1802. It ceased in summer, but returned at intervals during the years

1803-4, when the disease changed its character; and although scarlatina epidemics recurred very frequently during the next twenty-seven years, yet it was always in the simple or mild form, so that I have known an instance where not a single death occurred among eighty boys attacked in a public institution. The epidemic of 1801-2-3-4, on the contrary, was extremely fatal, sometimes terminating in death (as appears by the notes of Dr Percival kindly communicated to me) so early as the second day. It thinned many families in the middle and upper classes of society, and even left not a few parents childless. Its characters seem to have answered to the definition of the scarlatina maligna of authors.” The long immunity from malignant scarlatina which Graves asserts for Ireland after 1804, is made probable also for England and Scotland after 1805, by the fewness of the references to it in medical writings. Bateman in 1804 resumed the regular reports on the prevalent diseases of London, which Willan had left off at the end of 1800, and continued them until 1816[1335]; but he makes very few references to scarlatina compared with his predecessor. The two occasions when it is said to have been somewhat common were in 1807-8, during the severe epidemic of measles (and then it was “generally mild, presenting the eruption with a slight sore-throat”), and in 1814 when it was “very prevalent” along with measles. In Scotland during the same epidemic of malignant measles, in 1808, scarlatina was only occasional, and mild. It is heard of in its old malignant form from two localities of England, during the time of distress and typhus fever in 1810-11. At Nottingham it was “very prevalent, passing through whole families,” in September, 1810, and in October became more violent and often fatal[1336]. In the district around Debenham, in Suffolk, where it was last reported by the same observer in 1803, it made its appearance in February, 1810, in its very worst forms, causing deaths of children and adults in many houses, and destroying some children within forty-eight hours from the first attack. “All the surgeons for ten miles round have had to attend to scarlatina maligna in a variety of cases in all ages, from infants to fifty and sixty years.” It was still raging in October, 1810, and was breaking out “in different spots around this country, that appear to have had no communication with the afflicted[1337].” It is not until 1831 that we begin to hear much of malignant scarlatina again. But it is clear that scarlet fever was common enough all through that interval, probably in its milder form. It was now the usual epidemic trouble of schools. In September and October, 1814, there were fifty-five cases, mostly mild, in children and two in adults in the Asylum for Female Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal Military College at Marlow, having been followed by anasarca in only one instance[1339]. Heysham, whose exact records of epidemics at Carlisle were made twenty or thirty years earlier, mentions casually in 1814 that scarlet fever had been “more frequent of late,” but that it did not spread as formerly[1340]. Other references to it in this interval are to show how seldom fatal it was under the cold water treatment or the lowering regimen[1341]. At the Newcastle Dispensary fully twice as many cases of scarlatina were attended in the twenty-five years 1803-27 (795 cases) as in the twenty-five years 1777-1802 (355 cases); but in the larger total, which an increasing population might account for, there were actually fewer fatalities (30) than in the smaller (33); the highest number in any one year was 71 in 1824, of which every one is entered as having recovered. This is the impression derived from various sources--that the scarlatina from about 1803 until about 1830 may have been frequent, but that it was mild, or easily treated, or not often fatal. Macmichael, writing in 1822, not only testified that the “scarlatina of last summer was very mild,” but argued that the malady in general was taken by many in those years in so mild a form that it was not recognized as scarlatina, “a name that sounds so fearfully in the ears of mothers,” and a rare disease in families compared with measles or even with smallpox. His point is that scarlet fever was in fact as nearly universal as measles, but that, as it was often extremely slight, it passed for rose rash or the like; at the same time he identified these slighter forms with true scarlatina by simply pointing to the oedema which might follow them[1342]. The testimony of Graves, of Dublin, who occupies many pages of his ‘Clinical Medicine’ with the disastrous scarlatina in various parts of Ireland about 1834, is conclusive that the severe type was new in the experience of that generation: “I have already mentioned that the disease called scarlet fever assumed a very benign type in Dublin soon after the year 1804, and continued to be seldom attended with danger until the year 1831, when we began to perceive a notable alteration in its character, and remarked that the usual undisguised and inflammatory nature of the attack was replaced by a concealed and insidious form of fever, attended with great debility. We now began occasionally to hear of cases which proved unexpectedly fatal, and of families in which several children were carried off; still, it was not until the year 1834 that the disease spread far and wide, assuming the form of a destructive epidemic[1343].... Many parents lost three of their children, some four, and in one instance which came to my knowledge, five very fine children were carried off.” The severe cases were mixed with others of scarlatina simplex. The violence of the attack lay in the throat-affection, the congestion of the brain, or the irritability of the stomach and bowels, nausea, vomiting and diarrhoea being early symptoms, as in the malignant sore-throat with rash a century before. Graves proceeds, with much candour, to show how mistaken had been the reasons assigned equally for the mild type of scarlatina between 1804 and 1831 and for the severe type of it previous to 1804: “The long continuance of the period during which the character of scarlet fever was either so mild as to require little care, or so purely inflammatory as to yield readily to the judicious employment of antiphlogistic treatment, led many to believe that the fatality of the former epidemic was chiefly, if not altogether, owing to the erroneous method of cure then resorted to by the physicians of Dublin, who counted among their numbers not a few disciples of the Brunonian school; indeed, this opinion was so prevalent, that all those whose medical education commenced at a much later period, were taught to believe that the diminished mortality of scarlet fever was entirely attributable to the cooling regimen and to the timely use of the lancet and aperients, remedies interdicted by our predecessors. This was taught in the schools, and scarlet fever was every day quoted as exhibiting one of the most triumphant examples of the efficacy of the new doctrines. This I myself learned--this I taught: how erroneously will appear from the sequel. It was argued, that had the cases which proved fatal in 1801-2 been treated by copious depletion in their very commencement, the fatal debility would never have set in, for we all regarded this debility as a mere consequence of previous excessive reaction. The experience derived from the present [1834-35] epidemic has completely refuted this reasoning, and has proved that, in spite of our boasted improvements, we have not been more successful in 1834-5 than were our predecessors in 1801-2.” From 1829 to 1833 there are numerous references to the scarlatina maligna in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in 1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346] in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348] in 1832-1833. It is in 1830 that scarlet fever begins to have a line to itself in the old and inadequate bills of the Parish Clerks of London, the deaths that year being 94; in the next seven years they are 143, 388, 481, 523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths from it in Glasgow[1349] for five years, during which they fell much below the deaths from either measles or smallpox. _Deaths from Scarlatina in Glasgow._ Under one 1-2 2-5 5-10 10-20 20-30 30-40 40 and up. Total 1835 27 50 89 73 23 7 2 2 273 1836 34 57 136 86 25 9 5 3 355 1837 4 9 34 22 5 3 1 1 79 1838 3 15 42 17 7 1 1 1 87 1839 29 45 104 74 10 -- -- -- 262 The two first years of this period, which had the most scarlatina deaths, correspond to the years of the Dublin epidemic, and were also the years when it was common in Edinburgh[1350]. Probably the smaller mortality of Glasgow in 1837 and 1838 was general; for, when registration of the causes of death began in England and Wales in the latter half of 1837, it found the scarlatina mortality at a much lower figure than it reached in 1839 and continued to keep thereafter. Scarlatina since the beginning of Registration, 1837. The first returns of the causes of death under the new Registration Act happened to correspond with a great epidemic of typhus fever, and with an equally great epidemic of smallpox which took its victims in largest part among infants and young children. The deaths from scarlatina were also considerable during those two years and a half; but in 1840 scarlatina nearly doubled its mortality, and continued year after year for a whole generation to be the leading cause of death among the infectious maladies of childhood. The figures for England and Wales are given in a table at p. 614, in comparison with the annual deaths by smallpox, measles, and diphtheria. The enormous number of deaths from scarlatina during some thirty or forty years in the middle of the 19th century will appear in the history as one of the most remarkable things in our epidemiology. There can be no reasonable doubt that this scarlatinal period was preceded by a whole generation with moderate or small mortality from that disease, just as it is now being followed by annual death-rates which are less than a half, perhaps not more than a third, of the average during forty years before 1880. The first great epidemic all over England was in 1840 (it had reached a maximum in London the year before), another came in 1844, a third in 1848 (in which the London death-rate was 2·12 per thousand living). In the next decennial period, 1851-60, the worst years for scarlatina were 1858-59, which were also the years of the return of diphtheria; in the period 1861-70, the great scarlatinal years were 1863-64 and 1868-70; in the period 1871-80, the year 1874 was the epidemic year. The annual average death-rates per million inhabitants in all England and Wales were as follows in four decennial periods: 1851-60 832 1861-70 972 1871-80 716 1881-90 338 In the greatest epidemic years since 1863 the death-rates per million for the whole country have been: 1863 1498 1864 1443 1868 1020 1869 1275 1870 1461 1874 1062 In those years scarlatina made from four to six and a half per cent. of the deaths from all causes. While no county of England has been free from this infection, the bulk of the deaths have fallen upon the capital, the great Lancashire and West Riding towns, the Black Country of Staffordshire with Warwickshire, the mining districts of Durham and South Wales, and, in the earlier part of the period, upon the south-western counties. _Highest Mortalities by Scarlatina in three Epidemics._ /-----------\ /-----------------\ 1863 1864 1868 1869 1870 1874 England and Wales 30475 29700 21912 27641 32543 24922 ------------------------------------------------------------------- London 4955 3244 2916 5841 6040 2648 Lancashire 4580 4854 4445 4890 3702 6404 West Riding 2218 3135 1676 2870 3718 3779 Durham 1216 403 2678 1512 983 1941 South Wales 501 1990 285 804 1370 1388 Staffordshire 1147 1134 943 1198 1064 1270 Devonshire 778 1054 60 155 646 72 Cornwall 995 572 254 161 587 50 Somerset 773 1013 55 154 584 173 In Lancashire and South Staffordshire there has been less fluctuation of the mortality from year to year than elsewhere. The stress of an epidemic has not fallen equally on all the principal centres in the same year or years: thus Durham has had the epidemic in advance of other centres, while South Wales has had it in arrear. The decline of the south-western counties from their leading position in 1863-64 has been remarkable. Plymouth, Devonport and Stonehouse, which had contributed most to the high scarlatinal death-rate of Devonshire in 1863-64, were found on the average of the next decennial period to have low rates from scarlatina, but death-rates from measles which were unapproached in any other region of England. In the following table four Devonshire towns are compared with certain Staffordshire registration districts in which the scarlatinal death-rate has remained high. _Annual average Death-rates per 1000 living, 1871-80._ All causes Scarlatina Measles {Plymouth 22·63 ·25 1·13 {E. Stonehouse 28·23 ·33 1·79 {Stoke Damerel 20·42 ·37 1·19 {Exeter 24·99 ·50 ·82 {Stoke-on-Trent 25·80 1·22 ·49 {Wolverhampton 22·78 1·05 ·35 {Walsall 22·82 1·21 ·30 {Dudley 24·24 1·18 ·59 This looks like a correlation between measles and scarlatina. The excessive death-rate from measles in Plymouth, Stonehouse and Devonport was due to a disastrous epidemic in the last two years of the decennium, 1879 and 1880 (338 deaths at Plymouth, 121 at Stonehouse, and 235 at Devonport). Measles remained high in Plymouth all through the next decennium, scarlatina still continuing low until the very end of it, when in 1889 there was a mortality of 270, equal to a death-rate of 3·39 per 1000 living. In like manner Stoke-on-Trent had its great epidemic of measles in 1888, causing 342 deaths, or a rate of 2·8. The high Plymouth death-rate, after nearly twenty years with extremely little scarlet fever, was surpassed in 1882 by an epidemic of 346 deaths in the colliery townships of Aberystruth and Tredegar, Monmouthshire, equal to a death-rate of 6·1 per 1000. Other high death-rates for single years were at Wakefield and Swansea in 1889 and at Neath in 1890. The highest death-rates from scarlatina on an average of ten years, 1871-80, were at Durham 1·70, Todmorden 1·64, Auckland 1·63, Gateshead 1·60, Sheffield 1·49, Leigh 1·41, Wigan 1·30, Newcastle 1·28. The purely agricultural counties have the lowest death-rates[1351]. As to age-incidence, the proportion of deaths under five has been almost exactly two-thirds steadily for the last four decennial periods (supra p. 625). The following table by Dr Ogle, the Superintendent of Statistics, shows both age and sex of the scarlatina mortality[1352]: _Mean annual Mortality from Scarlet Fever per million living at successive age-periods 1859-85. England and Wales._ Age Males Females 0-1 1664 1384 1-2 4170 3874 2-3 4676 4491 3-4 4484 4332 4-5 3642 3556 0-5 3681 3482 5-10 1667 1613 10-15 346 381 15-20 111 113 20-25 59 77 25-35 36 58 35 and upwards 13 15 All ages 778 717 From certain hospital statistics on a large scale, and some figures of cases and deaths at Christiania, it was also found that the attacks of scarlatina were much more fatal in the first years of life, the fatality decreasing rapidly after five. This was only to be expected. But it was somewhat surprising to find that more girls were attacked than boys, while the fatalities among boys were more than among an equal number of girls at all ages until womanhood, when the few females attacked by scarlatina had more fatalities among them than the somewhat fewer males of the same ages. A slight excess of fatality in the female sex over the male between the ages of ten and twenty years, is shown also for smallpox by the table at p. 618. Recent notifications of infectious diseases to medical officers of health have enabled a comparison to be made between the number of cases of scarlatina notified, with age and sex, and the number of deaths certified in the corresponding time and place to the Registrar-General; from which the above generalities as to the proportions of fatal cases in the several age-periods of either sex have been confirmed[1353]. The enormous mortalities of some years may be taken to have depended in part upon an increased prevalence of the disease, but still more upon an increased fatality among the subjects of it. Since the establishment of the Metropolitan Fever Hospitals in 1870 the percentage of deaths to cases has ranged from 15·3 in 1879 to 6·6 in 1873 and 6·7 in 1891. Among the smaller totals of the London Fever Hospital the percentage of deaths has ranged even more widely from year to year[1354]. What is thus statistically proved is also a matter of common experience; there have been whole epidemics, extending perhaps over two or three years, marked by high malignancy, and epidemics just as uniformly marked by mildness of type. The severe type has usually been made by the sloughing in the neck or throat; but there has also been a class of cases tending to a fatal issue early in the attack by a sunken pulse and with few external manifestations. The cause of these variations in the severity of scarlatina is the old problem of epidemic constitutions: sometimes the constitution is “putrid” or “pestilential” or malignant, sometimes it is mild or benign. Graves, in the passage above cited, has sufficiently exposed the fallacy of attributing changes of type to modes of treatment. On the other hand there is reason to think that the percentage of deaths (by which the “type” is usually judged) is higher in children carried off to hospitals than in those treated at home. As the same fact has been uniformly observed in epidemics of Asiatic cholera, when the ambulances have been almost as busy as those of the Metropolitan Asylums Board during an ordinary autumnal rise of scarlatina, it is probable that the reasons which used to be given in the former case hold good also in the latter. _Scarlet Fever in London, 1890 and 1891._ All Cases Treated Treated in Fatalities Fatalities in Year Notified at Home Hospital at Home Hospital 1890 15330 8793 6537 348 510 or 3·95% or 7·8% 1891 11398 6136 5267 232 357 or 3·8% or 6·8% This is a comparison of two parts of the same epidemic, which had a very moderate fatality in any case. The real problem of malignity or severity of type arises over such epidemics as those of 1840, 1848, 1858-59, 1868-70 and 1874, in which the doubling of the deaths, for one year, or for two or even three consecutive years, had depended less upon an increased number of seizures than upon a higher ratio of fatalities. An explanation for each occasion will have to be sought either in the condition of the patients, or in the inherent properties or external favouring circumstances of the virus. As to the former, the most fatal epidemic years of scarlet fever have not been marked in any such uniform way as the great seasons of typhus or relapsing fever; nor is scarlatina an infection that keeps mainly within the poorer classes. Among factors of the external kind, a rainfall below the average has been thought a relevant thing: thus in the three years 1862-64, the annual average rainfall at Greenwich was only 20·6 inches, the scarlatina death-rate in London for the same years reaching the high figure of 1·33 per 1000 inhabitants; in the next three years, 1865-67, the death-rate fell to ·56 (it would have fallen in any case), while the rainfall reached the very high average of 29 inches; in the three years following, 1868-70, the death-rate reached the excessive annual average of 1·5 per 1000 in London, the rainfall of the same period averaging only 22·3 inches. Thereafter for a number of years the rainfall was moderate and the scarlatina death-rate low; but in the years 1883-87, they were both low together, the scarlatina death-rate of ·26 being lower than it had ever been since registration began[1355]. Although an empirical correspondence between the great scarlatina periods and a series of dry years has not been made out without important exceptions, hitherto unexplained, yet there is a very obvious correspondence between the great rise of scarlatina deaths in London every year and the season of late autumn, which is the season when the ground-water touches its lowest level or begins to rise therefrom to the high water-mark of spring. Of all the curves of seasonal rise and fall constructed by Buchan and Mitchell from the weekly bills of mortality in London from 1845 to 1874, that of scarlatina is the most decided next to that of infantile diarrhoea, the deaths rising in October and November far above the mean line of the year, and falling farthest below the mean in spring and early summer[1356]. This was an old observation--by Sydenham for the scarlatina simplex of that age, by Willan in the end of the 18th century (one or two spring epidemics being remarked upon as exceptional). It is a very curious fact, and one that is as certain (for London at least) as it is curious. Sydenham explained it by the doctrine of his time, that the favouring things were in the human body, namely, some susceptibility of the humours owing to the heat of the preceding summer; but, according to modern views, it should bring scarlatina into the same class with the soil-poisons of enteric fever, yellow fever and cholera, which are believed to become more rife owing to the greater activity of their respective miasmatic viruses when the pores of the ground are occupied to the greatest depth with air in place of water. It would be singular indeed if, after all, we should have to include scarlatina among the miasmatic diseases; for it is an exquisite instance of an infection which is passed from person to person, or by the agency of volatile contagion, or by fomites in clothes, bed-linen, house-furnishings and the like. The controversy which has raged so keenly in the past between contagionists and non-contagionists over the instances of plague, yellow fever and Asiatic cholera, would become still more keen over scarlatina--and be still more confused if it were not stated in more correct terms at the outset. What we all find so hard to learn is, that the one way of infection does not exclude the other. Plague was for the most part a miasmatic infection in the air of a plague-stricken town; but it could be conveyed in clothes or bales, while it was prudent to remain not too long in the company of a plague-patient. In like manner contagion from the person was, as Rush said and Blane confirmed, a “contingency” in yellow fever; and there are some authentic cases of Asiatic cholera which cannot well be explained except on the hypothesis of contact with the persons of those sick or dead of the disease. Scarlatina is more contagious than any of these, because it shows so much on the surface of the body and scatters its infective matter into the atmosphere of a room with the fine scales or dust of desquamation. Still, there are conditions for the contagiousness of scarlatina, just as there are for the rarer event of contagion from the persons of the sick in the plague, yellow fever and cholera. It is a remarkable fact that scarlet fever should ever be sporadic, or that a single case should appear in the midst of a crowded population (as I have seen in a coast town filled with strangers during the herring fishery to the extent of one-half more than its usual numbers), and no other cases follow for months after, although there had been not the smallest attempt at isolation. Every medical practitioner knows, if some laymen and legislators do not, that scarlatina is sometimes highly contagious, and sometimes hardly contagious at all; and who can say whether the mechanical routine of “stamping out” contagion, which certain persons pursue with more zeal than knowledge, may not be the means of turning a mere potency into an actuality? The tact of individuals rather than the grinding machinery of an Act of Parliament is needed in dealing with vagaries such as Willan thus describes: “I have seen in numerous families one child have scarlatina without communicating it to any of the rest; yet, perhaps, in the succeeding autumn, several of them were infected by only passing near a patient recovering from the disease, or by touching those who had a little time before visited some persons affected with it[1357].” There are two special forms of epidemic scarlatina which may prove to be finger-post instances for the general pathology. It happens from time to time in the surgical wards of hospitals for children, where many cases of suppurating diseases (especially of the bones or joints) are aggregated and kept together perhaps for months, that groups of the patients acquire a scarlet rash, or an erysipelatous rash, or a hybrid form of rash, along with the constitutional symptoms of scarlatina. Whether it be from the suppuration, or from the blood of operations, this disease must be reckoned a product of so-called “hospitalism.” It is not without significance that there may be an element of erysipelas in such cases. They are probably cases of “blood poisoning,” in a double meaning of the term--poisoning of the living blood by dead blood or by pus which is closely allied to blood[1358]. The other special kind of epidemic scarlatina is that which has broken out among the inmates of houses supplied with milk from a common source. There have been many such outbreaks, including one most remarkable instance in which a large number of guests at an evening party, who had partaken of cream with strawberries, were shortly thereafter attacked by scarlet fever at their widely scattered homes. There can be no question that milk, or cream, has been the vehicle of scarlatinal infection. The first hypothesis tried was that of scarlatina on the dairyman’s premises; the effluvia of a scarlatinal patient might have become mixed with the milk. In some instances, it was actually shown that there had been a case or cases of scarlet fever among the dairyman’s children; but there were other instances in which that could not be shown, and it was, of course, possible to refer the cases, where they did occur, to a common cause in the milk used at the dairy and in the milk distributed from it. As more and more outbreaks of the kind came to be investigated, it was indeed made probable that the infection had got into the milk from the cow[1359]. Someone threw out the suggestion that the cow suffered from scarlet fever, the sign of it being soreness of the paps. Without taking seriously so random a hypothesis as that, we find much agreement as to the fact that the cows, to which the contaminated milk has been traced, were affected, one or more of them, with sore paps. In some cases the disease of the teats had been admitted to be the same as cowpox; in other cases that has been denied; in a third variety, a cow has had cowpox on one teat and something else on another. It matters little what name be given to the affection of the cow’s paps. All soreness of the skin of the teats has the same effect so far as concerns the purity of the milk. Unless the milk be drawn off by a catheter (according to a German practice), the paps are necessarily made to bleed by being “stripped”; it has been admitted by milkers that the blood, pus, and scabs are apt to become mixed with the milk; and the discharges from the sore paps have actually been seen, by a scientific witness, to trickle over the fingers of the milkers into the milk-pail[1360]. The contamination of the milk which produces scarlatina in those who use it is neither more nor less specific than that. The disease is blood poisoning in the double sense of the term--poisoning of the living blood by dead blood. Blood is a peculiar fluid, and so is milk. When the two come together the result is peculiar. Both are animal fluids that curdle by some peculiar ferment-change in their constituents. Again, milk is peculiar in its property of taking up organic effluvia; thus the milk standing in shallow vessels has been known to acquire the taste and odour of tar from a tarpaulin in the adjoining farmyard. With such properties of the milk, a small quantity of blood or pus in it will go a long way. The one thing that connects the scarlatina of surgical wards in children’s hospitals and the scarlatina of the milk-pail is putrefying blood or pus: the disease is a septic effect of blood, just as a scarlet rash is known to be a toxic effect of very various drugs in peculiarly susceptible subjects. The obviously septic varieties of scarlatina make but an insignificant part of the whole; but they may be finger-post instances. Thus, if we assume that the infection may be miasmatic from the ground as well as contagious from the person, there are certain facts, or suspicions, that will fit the hypothesis of putrefying blood. A theory of scarlatina was put forward in 1871, on the basis of observations near Croydon, that its virus came from the blood and offal of slaughter-houses collected at particular spots to be used as manure[1361]. The first death in a recent small epidemic within the writer’s knowledge was of a school-girl who lived just across the road from a slaughter-house. The septic hypothesis of scarlatina might be made to include other corrupting animal matters. Some practitioners have a suspicion that scarlet fever is bred in the atmosphere of a horse-mews. On the greater scale, others have traced a connexion between the more signal outbreaks of angina maligna and preceding murrains of cattle[1362]. The animal matters which may become toxic to man, in miasmatic or other form, are indeed many. If scarlatinal drug-eruptions are any clue to the mystery of scarlet fever, we need not be surprised to find a somewhat uniform disease-effect produced by a variety of septic agents[1363]. But, in that hypothesis, the refuse of the shambles will merit most attention. This was thought the one great nuisance of London in the sanitary ordinances of Edward III., Richard II. and Henry VII.; it was then considered a danger to health in the measure of its offensiveness to sight and smell, but there may still be dangers from it which are subtle and unperceived. Reappearance of Diphtheria in 1856-59. The memorable outburst of epidemic throat-disease in Britain about the years 1858-59 was part of a sudden uprising of the malady all over the globe--in Europe, America, North Africa, India, China, and the Pacific[1364]. It was only in some parts of France, and of Norway and Denmark, that “diphtheria” had been epidemic in the generation before. Of its novelty to nearly the whole British profession in 1858, familiar as they were with the angina of scarlet fever, there can be no question. Its appearance among diseases coincided with the publication of Darwin’s hypothesis of the origin of species by natural selection; and it was in the terms of that hypothesis that Farr, of the Registration Department, spoke of the phenomenon of diphtheria. New diseases, he said, “are only recognized as distinct species when they have existed for some time. Diphtheria is an example. It obtains a distinct line in the Tables of this year [1859] for the first time”--with a total of 9587 deaths. For four years before that, it had been in a “provisional table” under the names of “diphtheria” and “cynanche maligna”; but in the general table, the deaths under these names had been merged with the scarlatinal deaths. This inclusion for a time of diphtheria under scarlatina could not have been because practitioners had any difficulty in diagnosing the one from the other, but probably because scarlatina anginosa seemed the nearest affinity in the nosological system. Diphtheria in 1858 had no scarlet rash, and yet it was supposed to be the same disease that had made so much commotion in England about the middle of the 18th century: “In Fothergill’s account,” says Farr, “the symptoms are confused by the