of children. The expansion of the larynx in boys, which becomes so obvious at puberty and remains so distinctive of the male sex, is one of those secondary sexual characters which begin to differentiate quite early in life, and are probably congenital to some extent. It is not known whether female children are more often attacked than males; but it is probable that they are predisposed both to acquire coughs of the convulsive suffocative kind and to have their lives shattered by the attack--for the same anatomical and physiological reasons, namely, the imperfect development of the posterior space of the glottis with the spasmodic closure by reflex action[1242]. The deaths have been nearly all under the age of five.
Deaths by Whooping-cough per million living at the respective age-periods.
0-5 5-10
1851-60 3624 174 1861-70 3766 152 1871-80 3652 135
These proportions are almost the same as those given by Watt in 1813 from three of the Glasgow registers.
Deaths by Period whooping-cough Under five Five to ten Above ten
1783-1812 1817 1713 98 3
Most of the deaths are in the first year, and in a rapidly declining ratio until the fifth, according to the following rates per million of male children living at each age-period (these figures are for a single year, 1882):
Under one One to two Two to three Three to four Four to five
3039 2115 826 433 248
The mortality from whooping-cough falls very unequally on town and country. Thus, in Scotland in 1889, it caused 2268 deaths, being 3·13 per cent. of the deaths from all causes, and equivalent to a rate of ·58 per 1000 living. The death-rate varied as follows: ·91 in the eight principal towns, ·46 in the group of large towns, ·45 in the group of small towns, ·25 in the mainland rural districts, and ·08 in the insular rural districts. In England, the capital has more than its share of deaths from whooping-cough, Lancashire coming next, while the death-rates of Monmouthshire, Cornwall and Warwickshire are also a good deal above the mean of the whole country. The lowest death-rates are found in the purely agricultural counties.
During the last half-century there has been a decline in the death-rate from all causes, including the infectious diseases as a group; but it can hardly be said that whooping-cough has had a due share in this decline. Notably in Ireland, where the decline of infectious disease has been most marked, it has been, as it were, pushed to the front of its class by the shrinkage of the other items. In Scotland it is now decidedly at the head of the list, and in England it has shared the first place with measles since the great diminution of scarlatina deaths.
Annual average Death-rates per 100,000 living.
Whooping-cough Measles Scarlatina
England { 1871-80 51·2 37·7 71·6 { 1881-90 45·1 44·1 33·8
Scotland { 1871-80 63·1 37·0 79·5 { 1881-90 60·7 38·3 28·8
Ireland { 1871-80 34·8 21·0 43·5 { 1881-90 28·5 19·2 20·8
There is a small decrease in the death-rate of whooping-cough within the last decennial period, whereas in that of measles there is a slight increase (except in Ireland). The comparative steadiness of whooping-cough among the causes of death is doubtless owing to the fact that the bulk of its fatalities are among infants, and that there appears to be an irreducible minimum of the deaths from all causes at that age-period.
Whooping-Cough as a Sequel of other Maladies.
Although it is convenient to group whooping-cough among the infectious diseases, and although it is a clear case of a malady that comes in epidemics, yet its pathology is peculiar. It seems to be more a sequel of other diseases than an independent or primary affection. The whoop of the breath, from which it is named, is really proper to any convulsive cough of some infants or children. Adults, having undergone the change in the form and relative size of the larynx at puberty, have the convulsive cough usually without the whoop if they have it at all. After the successive influenzas of recent years (1889-92), many adults suffered from convulsive paroxysmal cough which was whooping-cough in all respects but the whoop, the choking fits, the blackness of the face, and the vomiting being, of course, all kept in subjection by the greater control of adults over their reflex actions.
It has been often remarked that the ordinary whooping-cough of children has followed epidemics of influenza, or widely prevalent catarrhs. Thus, Hillary records in July, 1753, an epidemic of whooping-cough, or “the fertussis,” all over the island of Barbados following the epidemic catarrh which was at a height in January of the same year. Whooping-cough had not been known in the island for many years past, “neither could I find by the strictest inquiry that I could make that any child or elder person did bring it hither[1243].” Willan, in his corresponding records of the succession of diseases at the Carey Street Dispensary, London, from 1796 to 1800, has the following:
“There was also among infants and children during the month of January [1796], an epidemic catarrh attended with a watery discharge from the eyes and nostrils, a frequent though slight cough, a shortness of breath, or rather panting, a flushing of the cheeks, great languor with disposition to sleep, and a quick small irregular pulse.... It was succeeded in February by the hooping cough.”
Measles, which is usually a catarrhal malady, has undoubtedly been followed by whooping-cough in many individual cases and in epidemics as a whole; and it may be that there is a closer association of whooping-cough with measles than with any other infectious disease. In the table on p. 647, the deaths by whooping cough in London from 1731 to 1830 have been reduced to ratios per cent. of the deaths from all causes, in a parallel column with the ratios of measles; it will be seen that the increase of both is equally remarkable towards the end of the table. But the Glasgow ratios abstracted by Watt show no such decided increase of whooping-cough from 1783 to 1812, side by side with the astonishing increase of measles; while his annual bills for the same period show that there were many deaths from whooping-cough in Glasgow for years before measles began to replace smallpox or to divide the mortality with it. The first high monthly mortalities from whooping-cough in Watt’s bills were from November, 1785, to the end of 1786; but there had been so little measles for twenty-four months before that epidemic began, that only one death from it is recorded all the time. Again, the great measles epidemic of 1808 in Glasgow was indeed followed by many deaths from whooping-cough in 1809; but, while the height of the measles epidemic was in May and June, 1808, it was not until April, 1809, that whooping-cough began to cause many deaths.
Glasgow: Deaths by measles and whooping-cough.
Whooping-cough Measles
1807 Nov. 18 2 Dec. 18 1
1808 Jan. 10 2 Feb. 20 2 March 12 5 April 18 71 May 9 259 June 9 260 July 2 118 Aug. 2 32 Sept. 2 22 Oct. 2 10 Nov. 4 4 Dec. 2 2
1809 Jan. 7 4 Feb. 6 4 March 7 2 April 16 1 May 22 4 June 25 4 July 22 6 Aug. 15 2 Sept. 35 4 Oct. 23 1 Nov. 36 2 Dec. 45 10
1810 Jan. 33 4 Feb. 32 4 March 19 3
Whatever correspondence or relation there may be between measles and whooping-cough, (and it has been remarked by many in the ordinary way of experience), it eludes the method of statistics[1244]. As for the catarrhs of infants and children other than those which are part of the actual attack of measles or influenza, they are so common from year to year, and even from month to month, (perhaps coincident with teething, or with chicken-pox or other slight febrile disturbance), that a statistical study of whooping-cough in relation to them could lead only to an empirical, and possibly bewildering, result. It may be more useful to consider the antecedent probability of some such relationship, arising out of the pathology of the convulsive cough.
Whooping-cough is not only a paroxysmal cough coming on in convulsive fits at intervals, but the paroxysms, as they recur for many weeks, or, as they say in Japan, “for a hundred days,” have none of the obvious occasions of coughing, such as catarrh of the mucous membrane, congestion of the lungs from hot or close air, irritation of the bronchial tubes from dusty particles or vapours, or the presence of tubercles in the substance of the lungs. Such irritants can, indeed, produce whooping-cough, as in the following instance of “artificial chincough” related by Watt:
Two children having quarelled in their play, one of them thrust a handful of sawdust into the mouth of the other. Some of the sawdust passed into the windpipe. After a short time the child began to have violent convulsive fits of coughing, in which the whoop was very distinctly formed. Expectoration in the course of a few hours removed all the irritation, and the coughing thereupon ceased.
But in natural or ordinary whooping-cough there is no mechanical irritation, there is nothing to cough up, the reflex action, violent and paroxysmal though it be, has apparently no motive. I have, in another work, offered an original explanation of the paroxysmal cough of children as being the deferred reaction, the postponed liability, the stored-up memory, of some past catarrhal or otherwise irritated state of the respiratory organs, to which I refer without attempting to summarize it here[1245].
The epidemicity of whooping-cough presents no more difficulty if the malady be viewed as the sequel or dregs of something else than if it be taken for an independent primary affection. The many infants and children that suffer from it together may have equally been suffering together from one or other of the various things of which it is assumed to be the sequel--influenza, measles, sore-throat, the bronchitis of rickets, simple bronchial catarrh of the winter, simple coryza. Again, it may be a secondary or residual affection with many, but a communicable disease to others. Much of the whooping-cough of an epidemic is believed by good authorities, such as Bouchut and Struges[1246], to be simply mimetic, or a habit of coughing acquired by hearing other children coughing in a particular way, just as chorea is sometimes acquired in schools or hospital-wards through the mere spectacle of it. But it may be doubted whether much of the whooping-cough which swells the bills of mortality is acquired in that way. The children that die of it are probably most of them such as had only escaped dying of the measles or other infective disease, or of the non-specific catarrh, which had preceded the whooping-cough.