Chapter V: Measles (1)

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.”