Is Scarlet Fever One Disease? or Two? or Three?

During the Regency era, scarlet fever was generally recognized as having two forms: a simple version characterized by a mild fever and skin rash, and a malignant version, identified by a high fever and pockets of ulceration in the throat. The latter form was quite dangerous and often fatal, as indicated by Dr. William Buchan, a physician who wrote about diseases and their treatments for the general public.¹ Dr. Buchan made it seem so straightforward, but, in truth, Regency doctors were confused about the nature of scarlet fever.

Of course, we must remember that the germ theory of disease was not understood during the early 1800’s, which fact sometimes made practitioners twist themselves into pretzels as they tried unraveling the puzzle of scarlet fever. They were at a loss to explain why some children suffered a rash and recovered within two or three days while others developed the dreaded ulcerated sore throat and died on day 4 or 5 or even later, on day 8 or 11. It was a mystery.

17th-Century View of Scarlet Fever

The 17th-century physician Thomas Sydenham (1624-1689) has been called “The English Hippocrates” and “The Father of English Medicine.” He believed that diseases could be classified according to type, in the way that animals and vegetables are sorted. About scarlet fever he wrote that it was “nothing more than a moderate effervescence of the blood, occasioned by the heat of a receding summer.”² Other physicians believed scarlet fever was the same disease as measles or that it was akin to erysipelas,³ a skin infection often caused by the bacterium Streptococcus pyogenes.

18th-Century View of Scarlet Fever

William Withering (1741-1799), an English physician, botanist, chemist, geologist, and the discoverer of digitalis, saw many cases of ulcerated sore throat and had trouble separating the throat ulcers found in scarlet fever (then called Scarlatina anginosa) from those found in the putrid, ulcerated sore throat (called Angina gangrænosa).⁴ Intrigued by their similarities, Withering developed a table comparing the two diseases on such aspects as the season in which they occurred, what the rash looked like, and whether the throat and tonsils were inflamed.⁵ In the end he concluded that Scarlatina anginosa and Angina gangrænosa were one and the same disease and “owed their existence to the same specific contagion”⁶—a remarkable statement considering the germ theory of disease did not take root until the 1880’s.

Early 19th-Century View of Scarlet Fever

By the turn of the new century physicians were determined to figure out whether scarlet fever and the malignant, putrid, ulcerated sore throat were different diseases or only varieties of the same disease. Dr. Wilson Philip, physician to the Worcester Infirmary, classified scarlet fever among the contagious diseases, a group that included small-pox, chicken-pox, measles, the plague (how very interesting!), nettle-rash and scarlet fever.⁷

When Dr. Philip published his book in 1813, the disease scarlet fever (also known as scarlatina) was divided into two varieties: Scarlatina simplex and Scarlatina cynanchica. He learned from a colleague, who had encountered six or seven scarlet fever epidemics over the course of his career, that the disease nearly always appeared as Scarlatina cynanchica, which presented with ulcerations of the throat.⁸ Dr. Philip concluded that “true scarlet fever is a very mild disease. It is only in proportion as it partakes of the nature of the cynanche maligna that it becomes dangerous.”⁹ Thus, Dr. Philip argued for there being two forms of scarlet fever: mild and dangerous. (Cynanche refers to a severe sore throat.)

In 1814 Dr. Thomas Bateman published a treatise on cutaneous diseases, in which he described three varieties of scarlet fever.¹⁰ The first, Scarlatina simplex, consisted of a rash with a moderate degree of fever. The second variety—Scarlatina anginosa—presented with a more violent fever and ulcerations of the throat, along with a skin rash. The third variety, Scarlatina maligna, was the most severe, being characterized by high fever, early delirium, and numerous ulcers in the throat. With Scarlatina maligna the result was often “a fatal termination” in the second or third week.

Scarlet Fever: It’s One, No Two, No Three Diseases!

Over a period of some 160 years, physicians’ understanding of scarlet fever changed from considering it one disease—and a mild one at that!—in the 17th century, to classifying it as two distinct diseases in the 18th century, to identifying it as two or three varieties of the same disease in the early 19th century. It was not until the early 20th century that the bacterium that causes scarlet fever—streptococcus pyogenes—was confirmed.

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Sources:

¹Buchan, William. Domestic Medicine. (Boston, 1811), p. 189.

²Rush, Benjamin. The Works of Thomas Sydenham, M.D., on Acute and Chronic Diseases. (Philadelphia, Benjamin & Thomas Kite, 1809), p. 177 (PDF p. 224).

³Withering, William. An Account of the Scarlet Fever and Sore Throat; or Scarlatina Anginosa: Particularly as It Appeared at Birmingham in the Year 1778, 2nd ed. (London: G.G. & J. Robinson, 1793), pp. 28-51 (PDF pp. 33-56).

⁴Ibid., pp. 1-12 (PDF pp. 6-17)

⁵Ibid., p. 56 (PDF p. 61).

⁶Ibid., p. 5 (PDF p. 10).

⁷Philip, A. P. Wilson. A Treatise on Febrile Diseases, including The Various Species of Fever, and All Diseases Attended with Fever. (London: Thomas Underwood, 1813), p. 370 (PDF p. 391)

⁸Ibid., p. 456 (PDF p. 477).

⁹Ibid., p. 466 (PDF p. 487).

¹⁰Bateman, Thomas. A Practical Synopsis of Cutaneous Diseases, 3rd ed. (London: Longman, Hurst, Rees, Orme, and Brown, 1814), pp. pp. 69-87 (PDF pp. 106-124).