Field of Science

History of Scarlet Fever : Dancing fever, Civil War and a Revolutionary Scientist

Once upon a time, there was a wicked and vain queen with a strong desire to murder her stepdaughter. However, through a convoluted series of events involving a huntsman, seven dwarves and a handsome prince, the stepdaughter survived. In fact she ended up engaged to the handsome prince. As a wedding present to his new bride, the prince invited the queen to the wedding. A show of forgiveness? Not exactly.
As part of the nights entertainment, the queen is forced to wear a set of red hot iron shoes and dance for the amusement of all the guests. Until she drops dead. The moral of this story?

 Don't f*ck with Snow White.

Whilst this may seem like a cruel and unusual punishment for us, dancing yourself to death was a genuine fear for people when the Snow White legend came into being.
A medieval medic, known as Felix Platerus records a curious case involving a young lady. She appeared to have a supernatural compulsion that forced her to dance. Guards had to attend to her for a whole month to prevet her hurting herself, or others. She danced  until her feet were rubbed raw, and she could no longer stand. And then when she could stand, she started dancing again. A few of the writers of the time make references to Arabic descriptions of "Jumping limbs" and palsy, and a number of writers tended to notice the convulsiveness that characterised these dances.

In northern europe, it was believed to be caused by some form of demonic possession, and sufferers had to pray to St Vitus (the patron saint of dancers) to be relieved of this disease.  In Italy and Greece, it was believed that the cause of the disease was from the bite of a wolf spider. The remedy for this disorder was a frenzied dance which eventually became known as a tarantella.

It was not only these nations that took up dancing as the cure for this disease. In parts of Germany, magistrates employed people to play music for these people, and for others to act as dancing partners. This was to allow them to "dance out" their disease.
Choruses of sufferers roamed the streets. Musicians followed them, attempting to soothe their disease by providing rhythm. The greatest challenge in managing this chorus was ensuring the safety of the people who ended up collapsing from exhaustion.

In Strasbourg 1518, an outbreak of this fever prompted the council to set up a guildhall especially for the dancers, and paid people to dance with them, and others to play music for them. Yet still, many danced themselves to exhaustion, and death. Eventually, the Strasbourg council realised  this treatment was not working. Still unaware of the cause of the disease, and wanting to prevent contagion, the city banned all dancing. The sufferers who still danced in spite of the ban were sent on a pilgrimage to the shrine of St Vitus. Once they arrived they received holy oil, and red shoes.
 These choruses of dances lead to a particular name being ascribed to the disorder-  a Chorea. The literature documenting this disease is so littered with allusion and innuendo that it is difficult to get to the truth of the source of this illness.

And into this quagmire strolls the hero of this particular story. His name was Thomas Sydenham. He was a physician of the practical sort, whose personality and career was wrought in the events of the English civil war.

The English Civil War can be said to have begun with one man.  When King Charles came to the throne, he had high ambitions. He wanted to finish his father's work, to bring unity between Scotland, England and Ireland. Furthermore, he wanted to enter the brutal "Thirty Years" war that had been raging on the continent.
But what was more controversial was how he dealt with parliament. At the time, parliaments control was far less than it was today. It collected taxes, and controlled how they were spent. If the king wanted to use any of that money, he needed to consult with parliament. Charles however, was believed in the king's "Divine Right" to rule over his subjects, and that he should answer to no-one but God himself. Needless to say, there was some friction between the King and his parliament.

One example is when Charles demanded funding for an expensive military campaign on the continent. Parliament, initially supportive of this course of action, questioned him over putting one of his friends in command, instead of more competent individuals. Their fears were confirmed when the war ended in an expensive defeat. When parliament attempted to bring charges against the man responsible, Charles dissolved parliament.
 Such exchanges began to characterise the King's rocky relationship with his kingdom. Charles needed parliament to fund him, but in return they would want a say in how the money was spent.  So the king stopped convening parliament, and attempted to rule the kingdom as an autocracy. He levied new ( and illegal ) taxes upon the populace, as a replacement for the parliamentary purse. He instilled a new religious doctrine, and began to persecute those who did not adhere to it. For those in religious minorities, this was a worrying chain of events. Puritans, such as Thomas Hooker, sick of the religious persecution, emigrated to America.
  The Scot's also did not take these changes lightly. Soon, they were in open rebellion, and the King didn't have the money to fight them.  So after eleven years of "personal rule" , Charles was forced to convene parliament again, to secure more funds.
 Various members of parliament saw this as an opportunity to bring their king under control, and introduce more reforms. It did not turn out that way. Predictably, this resulted in another quarrel, and in less than a month, parliament was once again dissolved.
The king went to war anyway with what little funds he could muster. The ensuing fiasco ended with Scotland in control of the North of England. The Scots, magnanimous in victory, promised they wouldn't burn all of the cities in their possession so long as Charles paid them a ransom.
 The King couldn't just let the north burn. He needed to reconvene parliament . In return for the money, reforms were enacted that aimed to end the king's autocratic habit. But Charles would not crack so easily.
 By the time Thomas Sydenham began his studies in Oxford, events had come to a head. In January 1642 King Charles had marched with 400 men to parliament with the intention of arresting 5 of it's members, but without success.
Across the country, towns and constituencies began declaring fealty to either king or parliament. War was brewing.  Parliament began recruiting an army to do the unthinkable. To fight against their own king.
In the early stages of the war, Sydenham's mother was killed when Royalists raided their home. This act which drew the whole family deeper into the conflict.
Sydenham left Oxford, and joined his family to declare loyalty to parliament.  Their exploits during the war lead them to be known as"The Fighting Sydenhams".

Thomas's older brother, Francis Sydenham  became a legend in the Parliamentarian army. When attacking the seemingly impregnable town of Corfe, it was Francis who oversaw the construction of tank, which was used to great effect to assail the city.
 At one point, Francis pretended to defect to the Royalist side against his own family. In doing so, he tricked Royalist forces into entering a devastating ambush in Poole. And during that battle, by chance he encountered the man responsible for the death of his mother, and killed him on the spot*.

   Thomas's role in the war is largely overshadowed by those of his brothers and his father. It is known that he was wounded in a cavalry charge at the battle of Weymouth as the war was drawing to a close.  By the time the royalists had surrendered and the king executed. Two of his brothers, including Francis, were dead. It was a new England, with Oliver Cromwell and parliament in charge.
Thomas Sydenham returned to Oxford to take up his studies once more, and found it a much different place. It had been one of the last royalist strongholds to fall, and Parliamentary forces aimed to keep it under strict control.   Parliament had put "visitors" in place, who enforced parliament's political will on campus. They expelled anyone who spoke out against the new government.

 Thomas, being a leading member of the revolution, thrived in this environment. Parliament were eager to bestow some commendation upon him for his family's role in the war. As a result,  ended up with a doctorate within his first year of study. In addition to this, he may also have played a role in helping Cromwells "visitors" in expelling professors on the basis of their royalist leanings. This removal of old academics aided the careers of younger academics such as John Locke and Robert Boyle, both of whom were friends of Sydenham.

Nevertheless, the army was not yet done with Sydenham. Whilst Cromwell had successfully won the civil war, winning the peace was a different matter. After returning from a brutal and bloody campaign in Northern Ireland, Cromwell turned his eyes north. The Scottish parliament were jockeying for more power in the new order, and recruited the heir to the throne, Prince Charles II to force the issue. In 1651, Cromwell answered with an army of seasoned veterans. Once again, Thomas Sydenham found himself at war. He was put in charge of his own battalion, where he used his medical knowledge to fortify his troops against the northern frosts. But this didn't stop him from being left for dead on a battlefield and nearly shot at point blank range by a drunken trooper from his own side. When Scotland was defeated, Thomas left the army, never to return.

 He devoted the rest of his life to the study and the application of medicine, and managed to revolutionise the way it was practised in England. At the time, there were many explanations of diseases, and often doctors would prescribe treatments accordingly.  The vast increase in anatomical knowledge lead physicians to prescribe bleeding to balance the "humours" that allegedly controlled the body. Various beliefs on matter, and findings in chemistry lead to mercury being used as a purgative. The best "treatment" for a convulsive jerking disorder at the time was to "dance" the demons out.

When the founder of the British museum, Hans Sloane applied to be a student of Sydenham, he presented the physician with a letter of introduction . Sydenham glanced at the letter. It indicated that Sloane was "a ripe scholar, a good botanist, a skillful anatomist".
"This is all very fine," Sydenham cried "but it won't do! Anatomy ? botany! Nonsense! Sir, I know an old woman in Covent Garden who understands botany better, and as for anatomy, my butcher can dissect a joint fully as well. No, young man, all this is stuff; you must go to the bedside; it is there alone you can learn disease."

He recognised that many of the findings of anatomy and science were very much in their infancy. The application of their principles when they were so poorly understood was foolhardy. He staunchly believed that evidence was the guiding factor at the bedside.

"It is my nature, to think where others read; to ask less whether the world agrees with me than whether I agree with the truth" he says in one of his works.  He flatly states that to speculate on the causes of diseases was a "difficult and perhaps inexplicable affair; and I choose to keep my hands clear of it".

He was one of the few men of the day who recognised that they simply didn't have the tools to speculate on the causes of disease, and that the bedside was a far better teacher than the library.
What Sydenham frequently found was that the application of unproven theories to the treatment of patients did more harm than good, and that often the best thing to do was to let nature take its course.

Sydenham had very little patience for nonsense. So one wonders what he thought when he first heard of the dancing fever. When he first encountered a patient,  He did not speculate on whether it was caused by demonic possession, or by a spider bite.  He focused on collecting as much information as possible about the disease, and then letting the evidence speak for itself.  He described the patients as exhibiting convulsive movements out of their control,** . Instead of prescribing dancing, or prayer, he simply let the disease run its course, and found that patients would eventually get better without interference. The deaths attributed to this disease were probably caused by the forcing of sufferers to "dance out" their disease. Whilst he did not know it at the time, this dancing disease was related to another disease he studied, the disease that is the subject of this series.

 It was Thomas Sydenham who gave scarlet fever it's name***. His initial studies on epidemiology in 1666 are where he first describes the disease, although the actual name “Scarlet Fever” only appears in the 1683 edition. . He noted the seasonality of this disease, and made key observations on it's disease course, and that the treatments of the time were at best ineffective.
Unfortunately, his description of the fever leaves out many of the essential details that were catalogued by Sennert. Sydenham's failure to recognise the more severe forms of this disease (such as the dropsy and arthritis) meant that subsequent physicians often confused it with measles. Such was Sydenham's repute that his word was deemed to be the last one on this issue for over a century.

Nevertheless, his work was revolutionary. The Dancing fever would eventually be named after him, and called Sydenham's Chorea, and the wide regard of his work raised awareness about Scarlet Fever.
Unbeknownst to him, the two diseases are linked. Previously, I talked about how Sennert was amongst the first to recognize that scarlet fever can trigger other diseases, such as "dropsy" and rheumatism.
Today we know that these occur because the bacteria that causes scarlet fever, Streptococcus pyogenes, often uses a variety techniques to hoodwink the immune system. In some cases it can turn the immune system against the rest of the body. These immune reactions are what cause these "disease sequels".

In the case of Sydenham's chorea, the immune system has a bad reaction with the nervous system, causing damage. This manifests itself as the juddering dancing motions characteristic of the disease. It usually resolves of its own accord after the underlying bacterial disease is cleared. So Sydenhams basic treatment of "Wait and See", or even the religious method of "Wait and Pray" would have worked far better than other treatments available at the time.

But what Sydenham did for medicine was not limited to his descriptions of diseases. Indeed, in many of his writings he often proclaims his ignorance on many subjects. It was the way he practiced medicine that secured his place in history. His re-introduction of Hippocratic methods of evidence gathering were the key to his success.  After his death, the following was written of the great practitioner;

"The great merit of Sydenham, was to proclaim the great truth that science was, and always must be incomplete; and that danger lurks in the natural tendency to act upon it as if it were complete. A practical man has to be guided not only by positive knowledge, but by that which is imperfectly known. He must listen to the hints of nature, as well as to her clear utterances. to combine them may be difficult; but the difficulty is solved in minor matters by the faculty called common sense; in greater affairs by the synthetic power of Genius " ***

* In one account , it was said to be Thomas himself who avenged his mother, but sources that are more reliable indicate that it was actually Francis.
** There seems to be a bit of controversy over the actual causes of the medieval dancing disease. Whilst  the diagnosis of Sydenham's Chorea may make sense in the context of the devastating streptococcal outbreaks pushing their way through Germany at the time (as documented by Weyer and Sennert), it does not explain everything.
The medieval descriptions of the sufferers of Chorea differ much from Sydenhams own account. They talk of sufferers leaping and so forth. It is the impreciseness of language that makes it hard to definitively describe the disease. It appears that only arabic accounts agree with Sydenham's description, but I have not been able to source the relevant documents to back this up, and even if I did, I can't read arabic.
It is also likely that hysteria may have played a role, especially where people were employed to dance with these victims. In fact, the dancing bans in Strasbourg likely helped to quell the spread of this hysteria.
There are also theories that a rye fungus outbreak spread hallucinogenic substances on foodstuffs, although nothing in the accounts I read indicates that these dancers were actually hallucinating.
The truth is that there is no truly satisfactory explanation for this disease. Sydenham's explanation was good enough for those who lived contemporaneously with the disease, so I decided that it was good enough for me.

***Samuel Pepys is probably the first person recorded to use the term "scarlet fever" to describe a disease, it is unlikely to refer to the disease we know today. It may have been used interchangeably with measles, and other diseases that produced a red rash. It should also be noted that colour based adjectives were often imbued with some form of emotion, with "scarlet" and "black"  being not only descriptive, but emotional terms. When researching these articles, I was struck by how almost every disease was described as a "black plague", including those which exhibited streptococcal symptoms. But in some cases, the writers may have well have said "terrible plague" or "scary plague". This use of language makes investigating diseases in the past a very confusing affair to the novice.

*** I have scoured the internet for the source of this quote, and came up with zip. Any help with this would be appreciated.


Google Books

"A History of Madness in Sixteenth-Century Germany" By H. C. Erik Midelfort

"Anatomy of Melancholy," by Robert Burton

"The continuum companion to Locke", by Sami-Juhani Savonius-Wroth, Paul Schuurman, Jonathan Walmsley

Dr Thomas Sydenham- by Unknown.


Rolleston, J. (1928). THE HISTORY OF SCARLET FEVER BMJ, 2 (3542), 926-929 DOI: 10.1136/bmj.2.3542.926

Fischer WJ (1913). THOMAS SYDENHAM, THE ENGLISH HIPPOCRATES: (1624-1689). Canadian Medical Association journal, 3 (11), 931-46 PMID: 20310434

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