I. TYPHUS AND OTHER CONTINUED FEVERS

I. TYPHUS AND OTHER CONTINUED FEVERS

It was remarked by Dr James Lind, in 1761, that a judicious synopsis of the writings on fevers, in a chronological sense, would be a valuable book: it would bring to light, he was fain to expect, treasures of knowledge; “and perhaps the influence of a favourite opinion, or of a preconceived fancy, on the writings of some even of our best instructors, such as Sydenham and Morton, would more clearly be perceived[1].” Lind himself was the person to have delivered such a history and criticism. He was near enough to the 17th century writers on fevers to have entered correctly into their points of view; while so far as concerned the detection of theoretical bias or preconceived fancies, he had shown himself a master of the art in his famous satire upon the “scorbutic constitution,” a verbal or mythical construction which had been in great vogue for a century and a half, and was still current, at the moment when Lind destroyed it, in the writings of Boerhaave and Haller. A judicious historical view of the English writings on fevers, such as this 18th century critic desired to see, may now be thought superfluous. The theories, the indications for treatment, the medical terms, have passed away and become the mere objects of a learned curiosity. But the actual history of the old fevers, of their kinds, their epidemic prevalence, their incidence upon rich or poor, upon children or adults, their fatality, their contagiousness, their connexion with the seasons and other vicissitudes of the people--all this is something more than curious.

Unfortunately for the historian of diseases, he has to look for the realities amidst the “favourite opinions” or the “preconceived fancies” of contemporary medical writers. Statements which at first sight appear to be observations of matters of fact are found to be merely the necessary truths or verbal constructions of some doctrine. One great doctrine of the 17th and 18th centuries was that of obstructions: in this doctrine, as applied to fevers, obstructions of the mesentery were made of central importance; the obstructions of the mesentery extended to its lymphatic glands; so that we come at length, in a mere theoretical inference, to something not unlike the real morbid anatomy of enteric fever. Another great doctrine of the time, specially applied by Willis to fevers, was that of fermentations and acrimonies. “This ferment,” says a Lyons disciple of Willis in 1682, “has its seat in the glandules of the velvet coat of the stomach and intestines described by Monsieur Payer[2].” But the Lyons physician is writing all the while of the fevers that have always been common in the Dombes and Bresse, namely intermittents; the tertian, double tertian, quotidian, quartan, or double quartan paroxysm arises, he says, from the coagulation of the humours by the ferment which has its seat in the glandules described by M. Payer, even as acids cause a coagulation in milk, the paroxysm of ague continuing, “until this sharp chyle be dissipated and driven out by the sweat or insensible perspiration.” The lymphatic follicles of the intestine known by the name of Payer, or Peyer, were then the latest anatomical and physiological novelty, and were chosen, on theoretical grounds, as the seat of fermentation or febrile action in agues. On the ground of actual observation they were found about a century and a half after to be the seat of morbid action in typhoid fever.

While there are such pitfalls for the historian in identifying the several species of fevers in former times, there are other difficulties of interpretation which concern the varieties of a continued fever, or its changes of type from generation to generation. Is change of type a reality or a fiction? And, if a reality, did it depend at all upon the use or abuse of a certain regimen or treatment, such as blooding and lowering, or heating and corroborating? A pupil of Cullen, who wrote his thesis in 1782 upon the interesting topic of the change in fevers since the time of Sydenham[3], inferred that the great physician of the Restoration could not have had to treat the low, putrid or nervous fevers of the middle and latter part of the 18th century, otherwise he would not have resorted so regularly to blood-letting, a practice which was out of vogue in continued fevers at the time when the thesis was written, as well as for a good many years before and after. Fevers, it was argued, had undergone a radical change since the time of Sydenham, in correspondence with many changes in diet, beverages and creature comforts, such as the greatly increased use of tea, coffee and tobacco, and of potatoes or other vegetables in the diet, changes also in the proportion of urban to rural population, in the use of carriages, and in many other things incident to the progressive softening of manners. In due time the low, putrid, nervous type of typhus fever, which is so much in evidence in the second half of the 18th century, ceased to be recorded, an inflammatory type, or a fever of strong reaction, taking its place; so that Bateman, of London, writing in 1818, said: “The putrid pestilential fevers of the preceding age have been succeeded by the milder forms of infectious fever which we now witness”; while Armstrong, Clutterbuck, and others, who had revived the practice of blood-letting in fevers shortly before the epidemic of 1817-18, claimed the comparatively slight fatality and short duration of the common fever of the time as an effect of the treatment. After 1831, typhus again became low, depressed, spotted, not admitting of the lancet; on which occasion the doctrine of “change of type” was debated in the form that the older generation of practitioners still remember.

Thus the task of the historian, whose first duty is to ascertain, if he can, the actual matters of fact, or the realities, in their sequence or chronological order, is made especially difficult, in the chapter on continued fevers, by the contemporary influence of theoretical pathology or “a preconceived fancy,” by the ascription of modifying effects to treatment, whether cooling or heating, lowering or supporting, and, most of all, by the absence of that more exact method which distinguishes the records of fever in our own time. Nor can it be said that the work of historical research has been made easier in all respects, by the exact discrimination and perfected diagnosis to which we are accustomed in present-day fevers. In the years between 1840 and 1850, the three grand types of fever then existing in Britain, namely, spotted typhus, enteric, and relapsing fever, were at length so clearly distinguished, defined and described that no one remained in doubt or confusion. Thereupon arose the presumption that these had always been the forms of continued fever in Britain, and that the same fevers, presumably in the same relative proportions to each other, might have been left on record by the physicians of former generations, if they had used the modern exactness and minuteness in observing both clinical history and anatomical state, which were seen at their best in Sir William Jenner. It would simplify history, indeed it would make history superfluous, if that were really the case. There are many reasons for believing that it was not the case. As Sydenham looked forward to his successors having experiences that he never had, so we may credit Sydenham with having really seen things which we never see, not even those of us who saw the last epidemics of relapsing fever and typhus. It is due to him, and to his contemporaries and nearest successors, to reciprocate the spirit in which he concludes the general chapter on epidemics prefatory to his annual constitutions from 1661 to 1676:

“I am far from taking upon myself the credit of exhausting my subject in the present observations. It is highly probable that I may fail even in the full enumeration of the epidemics. Still less do I warrant that the diseases which during the years in question have succeeded each other in the sequence about to be exhibited shall remain the same in all future years. One thing most especially do I aim at. It is my wish to state how things have gone lately; how they have been in this country, and how they have been in this the city which we live in. The observations of some years form my ground-work. It is thus that I would add my mite, such as it is, towards the foundation of a work that, in my humble judgment, shall be beneficial to the human race. Posterity will complete it, since to them it shall be given to take the full view of the whole cycle of epidemics in their mutual sequences for years yet to come[4].”

The epidemic fever of 1661, according to Willis.

On the very threshold of the period at which the history is resumed in this volume, we find a minute account by Willis of an epidemic in the year 1661, which at once raises the question whether a certain species of infectious fever did really exist at that time which exists no longer, or whether Willis described as “a fever of the brain and nervous stock” what we now call enteric fever. Willis’s fever corresponds in every respect to the worm fever, the comatose fever, the remittent fever of children, the acute fever with dumbness, the convulsive fever, which was often recorded by the medical annalists and other systematic observers as late as the beginning of the 19th century[5]. It ceased at length to be recorded or described, and it has been supposed that it was really the infantile or children’s part of enteric fever, which had occurred in former times as now[6]. The epidemic fever which Willis saw in the summer of 1661, after a clear interval of two years from the great epidemics of agues, with influenzas, in 1657-59, is called by him “a certain irregular and unaccustomed fever[7].” It was not, however, new to him altogether; for he had seen the same type, and kept notes of the cases, in a particular household at Oxford in 1655, as well as on other occasions. It was an epidemical fever “chiefly infestous to the brain and nervous stock.” It raged mostly among children and youths, and was wont to affect them with a long and, as it were, a chronical sickness. When it attacked the old or middle-aged, which was more rarely, it did sooner and more certainly kill. It ran through whole families, not only in Oxford and the neighbouring parts, “but in the countries at a great distance, as I heard from physicians dwelling in other places.” Among those other witnesses, we shall call Sydenham; but meanwhile let us hear Willis, whose account is the fullest and least warped by theory.

Its approach was insidious and scarce perceived, with no immoderate heat or sharp thirst, but producing at length great debility and languishing, loss of appetite and loathing. Within eight days there were brain symptoms--heavy vertigo, tingling of the ears, often great tumult and perturbation of the brain. Instead of phrensy, there might be deep stupidity or insensibility; children lay sometimes a whole month without taking any notice of the bystanders, and with an involuntary flux of their excrements; or there might be frequent delirium, and constantly absurd and incongruous chimaeras in their sleep. But in men a fury, and often-times deadly phrensy, did succeed. If, however, neither stupidity nor great distraction did fall upon them, swimmings in the head, convulsive movements, with convulsions of the members and leaping up of the tendons did grievously infest them. In almost all, there were loose and stinking motions, now yellow, now thin and serous; vomiting was unusual; the urine deep red. The sufferers in this prolonged sickness wasted to a skeleton, with no great heat or evacuations to account for the wasting. Some, at the end of the disease, had a severe catarrh. In others, with little infection of the head, soon after the beginning of the fever a cruel cough and a stinking spittle, with a consumptive disposition, grew upon them, and seemed to throw them suddenly into a phthisis, from which, however, they recovered often beyond hope. In some there were swellings of the glands near the hinder part of the neck, which ripened and broke, and gave out a thin stinking ictor for a long time. “I have also seen watery pustules excited in other parts of the body, which passed into hollow ulcers, and hardly curable. Sometimes little spots and petechiales appeared here and there.” But none of the spots were broad and livid, nor were there many malignant spots.

Willis then gives several cases clinically, in his usual manner. The first is of a strong and lively young man, who was sick above two months and seemed near death, but began to mend and took six weeks to recover, sweating every night or every other night of his convalescent period. The second case, aged twelve, was restored to health in a month. Numbers three and four were children of a nobleman, who both died, the convulsive type being strongly marked; one of the two was examined after death, and found to have several sections of the small intestine telescoped, but all the abdominal viscera free from disease[8], the lungs engorged, the vessels of the brain full, much water in the sub-arachnoid space, and more than half a pint in the lateral ventricles.

In farther illustration of this type of fever, epidemic in 1661, Willis goes back to his notes of a sporadic outbreak of what he thinks was the same disease in a certain family at Oxford in the winter of 1653-4[9]: “yea I remember that sometime past very many laboured with such a fever.” In the family in question, five children took the fever one after another during a space of four months, two of the cases proving fatal; the domestics also took it, and some strangers who came in to help them, “the evil being propagated by contagion.” The cases in the children are fully recorded[10], the following being some of the symptoms:

In case 1, aged seven, the illness began at the end of December, 1653 (or 1655): there were contractions of the wrist tendons, red spots like fleabites on his neck and other parts, drowsiness, and involuntary passage of the excrements. At the end of a fortnight, a flux set in and lasted for four days; next, after that, a whitish crust or scurf, as it were chalky, began to spread over the whole cavity of his mouth and throat, which being often in a day wiped away, presently broke forth anew. He mended a little, but had paralysis of his throat and pharynx, was reduced to a living skeleton, but at length got well.

Case 2, a brother, aged nine, had frequent loose and highly putrid motions on the eleventh day; and next day, the flux having ceased, the most severe colic, so that he lay crying out day and night, his belly swollen and hard as a drum, until, on the 24th day, he died in an agony of convulsions.

Case 3, a brother, aged 11, was taken with similar symptoms on the 13th February, and died on the 13th day.

Case 4, a sister, was taken ill in March, with less marked symptoms, and recovered slowly, having had no manifest crisis.

Case 5, a boy of the same family, and the youngest, fell ill about the same time as No. 4, and after the like manner, “who yet, a looseness arising naturally of itself, for many days voiding choleric and greenish stuff, was easily cured.”

Then comes a general reference to the domestics and visitors, who fell sick of the same and all recovered.

The prolonged series of cases in the household of this “venerable man” appears to have made a great impression upon Willis, as something new in his experience, as well as in the experience of several other physicians who gave their services. That it was malignant he considers proved “ex contagio, pernicie, macularum pulicularum apparentia, multisque aliis indiciis.” He adds that he had seen the same disease sporadically at other times; and again “I remember that formerly several laboured under such a fever.” Those cases were all previous to the general prevalence of the fever which he identifies with them in the summer of 1661, under the name of a “fever of the brain and spinal cord.”

The signs given by Willis are as nearly as may be the signs of infantile remittent fever, or worm fever, or febris synochus puerorum, or hectica infantilis, or febris lenta infantum, or an acute fever with dumbness, of which perhaps the first systematic account in this country was given by Dr William Butter of Lower Grosvenor Street, in 1782[11]. It is, he says, both a sporadical and an epidemical disease, “and when epidemical it is also contagious.” The age for it is from birth up to puberty; but “similar symptoms are often observed in the disorders of adults.” Morton, writing in 1692-94, clearly points to the same fever under the name of worm fever (febris verminosa). He adds it at the very end of his scheme of fevers, as if in an appendix, having been unable to find a place for it in any of his categories owing to its varying forms--hectic, acute, intermittent, continued, συνεχής, inflammatory, but for the most part colliquative or σύνοχος, “and malignant according to the varying degrees of the venomous miasm causing it[12].” Butter also recognizes its varying types: it has many symptoms, but they seldom all occur in the same case; there are three main varieties--the acute, lasting from eight to ten days up to two or three weeks; the slow, lasting two or three months; and the low, lasting a month or six weeks. The slow form, he says, is only sporadic; the low is only epidemic, and is never seen but when the acute is also epidemical; it is rare in comparison with the latter, and not observed at all except in certain of the epidemical seasons. Waiving the question whether the remittent fever of children, thus systematically described, was not a composite group of maladies, of which enteric fever of children was one, we can hardly doubt that Willis found a distinctive uniform type in the epidemic of 1661, in Oxford as he saw it himself, in other parts of England by report. It had symptoms which were not quite clearly those of enteric fever: spots, like fleabites, on the neck and other parts, swelling and suppuration of the glands in the hinder part of the neck, effusion of fluid on the brain and in the lateral ventricles, and the intestine free from disease[13].

Confirming Willis’s account for Oxford, is the case of Roger North, when a boy at Bury St Edmunds Free School in 1661, as related by himself in his ‘Autobiography[14].’ Being then “very young and small,” after a year at school he had “an acute fever, which endangered a consumption.” Elsewhere he attributes his bad memory with “confusion and disorder of thought,” to that “cruel fit of sickness I had when young, wherein, I am told, life was despaired of, and it was thought part of me was dead; and I can recollect that warm cloths were applied, which could be for no other reason, because I had not gripes which commonly calls for that application.” That “great violence of nature,” while it had impaired his mental faculties, had sapped his bodily vigour somewhat also, of which he gives a singular illustration.

This special prevalence of epidemic fevers in the summer and autumn of 1661 is noticed also by the London diarists.

Evelyn says that the autumn of 1661 was exceedingly sickly and wet[15]. Pepys has several entries of fever[16]. On 2 July, 1661: “Mr Saml. Crewe died of the spotted fever.” On 16 August: “At the [Navy] Office all the morning, though little to do; because all our clerks are gone to the burial of Tom Whitton, one of our Controller’s clerks, a very ingenious and a likely young man to live as any in the office. But it is such a sickly time both in the city and country everywhere (of a sort of fever) that never was heard of almost, unless it was in a plague-time. Among others the famous Tom Fuller [of the ‘Worthies of England’] is dead of it; and Dr Nichols [Nicholas], Dean of St Paul’s; and my Lord General Monk is very dangerously ill.” On 31 August: “The season very sickly everywhere of strange and fatal fevers.” On 15 January, 1662: “Hitherto summer weather, both as to warmth and every other thing, just as if it were the middle of May or June, which do threaten a plague (as all men think) to follow; for so it was almost the last winter, and the whole year after hath been a very sickly time to this day.”

The great medical authority of the time is Sydenham. His accounts of the seasons and reigning diseases of London extend from 1661 to 1686, so that they begin with the year for which Willis described the epidemic fever “chiefly infestous to the brain and nervous stock,” popularly called the new disease. But Sydenham did not describe the epidemic in the same objective way that Willis did. He records a series of “epidemic constitutions of the air,” the particular constitution of each year being named from the epidemic malady that seemed to him to dominate it most. It was, perhaps, because it had to conform to Sydenham’s “preconceived fancy,” as Lind said, that his account of the dominant type of fever in 1661 differs somewhat from that given by Willis.

Sydenham’s epidemic Constitutions.

Sydenham adopted the epidemic constitutions from Hippocrates, as he did much else in his method and practice. In the first and third books of the ‘Epidemics,’ Hippocrates describes three successive seasons and their reigning diseases in the island of Thasos, as well as a fourth plague-constitution which agrees exactly with the facts of the plague of Athens as described by Thucydides. The Greek term translated “constitution” is κατάστασις, which means literally a settling, appointing; ordaining, and in the epidemiological sense means the type of reigning disease as settled by the season. The method of Hippocrates is first to give an account of the weather--the winds, the rains, the temperature and the like,--and then to describe the diseases of the seasons[17]. Sydenham followed his model with remarkable closeness. The great plague of London has almost the same place in his series of years that the plague-constitution, the fourth in order, has in that of Hippocrates. It looks, indeed, as if Sydenham had begun with the year 1661, more for the purpose of having several constitutions preceding that of the plague than because he had any full observations of his own to record previous to 1665. He is also much influenced by the example of Hippocrates in giving prominence to the intermittent type of fevers. It was remarked by one of our best 18th century epidemiologists, Rogers of Cork, and with special reference to Sydenham’s “intermittent constitutions,” that fevers proper to the climate of Thasos were not likely to be identified in or near London excepted by a forced construction.

Sydenham’s Constitutions.

----------------------------------------------------------------------- | | Total | | Fever | | | | Constitutions | deaths|Plague| and |Smallpox|Measles| | | in | |Spotted| | | | | London| | Fever | | | ----|-------------------------|-------|------|-------|--------|-------| 1661|“Intermittent” | 16,665| 20| 3,490 | 1,246 | 188 | 1662| constitution: with a | 13,664| 12| 2,601 | 768 | 20 | 1663| continued fever | 12,741| 9| 2,107 | 411 | 42 | 1664| throughout. | 15,453| 5| 2,258 | 1,233 | 311 | | | | | | | | 1665|Constitution of plague | 97,306|68,596| 5,257 | 655 | 7 | 1666| and pestilential fever.| 12,738| 1,998| 741 | 38 | 3 | | | | | | | | 1667|Constitution of smallpox,| 15,842| 35| 916 | 1,196 | 83 | 1668| with a continued | 17,278| 14| 1,247 | 1,987 | 200 | 1669| “variolous” fever. |} | | | | | | |}19,432| 3| 1,499 | 951 | 15 | 1669|Constitution of dysentery|} | | | | | 1670| and cholera nostras, | 20,198| 0| 1,729 | 1,465 | 295 | 1671| with a continued fever.| 15,729| 5| 1,343 | 696 | 17 | 1672| Measles in 1670. | 18,230| 5| 1,615 | 1,116 | 118 | | | | | | | | 1673|Constitution of | 17,504| 5| 1,804 | 853 | 15 | 1674| “comatose” fevers. | 21,201| 3| 2,164 | 2,507 | 795 | 1675|Influenza in 1675. | 17,244| 1| 2,154 | 997 | 1 | 1676| | 18,732| 2| 2,112 | 359 | 83 | | | | | | | | 1677|Not recorded. | 19,067| 2| 1,749 | 1,678 | 87 | | | | | | | | 1678|Return of the | 20,678| 5| 2,376 | 1,798 | 93 | 1679| “intermittent” | 21,730| 2| 2,763 | 1,967 | 117 | 1680| constitution, absent | 21,053| 0| 3,324 | 689 | 49 | | since 1661-64. | | | | | | | | | | | | | 1681|“Depuratory” fevers, | 23,951| 0| 3,174 | 2,982 | 121 | 1682| or dregs of the | 20,691| 0| 2,696 | 1,408 | 50 | 1683| intermittents. | 20,587| 0| 2,250 | 2,096 | 39 | 1684| | 23,202| 0| 2,836 | 1,560 | 6 | | | | | | | | 1685|Constitution of a | 23,222| 0| 3,832 | 2,496 | 197 | 1686| “new” continued fever. | 22,609| 0| 4,185 | 1,062 | 25 |

-------- |Griping | in the | Guts | |------- | 1,061 | 835 | 866 | 1,146 | | 1,288 | 676 | | 2,108 | 2,415 | | 4,385 | | 3,690 | 2,537 | 2,645 | | 2,624 | 1,777 | 3,321 | 2,083 | | 2,602 | | 3,150 | 2,996 | 3,271 | | | 2,827 | 2,631 | 2,438 | 2,981 | | 2,203 | 2,605

The foregoing is a Table of Sydenham’s epidemic constitutions from 1661 to 1686, compiled from his various writings, with the corresponding statistics from the London Bills of Mortality.

I give this Table both as a convenient outline and in deference to the great name of Sydenham. But we should be much at fault in interpreting the figures of the London Bills, or the history of epidemic diseases in the country at large, if we had no other sources of information than his writings. Only some of the figures in the Table concern us in this chapter; plague has been finished in the previous volume, smallpox, measles and “griping in the guts” are reserved each for a separate chapter, as well as the influenzas and epidemic agues which formed the chief part of the “strange” or “new” fevers. If this work had been the Annals of Epidemics in Britain, it would have been at once proper and easy to follow Sydenham’s constitutions exactly, and to group under each year the information collected from all sources about all epidemic maladies. But as the work is a history, it proceeds, as other histories do, in sections, observing the chronological order and the mutual relations of epidemic types as far as possible; and in this section of it we have to cull out and reduce to order the facts relating to fevers, beginning with those of 1661.

Cases of fever, says Sydenham, began to be epidemic about the beginning of July 1661, being mostly tertians of a bad type, and became so frequent day by day that in August they were raging everywhere, and in many places made a great slaughter of people, whole families being seized. This was not an ordinary tertian intermittent; indeed no one but Sydenham calls it an intermittent at all, and he qualifies the intermittence as follows:

“Autumnal intermittents do not at once assume the genuine type, but in all respects so imitate continued fevers that unless you examine the two respectively with the closest scrutiny, they cannot be distinguished. But, when by degrees the impetus of the ‘constitution’ is repelled and its strength reined in, the fevers change into a regular type; and as autumn goes out, they openly confess themselves, by casting their slough (larva abjecta) to be the intermittents that they really were from the first, whether quartans or tertians. If we do not attend to this diligently” etc. And again, in a paragraph which does not occur in the earlier editions, he writes as follows in the context of the “Intermittent Fevers of the years 1661-1664:”

“It is also to be noted that in the beginning of intermittent fevers, especially those that are epidemic in autumn, it is not altogether easy to distinguish the type correctly within the first few days of their accession, since they arise at first with continued fever superadded. Nor is it always easy, unless you are intent upon it, to detect anything else than a slight remission of the disease, which, however, declines by degrees into a perfect intermission, with its type (third-day or fourth-day) corresponding fitly to the season of the year.”

The intermittent character of these fevers seems to have struck Sydenham himself in a later work as forced and unreal. Writing in 1680, when the same kind of fevers were prevalent, after the epidemic agues of 1678 and 1679, he calls them “depuratory,” and says that “doubtless those depuratory fevers which reigned in 1661-64 were as if the dregs of the intermittents which raged sometime before during a series of years,” i.e. the agues of 1657-59[18].

Theory or names apart, Sydenham’s account of the fatal epidemic fever of the summer and autumn of 1661, comes to nearly the same as Willis’s. Without saying expressly, as Willis does, that the victims were mostly children or young people, he speaks in one place of those of more mature years lying much longer in the fever, even to three months, and he specially mentions the same sequelae of the fever in children that Willis mentions, and that Roger North remembered in his own case--namely that they sometimes became hectic, with bellies distended and hard, and often acquired a cough and other consumptive symptoms, “which clearly put one in mind of rickets.” He refers also to pain and swelling of the tonsils and to difficulty of swallowing, which, if followed by hoarseness, hollow eyes, and the facies Hippocratica, portended speedy death. Among the numerous other accidentia of the fever, was a certain kind of mania. Among the symptoms were phrensy, and coma-vigil; diarrhœa occurred in some owing, as he thought, to the omission of an emetic at the outset; hiccup and bleeding at the nose were occasional.

But, although Sydenham must have had the same phenomena of fever before him that Willis had, the epidemic being general, according to the statements of both, one would hardly guess from his way of presenting the facts, that the fever was what Willis took it to be--a slow nervous fever, with convulsive and ataxic symptoms, specially affecting children and the young. Both Willis and Sydenham recognised something new in it; the common people called it, once more, the “new disease,” and Pepys calls it a “sort of fever,” and “strange and fatal fevers.”

As Sydenham maintains that the same epidemic constitution continued until 1664 (although the fever-deaths in London are much fewer in 1662-3-4 than in the year 1661, which was the first of it), we may take in the same connexion Pepys’s account of the Queen’s attack of fever in 1663. The young princess Katharine of Portugal, married to Charles II. in 1662, had the beginning of a fever at Whitehall about the middle of October, 1663; Pepys enters on the 19th that her pulse beat twenty to eleven of the king’s, that her head was shaved, and pigeons put to her feet, that extreme unction was given her (the priests so long about it that the doctors were angry). On the 20th he hears that the queen’s sickness is a spotted fever, that she was as full of the spots as a leopard: “which is very strange that it should be no more known, but perhaps it is not so.” On the 22nd the queen is worse, 23rd she slept, 24th she is in a good way to recovery, Sir Francis Prujean’s cordial having given her rest; on the 26th “the delirium in her head continues still; she talks idle, not by fits, but always, which in some lasts a week after so high a fever, in some more, and in some for ever.” On the 27th she still raves and talks, especially about her imagined children; on the 30th she continues “light-headed, but in hopes to recover.” On 7th December, she is pretty well, and goes out of her chamber to her little chapel in the house; on the 31st “the queen after a long and sore sickness is become well again.”

Typhus fever perennial in London.

Sydenham says that a continued fever, the symptoms of which so far as he gives them suggest typhus, was mixed with the masked intermittent, (or the convulsive fever of children, as in Willis’s account), in every one of the years 1661-4; and that statement raises a question which may be dealt with here once for all. Fever in the London bills is a steady item from year to year, seldom falling below a thousand deaths and in the year 1741, during a general epidemic of typhus, rising to 7500. The fevers were a composite group, as we have seen, and shall see more clearly. But the bulk of them perennially appears to have been typhus fever. Where the name of “spotted fever” is given there can be little doubt. Every year the bills have a small number of deaths from “spotted fever,” and the number of them always rises in the weekly bills in proportion to the increase of “fever” in general, sometimes reaching twenty in the week when the other fevers reach a hundred. It would be a mistake to suppose that only the fevers called spotted were typhus, the other and larger part being something else. The more reasonable supposition is that the name of spotted was given by the searchers in cases where the spots, or vibices or petechiae of typhus were especially notable. If a score, or a dozen or half-a-dozen deaths in a week are set down to spotted fever, it probably means that a large part of the remaining hundred, or seventy, or fifty cases of “fever” not called spotted were really of the same kind, namely typhus. In the plague itself, the “tokens,” which were of the same haemorrhagic nature as the larger or more defined spots of typhus, were exceedingly variable[19]. One of the synonyms of typhus (the common name in Germany) is spotted typhus; but the spots were of at least two kinds, a dusky mottling of the skin and more definite spots, sometimes large, sometimes like fleabites.

Assuming that the cases specially called “spotted” in the London Bills were only a part of all that might have been called by the same name in the wider acceptation of the term (as in Germany), it is a significant fact that there are few of the weekly bills for a long series of years in the 17th and 18th centuries without some of the former. Such a case as that of Mr Samuel Crewe, brother of Lord Crewe, who died of the “spotted fever” on 2 July, 1661, probably means that there were more cases of the same kind in the poorer parts of the town, from which no account of the reigning sicknesses ever came unless it were the number of deaths in the bills. The conditions of endemic typhus were there long before we have authentic accounts, towards the end of the 18th century, of that disease being ever present in the homes of the lower classes. In the time of Sydenham, and even in the time of Huxham two generations after, there was no thought of the unwholesome domestic life graphically described by Willan and others, as a cause of typhus--the overcrowding, the want of ventilation, the foul bedding and the excremental effluvia.

If there had been any reason to suppose that the London of the Restoration, or of the time of Queen Anne, or of the first Georges had enjoyed better public health in its crowded liberties and out-parishes than we know it to have done from the time when the authentic accounts of Lettsom and other dispensary physicians begin, then one might err in assuming the perennial existence of typhus fever and in assigning to that cause the bulk of the deaths under the heading of “fevers” in the Parish Clerks’ bills. But the public health was undoubtedly worse in the earlier period. A writer as late as the year 1819, who is calling for that reform of the dwellings of the working classes in London which was soon after carried out, namely the construction of regular streets instead of mazes of courts and alleys, speaks of the “silent mortality” that went on in the latter[20]. It was still more silent in earlier times, when the west end of London knew nothing of what was passing in the east end[21].

In all matters of public health, after the somewhat romantic interest in plague had ceased, the poorer parts of London were for long an unexplored territory. Dr John Hunter, who had been an army physician and was afterwards in practice in Mayfair, began about the year 1780 to visit the homes of the poor in St Giles’s or other parishes near him, and was surprised to find in them a fever not unlike the hospital typhus of his military experience. I quote at this stage only a sentence or two[22].

“It may be observed, that though the fever in the confined habitations of the poor does not rise to the same degree of violence as in jails and hospitals, yet the destruction of the human species occasioned by it must be much greater, from its being so widely spread among a class of people whose number bears a large proportion to that of the whole inhabitants. There are but few of the sick, so far as I have been able to learn, that find their way into the great hospitals in London.” I shall defer the subject of the dwellings of the working class in London until a later stage.

The “constitution” in Sydenham’s series which succeeded the febrile one of 1661-64 was “pestilential fever.” It began in the end of 1664, lasted into the spring of 1665, and passed by an easy transition into the plague proper. The bills for those months have very large weekly totals of deaths from “fever,” as well as a good many deaths from “spotted fever,” before they begin to have more than an occasional death from plague. It is this particular form of typhus fever that Bateman had in mind when he wrote, in 1818, “We never see the pestilential fever of Sydenham and Huxham”; although Willan, who preceded him at the Carey Street dispensary, described in 1799 a fever of so fatal a type that it gave rise to the rumour that the plague was back in London. The term “pestilential” was technically applied to a kind of fever a degree worse than the “malignant.”

Willis, the earliest of the Restoration authorities on fevers, had three names in an ascending scale of severity--putrid, malignant and pestilential. The putrid fevers were what we might call idiopathic, engendered within the body in some way personal to the individual from “putrefaction” or fermentation of the humours; all the intermittents were included in that class, and the theory of their cure by bark was that the drug corrected putridity. In the malignant and pestilential, an altogether new element came in--the τὸ θεῖον of Hippocrates, the mysterious something which we call infection; and of these two infectious fevers, the malignant was milder than the pestilential[23].

Morton drew out the scale of fevers in an elaborate classification, of which only the last section of continued contagious fevers concerns us at present[24]:

{ {Fever mostly with sweats and {Simple Malignant Fever {other signs of malignity, but { {without buboes, carbuncles, { {petechiae or miliary rash. Synochus { { {Fever with petechiae, purple {Pestilential Fever {spots, miliaria, morbillous rash { {on the chest. { {Plague {With buboes, carbuncles and { {black spots.

The order in this Table was also the order in time: the fever of 1661, which Willis calls malignant, remained as the constitution of the years following until the end of 1664; then began the pestilential, which passed definitely in the spring of 1665 into the plague proper. Willis, Sydenham and Morton, differing as they did on many points of theory and treatment, all alike taught the scale of malignity in fevers and plague, and all used the language of “constitutions.” The Great Plague of 1665 was, in their view, the climax of a succession of febrile constitutions of the air, being attended by much pestilential fever and followed by a fever which Morton places in the milder class of συνεχής.

The epidemic Constitutions following the Great Plague.

During the ten or twelve years following the Great Plague of London, the epidemic maladies which Sydenham dwelt most upon as the reigning types will appear on close scrutiny to have been on the whole proper to the earlier years of life. This cannot be shown in the simple way of figures; for the ages at death from the several maladies, although they were in the books of the Parish Clerks, were not published.

There was some continued fever every year, which we may take to have been chiefly the endemic typhus of a great city, and there were also deaths among adults due to those reigning epidemics which fell most on the young. In 1667 and 1668 the leading epidemic was smallpox, with a continued fever towards the end of the period which Sydenham called “variolous,” for no other reason, apparently, than that it was part of a variolous constitution. In the autumn of 1669, and in the three years following, the epidemic mortality was peculiarly infantile, in the form of diarrhoea or “griping in the guts,” with some dysentery of adults, and some measles in 1670. From 1673 to 1676, the constitution was a comatose fever, which chiefly affected children, with a sharp epidemic of measles in the first half of 1674, attended by a very high mortality from all causes, and a severe smallpox in the second half of 1674, attended by a much lower mortality from all causes. There was also an influenza for a few weeks in 1675. In 1678 the “intermittent” constitution returned, having been absent for thirteen years, and continued through 1779-80, until its “strength was broken.” In 1681 smallpox was unusually mortal, the deaths being more than in any previous year. Most of these constitutions fall to be dealt with fully in other chapters: but as we are here specially concerned with the succession to the plague, it is to be noted how largely the epidemic mortality in London fell upon the age of childhood for a number of years after the Great Plague of 1665. It was observed both by English and foreign writers that the next epidemic following the Black Death of 1348-49, namely, that of 1361 in England and of 1359-60 in some other parts of Europe, fell mostly upon children and upon the upper classes of adults. There is doubtless some particular application of the population principle in the earlier instance as in the later, but not the same application in both. The conditions at the beginning of the three hundred years’ reign of plague in Britain were different from those at the end of it. The increased prevalence of smallpox in the generation before the last great outburst of plague, and the infantile or puerile character of the epidemic fever of 1661, as described by Willis, show that the incidence of infectious mortality had already begun to shift towards the age of childhood. It looks as if the conditions of population, intricate and obscure as they must be confessed to be, were somehow determining what the reigning infectious maladies, with their special age-incidence, should be. Such a gradual change is the more probable for the reason that infectious mortality came in due time to be mostly an affair of childhood. The plague, which was the great infection of the later medieval and earlier modern period, was peculiarly fatal to adult lives; on the other hand, the mortality from infectious diseases in our own time falls in much the larger ratio upon infants and children. It looks as if this change, now so obvious, had begun before the end of plague in Britain, having become more marked in the generation following its extinction. The direct successor of plague, so far as concerns age-incidence and nosological affinity, was the pestilential or malignant typhus, which came into great prominence in 1685-86, in circumstances that seemed to contemporaries to forebode a return of the plague. But before we come to that, there remains a little to be said of some other fevers, especially of the comatose fever of 1673-76, which was largely an affair of childhood.

Pepys says that he went on 3 May, 1668, to Old Street (St Luke’s) to see Admiral Sir Thomas Teddiman, “who is very ill in bed of a fever,” and, in a later entry, that he “did die by a thrush in his mouth” on the 12th of May. Next year, 1669, Pepys and his wife went on tour through several parts of Europe, and had hardly returned to their house in Seething Lane when the lady fell ill of a fever; on 2nd November, it was “so severe as to render her recovery desperate,” and on 10th November she died, in her 29th year,--a surprising sequel, as her husband felt, to a “voyage so full of health and content.” These two years, for which we have a sample of the London fevers, were marked in the Netherlands by epidemics of fevers which are among the most extraordinary in the whole history. At Leyden in 1669 the fever reached such a height as to cut off 7000--a mortality which would not have been surprising if the disease had been plague; but it was not plague, it wanted the buboes, carbuncles &c., was longer in its course, and, strangest of all, affected the upper classes far more severely than the poor, so much so “that of seventy men administering the public affairs, scarcely two were left[25],” while, according to Fanois, who was the Leyden poor’s doctor, the lower classes, “protected as it were by having survived the simpler forms of fever,” suffered from this malignant epidemic far less than the rich[26]. The mortality is said to have risen as high as three-fourths of the attacks. At Haarlem the burials in a week rose to three or four hundred (which was a fair week’s average for London itself in an ordinary season), the epidemic lasting four months and leaving hardly one family untouched. Among the symptoms were extreme praecordial anxiety, weight at the pit of the stomach, constant nausea and loathing, vomiting, in part bilious but chiefly “pituitous,” thirst and restless tossing. It was attended by an affection of the throat and mouth--an angina with aphthae or thrush of the palate. The pools and other sources of water for domestic use were unusually stagnant that summer in Holland, and were commonly blamed for the epidemic; but Fanois points out that at Haarlem and Emden, where similar fevers raged, “salubriores non desunt aquae[27].”

After such an instance as the Leyden fever of 1669, nothing is incredible in the records of fever subsequent to the extinction of plague. Turning to Sydenham’s account of the continued fever which occurred in London during the same season, the latter half of 1669, as well as in the three years following, we find that it was characterized rarely by diarrhoea or sweats, commonly by pain in the head, by a moist white tongue which afterwards became covered by a dense skin, and by a greater tendency than Sydenham had ever seen to aphthae (the “thrush in the mouth” of Admiral Teddiman in 1668) when death threatened--the same being a “deposition from the blood of foul and acrid matter upon the mouth and throat.” But London in 1668 and 1669 suffered little from fevers in comparison to Leyden, Haarlem and other Dutch towns, its high mortality in the summer and autumn of 1669 being from infantile diarrhoea, cholera nostras and dysentery.

Sydenham’s continued fever from 1673 to 1676 (he was absent from his practice in 1677 owing to ill health) was a malady which affected adults as well as children, but, it would appear, the latter especially. The only characteristic case given is of a boy of nine who did not begin to mend until the thirtieth day. Many recovered in a fortnight, while others were not clear of the fever in a month. On account of the remarkable stupor which almost always attended it, Sydenham called the fever of this constitution a comatose fever. It began with sharp pains in the head and back, pains in the limbs, heats and chills, etc. His account of the comatose state is exactly like that given by Willis for the fever of children in 1661--profound stupor, sometimes for a week long, so profound in some as to pass into absolute aphonia (the “acute fever with dumbness” of later writers), while others would talk a few words in their sleep, or would seem to be angry or perturbed by something (the chimaeras mentioned by Willis) and would then become tranquil again; when roused to take physic or to drink they would open the eyes for a moment and then fall back into stupor. When they began to mend, they would crave for absurd things to eat or drink. During convalescence the head, through weakness, could not be kept straight but would incline first to one side and then to the other[28].

The years 1678-1680 witnessed remarkable epidemics of ague, such as had occurred on several occasions before, the last in the years 1657-59. They engross so much of Sydenham’s writing, especially in connexion with the Peruvian-bark controversy, that we hear little of any other fever until the great epidemic of continued fever, or typhus, in 1685-6. But he does mention briefly that the interval between the decline of the agues in 1680 and the beginning of the “new fever” of 1685, was occupied by “continued depuratory” fevers--depuratory of the dregs of the preceding intermittent constitution, and comparable in that respect to the fevers of 1661-64 which followed the agues of 1657-59[29].

Sydenham’s term “depuratory” does not help us much; but we learn something from Morton as to what fevers were prevalent, besides the epidemical intermittents, in the years preceding the epidemic of 1685-86. Morton classes them as continued συνεχής (Synocha), by which he means something less malignant than Synochus. A fever which began in the milder form would often degenerate into the more malignant, the cause assigned, in the usual recriminatory manner of the time between rival schools, being mistaken treatment. But sometimes the fever was malignant from the outset, with purple spots, petechiae, morbillous efflorescence, watery vesicles on the neck and breast, buboes, and anthraceous boils. All these fevers, says Morton, whether they were spurious forms of synocha, or malignant from the outset, were sporadic, “neque contagione, ut in pestilentiali constitutione, sese propagabant[30].” This points to their having been part of that strange aguish epidemic of which an account is given in another chapter. In Short’s abstracts of parish registers, the year 1680 seems to have been the most unhealthy of the series in country parishes, and that is borne out by one Lamport, or Lampard, an empiric who practised in Hampshire: “I will tell you somewhat concerning a malignant fever. In the year ’80 or ’81 there were great numbers of people died of such fevers, many whereby were taken with vomitings, etc., yet I had the good fortune to cure eighteen in the parish of Aldingbourn, not one dying, in that great compass, of that disease[31].” The moral is that the empiric recovered his cases, whereas the regular faculty lost theirs; which means that the fevers were of various degrees, some aguish, some typhus, as in the exactly similar circumstances a century after, 1780-85.

In the London Bills from 1681 to 1684, the deaths from fever were many, with some from “spotted fever” nearly every week, while the annual mortalities from all causes were high. It is the more remarkable, therefore, that Sydenham should have discovered, in the beginning of 1685, the outbreak of a new fever, different from any that had prevailed for seven years before. The explanation seems to be that a malignant typhus fever, such as might have been discovered in any year in the crowded parishes where the working classes lived, broke out at the Court end of the town, where Sydenham’s practice lay.

The epidemic fever of 1685-86.

A letter of 12 March, 1685, says: “Sir R. Mason died this morning in his lodging at Whitehall. A fever rages that proves very mortal, and gives great apprehensions of a plague[32].” Sydenham also was reminded of the circumstances preceding the Great Plague of London in 1665. In his first account of the epidemic of fever in 1685[33], which began with a thaw in February, he points out that the thaw in March, 1665, had been followed by pestilential fever and thereafter by the plague proper. In a later reference, when the epidemic of fever was in its second year (1686) he says: “How long it may last I shall not guess; nor do I quite know whether it may not be a certain more spirituous, subtle beginning, and as if primordium, of the former depuratory fever (1661-64) which was followed by the most terrible plague. There are some phenomena which so far incline me to that belief[34].” However, no plague followed the malignant, if not pestilential, fever of 1685-86. The reign of plague, as the event showed, was over; the fever which had been on former occasions its portent and satellite, came into the place of reigning disease. It is true that Sydenham does not identify the fever of 1685-86 by name as pestilential fever; on the contrary, he entitles his essay “De Novae Febris Ingressu.” But the novelty of type was partly in contrast to the fevers immediately preceding, which admitted treatment by bark, and its principal difference from the pestilential fever of former occasions seems to have been that it was not followed by plague[35]. Its antecedents and circumstances were very much those of plague itself. Its mortality was greatest in the old plague-seasons of summer and autumn, it had slight relation to famine or scarcity, or to other obvious cause of domestic typhus. Sydenham can find no explanation of the new constitution but “some secret and recondite change in the bowels of the earth pervading the whole atmosphere, or some influence of the celestial bodies.” He enlarges, however, on the character of the seasons preceding, which would have affected the surface, if not the bowels, of the earth, and the levels of the ground-water.

The winter of 1683-84 was one of intense frost; an ice-carnival was held on the Thames during the whole of January. The long dry frost of winter was followed by an excessively hot and dry summer, the drought being such as Evelyn did not remember, and as “no man in England had known.” For eight or nine months there had not been above one or two considerable showers, which came in storms. The winter of 1684-85 set in early, and became “a long and cruel frost,” more interrupted, however, than that of the year before. The spring was again dry, and it was not until the end of May 1685 that “we had plentiful rain after two years’ excessive drought and severe winters[36].”

The two years of excessive drought, with severe winters, had their effect upon the public health, as will appear from Short’s abstracts of parish registers in town and country[37]; the years 1683-85 being conspicuous for the excess of burials over baptisms:

Country Parishes.

Year Registers Registers with Deaths in Births in examined excess of death them them

1683 140 37 923 685 1684 140 31 900 629 1685 140 19 574 478 1686 140 16 419 301 1687 143 19 522 427 1688 143 11 327 267

Towns.

1683 25 8 1398 1169 1684 25 8 1243 865 1685 25 4 1191 741 1686 25 2 555 418 1687 25 1 313 269 1688 25 2 191 146

There is no clue to the forms of sickness that caused the excessive mortality in country parishes and provincial towns. But in London it appears from the Bills that the one great cause of the unusual excess of deaths in 1684 was an enormous mortality from infantile diarrhoea, from the end of July to the middle of September, during the weather which Evelyn describes as excessively hot and dry with occasional storms of rain.

It was in the second year of the long drought, February, 1685, that Sydenham dated the beginning of his new febrile constitutions. The mortality of 1685 was just twenty deaths more than in 1684 (23,222); but fever (with spotted fever) and smallpox had each a thousand more out of the total than in the year before. Sydenham says that the fever did not spare children, which might be alleged of typhus at all times; but a fever of the kind, even if it ran through the children of a household, seldom cut off the very young, the mortality being in greatest part of adults and adolescents. Excepting smallpox for the year 1685, infantile and children’s maladies were not prominent during the constitution of the “new fever;” the usual items of high infantile mortality, such as convulsions and “griping in the guts” or infantile diarrhoea, were moderate and even low. Hence, although the weekly fever-deaths in the following Table may not appear sufficient for the professional and other interest that they excited, it is to be kept in mind that they had been mostly of adult lives. It is probable also that a good many of them had been among the well-to-do, and perhaps at first in the West End; for there is nothing in the height of the weekly bills for all London to bear out the remark of the letter of 12 March, already quoted, “A fever rages that proves very mortal and gives apprehensions of a plague.”

Weekly Mortalities in London.

1685.

Week Of spotted Of Of griping ending Dead Of fever fever smallpox in the guts

March 3 376 49 0 11 35 10 458 73 2 30 31 17 367 53 1 25 17 24 441 63 3 33 27 31 366 53 5 24 36 April 7 421 47 10 28 30 14 433 64 8 32 27 21 473 66 6 47 45 28 470 68 3 49 45 May 5 385 50 6 35 39 12 447 75 3 59 41 19 437 79 4 58 43 26 452 61 2 74 39 June 2 469 65 8 65 36 9 521 88 14 62 41 16 499 91 9 66 34 23 478 76 12 71 53 30 526 82 13 84 45 July 7 497 81 8 87 53 14 478 82 11 78 51 21 464 79 11 87 47 28 488 62 6 68 54 Aug. 4 493 82 5 86 51 11 529 109 13 89 47 18 580 74 13 99 71 25 536 91 7 67 85 Sept. 1 556 94 13 53 104 8 539 82 10 81 77 15 485 90 7 63 70 22 459 90 10 37 51 29 502 114 3 58 53 Oct. 6 444 108 11 40 54 13 445 89 13 61 38 20 369 86 5 40 28 27 379 73 7 29 45 Nov. 3 443 96 8 55 43 10 410 84 7 26 35 17 432 103 8 35 39 24 471 107 6 56 31 Dec. 1 384 87 4 36 24 8 452 98 8 49 24 15 403 69 3 29 47 22 438 99 2 34 27 29 432 80 9 28 28

Weekly Mortalities in London.

1686.

Week Of spotted Of Of griping ending Dead Of fever fever smallpox in the guts

Jan. 5 394 80 5 28 29 12 400 80 3 27 48 19 396 67 5 36 32 26 366 76 2 21 30 Feb. 2 452 87 8 16 30 9 416 78 5 37 30 16 405 94 9 20 25 23 419 74 7 16 40 March 2 417 84 1 20 37 9 455 95 6 18 30 16 415 71 10 31 21 23 453 78 11 22 46 30 372 58 8 17 35 April 6 392 80 11 13 27 13 393 72 7 21 29 20 420 61 10 26 37 27 471 99 9 27 22 May 4 429 78 21 28 46 11 374 71 6 16 22 18 395 69 5 17 3 (sic) 25 395 66 11 24 36 June 1 383 63 4 15 49 8 404 66 6 26 38 15 523 88 9 43 64 22 503 99 9 25 73 29 473 90 10 31 62 July 6 430 71 6 18 62 13 401 76 2 19 56 20 464 87 14 24 74 27 508 99 3 23 76 Aug. 3 506 86 9 14 90 10 493 74 7 14 104 17 522 99 7 26 101 24 536 115 5 18 104 31 520 90 8 22 93 Sept. 7 531 94 4 21 104 14 498 84 6 18 110 21 540 100 3 17 101 28 443 90 5 13 67 Oct. 5 425 81 4 13 60 12 432 96 2 9 56 19 391 73 1 9 33 26 402 79 3 11 43 Nov. 2 373 64 1 23 39 9 456 85 1 19 31 16 401 73 2 9 23 23 359 61 4 10 54 30 397 68 1 7 34 Dec. 7 359 76 0 9 21 14 438 60 0 8 46 21 354 49 1 8 39 28 356 53 2 9 32

Sydenham says that he regarded the new fever at first as nothing more than the “bastard peripneumony” which he had described for previous seasons; but he had soon cause to see that it wanted the violent cough, the racking pain in the head during coughing, the giddiness caused by the slightest movement, and the excessive dyspnoea of the latter (Huxham likewise distinguished typhus from “bastard peripneumony”). The early symptoms of the “new fever” were alternating chills and flushings, pain in the head and limbs, a cough, which might go off soon, with pain in the neck and throat. The fever was a continued one, with exacerbation towards evening; it was apt to change into a phrensy, with tranquil or muttering delirium; petechiae and livid blotches were brought out in some cases (Sydenham thought they were caused by cordials and a heating regimen), and there were occasional eruptions of miliary vesicles. The tongue might be moist and white at the edges for a time, latterly brown and dry. Clammy sweats were apt to break out, especially from the head. If the brain became the organ most touched, the fever-heat declined, the pulse became irregular, and jerking of the limbs came on before death.

Later writers, for example those who described the great epidemic fever of 1741, have identified the fever of 1685-86 with the contagious malignant fever afterwards called typhus, and Murchison, in his brief retrospect of typhus in Britain, has included it under that name. Sydenham mentions petechiae and livid blotches in some cases, and the Bills give a good many of the deaths in the worst weeks of the epidemic under the head of “spotted fever.” It is not at first easy to understand why Sydenham should have written an essay specially upon it, in September, 1686, to claim it as a new fever[38] and not rather as the old pestilential fever--“populares meos admonens de subingressu novae cujusdam Constitutionis, a qua pendet Febris nova species, a nuper grassantibus multum abludens.” It should be kept in mind that his motive was correct treatment, and that the fashionable treatment of the day by Peruvian bark was, in his judgment, unsuited to this fever, however much it may have suited the epidemical intermittents of 1678-79 and the “depuratory” dregs of them for several years after. Physicians, he says, had learned to drive off by bark the fevers of the former constitution, from 1677 to the beginning of 1685, even when the fever intermitted little and sometimes when it intermitted not at all; and they saw an indication for bark in the nocturnal exacerbations of the new fever. Sydenham found that even large doses of bark did not free the patient from fever, and that restoration to health under treatment with the bark was due “magis fortunato alicui morbi eventu quam corticis viribus.” He seeks to establish the indications for another treatment by setting forth the symptoms minutely; and as the question of bark in fevers was the great medical question of the time, this may well have been Sydenham’s motive for discovering in the epidemic of 1685-6 a “new fever” although he does not say so in as many words. We have a good instance of how the bark-craze was at this time influencing the very highest circles of practice in the case of Lord Keeper Guildford, in July, 1685, as related in another chapter.

It will be seen from the table of weekly deaths that the second of the two hard winters was over before the fever began to attract notice. Sydenham compares its beginning after the thaw in February, 1685, to the beginning of the plague when the frost broke in March, 1665.

If it had been merely the typhus of a hard winter, of overcrowding indoors, of work and wages stopped by the frost, and of want of fuel (which things Evelyn mentions as matters of fact), it would have come sooner than the spring of 1685. The Bills for years before have regularly a good many deaths from fever, and always some from spotted fever; but these may have come from parishes wholly beyond the range of Sydenham’s practice. The fever began definitely for him in February, 1685, and was at its worst in the old plague-seasons of summer and autumn. If the seasons had any relation at all to it, the epidemic was a late effect of the long drought, an effect which was manifested most when the rain came, in the summer of 1685 and throughout the mild winter and normal summer of 1685-86. It must have been for that reason that Sydenham traced the source of it to “some secret and recondite change in the bowels of the earth,” rather than to a change in the sensible qualities of the air. One must ever bear in mind that the physicians of the Restoration gave no thought to insanitary conditions of living; in that respect the later Stuart period seems to have been behind the Elizabethan or even the medieval; we cannot err in assuming, behind all Sydenham’s speculative causes, a great deal of unwholesomeness indoors. Sydenham’s fullest reference to the subterranean sources of poisonous miasmata occurs in his tractate on Gout:

“Whether it be that the bowels of the earth, if one may so speak, undergo various changes, so that by the accession of vapours exhaled therefrom the air is disturbed, or that the whole atmosphere is infected by a change which some peculiar conjunction of certain of the heavenly bodies induces in it;--the matter so falls out that at this or that time the air is furnished with particles that are adverse to the economy of the human body, just as at another time it is impregnated with particles of a like kind that agree ill with the bodies of some species of brute animals. At these times, as often as by inspiration we draw into the naked blood miasmata of this kind, noxious and inimical to nature, and we fall into those epidemical diseases which they are apt to produce, Nature raises a fever,--her accustomed means of vindicating the blood from some hostile matter. And such diseases are commonly called epidemical; and they are short and sharp because they have thus a quick and violent movement[39].”

It was Sydenham’s intimate friend Robert Boyle who worked out the hypothesis of subterraneous miasmata as a cause of epidemic (and endemic) diseases. An account of his theory will be found in the chapter on Influenzas and Epidemic Agues. It may be said here that it needs only a few changes, especially the substitution of organic for inorganic matters in the soil, to bring it into line with the modern doctrine of miasmatic infective disease as expounded by the Munich school.

It has not been usual to think of spotted fever, (or of influenzas), in that connexion; but a telluric source of the epidemic constitution of 1685-86 was clearly Sydenham’s view; and as the fever came in circumstances like those of the last great plague, and was thought at the time to be the forerunner of another great plague, its connexion with recondite decompositions in the soil, dependent on the phenomenal drought of two whole years before, cannot be set aside as a possibility, the less so that the fever, although of the type of typhus, was not a fever of cold, hunger, and domestic distress, but mainly of the warm, or mild, or soft weather following the long drought, and of many well-to-do-people, as in the great Netherlands fever of 1669. My view of it is that it was the modified successor of plague, the pestis mitior, which used to precede and accompany the plague, now become the dominant constitution. The authentic figures of its mortality come from London; but Sydenham says that its “effects were felt far more in other places”; although Short’s abstracts of parish registers, given above, do not indicate excessive mortality throughout England.

Retrospect of the great Fever of 1623-25.

The most instructive instance of pestis mitior in Britain is not the pestilential fever which led up to the last plague (1665-6), but the great epidemic of fever all over England and Scotland which reigned for two or three years before the great outburst of plague in 1625. I go back to this because it was not wholly or even mainly a famine fever (although it was as general as one of the medieval famine-fevers), and because in that respect it furnishes a close parallel to the fever of 1685-86, which I regard as the successor of the plague. After this interlude in the history, we shall proceed to consider the question of the final extinction of plague.

In Scotland the fever of 1622-23 was directly connected with famine, but in England it was not obviously so according to the records that remain. The dearth in Scotland began as early as the autumn of 1621: “Great skarsitie of cornes throw all the kingdome,” the harvest having been spoiled by wet weather and unheard of river floods; however, abundance of foreign victual came in, and the scarcity was got over[40]. In England the same harvest of oats was abundant, and probably yielded the “foreign victual” which relieved the Scots; but the price of wheat rose greatly[41]. It was the year following, 1622, that really brought famine and famine-sickness to Scotland, as the second of two bad harvests had always done. On 21 July, 1622, a fast was proclaimed at Aberdeen for “the present plague of dearth and famine, and the continuance thereof threatened by tempests, inundations and weets likely to rot the fruit on the ground[42].”

In an entry of the Chronicle of Perth, subsequent to July, 1622, it is said: “In this yeir about the harvest and efter, thair wes suche ane universall seikness in all the countrie as the ellyke hes not bene hard of. But speciallie in this burgh, that no familie in all the citie was frie of this visitation. Thair was also great mortalitie amonge the poore.” From which it appears that the autumnal fever of 1622 was among all classes in Scotland. The famine in Scotland became more acute in the spring and summer of 1623; the country swarmed with beggars, and in July, says Calderwood, the famine increased daily until “many, both in burgh and land, died of hunger.” At Perth ten or twelve died every day from Midsummer to Michaelmas; the disease was not the plague, but a fever[43]. At Dumfries 492 died during the first ten months of 1623, perhaps a ninth part of the inhabitants, about one hundred of the deaths being specially marked as of “poor[44].” The “malignant spotted fever” which caused numerous deaths in 1623 in Wigton, Penrith and Kendal is clearly part of the famine-fever of Scotland extending to the Borders and crossing them. This is a famine-fever of the old medieval type, like that of 1196 which, according to William of Newburgh “crept about everywhere,” always the same acute fever, putting an end to the miseries of the starving, but attacking also those who had food.

The same spotted fever was all over England in 1623, but it did not, as in Scotland, come in the wake of famine. It is true that the English harvest of 1622 was a good deal spoiled; a letter of 25 September says[45]: “Though the latter part of this summer proved so far seasonable, yet the harvest is scant, and corn at a great price by reason of the mildews and blasting generally over the whole realm,” rye being quoted a few weeks later at 7/- the bushel and wheat at 10/-, although the average of wheat for the year, in Rogers’s tables, is not more than 51/1_d._ per quarter, while the average of next year falls to 37/8_d._ These were not famine-prices in England, and there is no evidence of general sickness directly after the harvest of 1622, when corn was dearest. Also, although the autumn of 1623 was a time of “continual wet” in England[46], the price of wheat remained moderate, and even low as compared with the rather stiff price of the winter of 1622-23. But it was not until the summer and autumn of 1623 that the spotted fever became epidemic in England. Short’s abstracts of the registers of market towns show how sickly that year was:

Year. No. of No. with Buried Baptised registers excess of in the in the examined. burials. same. same.

1622 25 4 442 345 1623 25 16 2254 439 (sic) 1624 25 9 978 714 1625 25 9 666 563

In September, 1623, the corporation of Stamford made a collection “in this dangerous time of visitation,” and sent £10 of it to Grantham, the rest to go “to London or some other town, as occasion offered.” A London letter of 6 December, 1623, from Chamberlain to Carleton says[47]:--

“Here is a contagious spotted or purple fever that reigns much, which, together with the smallpox, hath taken away many of good sort, as well as meaner people.” He then gives the names of notables dead of it, and adds: “Yet many escape, as the dean of St Paul’s [Dr Donne, who used the occasion to compile a manual of devotion] is like to do, though he were in great danger.” One of the Coke family writes early in January, 1624, from London[48]: “Having two sons at Cambridge, we sent for them to keep Christmas with us, and not many days after their coming my eldest son Joseph fell suddenly into the sickness of the time which they call the spotted fever, and which after two days’ extremity took away his life.” From another letter it appears that one of his symptoms was “not being able to sleep,” the unmistakable vigil of typhus. Although there is no word of the epidemic continuing in Scotland in 1624, it was undoubtedly as prevalent in England in that year as the year before, and prevalent in country houses as well as in towns and cities. Thus, on 7 August, 1624, Chamberlain writes: “The [king’s] progress is now so far off that we hear little thence, but only that there be many sick of the spotted ague, which took away the Duke of Lennox in a few days. He died at Kirby,” a country house in Northamptonshire[49]. On 21 August he writes again: “This spotted fever is cousin-german to it [the plague] at least, and makes as quick riddance almost. The Lady Hatton hath two or three of her children sick of it at her brother Fanshaw’s in Essex, and hath lost her younger daughter, that was buried at Westminster on Wednesday night by her father; a pretty gentlewoman, much lamented.” A letter of 4 September says there was excessive mortality in London, in great part among children (doubtless from the usual infantile trouble of a hot autumn, diarrhoea), while “most of the rest are carried away by this spotted fever, which reigns almost everywhere, in the country as ill as here.” Sir Theodore Mayerne, the king’s physician, confirms this, under date 20 August, 1624: the purple fever, he says, was “not so much contagious as common through a universal disposing cause,” seizing upon many in the same house, and destroying numbers, being most full of malignity[50]. It was clearly an inexplicable visitation. The summer was hot and dry, from which character of the season, says Chamberlain, “some have found out a far-fetched speculation, which yet runs current, and would ascribe it [the spotted fever] to the extraordinary quantity of cucumbers this year, which the gardeners, to hasten and bring forward, used to water out of the next ditches, which this dry time growing low, noisome and stinking, poisoned the fruit. But,” adds Chamberlain, “that reason will reach no farther than this [London] town, whereas the mortality is spread far and near, and takes hold of whole households in many places.” He then gives the names of several eminent persons dead of it, and speaks of others who were “still in the balance[51].” On 9 October, “the town continues sickly still,” and Parliament had been put off, “in consideration of the danger,” from 2 November, 1624, to 15 February, 1625. On Ash Wednesday, 1625, the Marquis of Hamilton died of the pestilent fever at Moor Park, Rickmansworth. Thus far there had been no plague; and if the spotted fever were cousin-german to the plague, as Chamberlain said, it was remarkable in this that it prevailed in the mansions of the rich in town and country and took off more victims among the upper classes than the plague itself even in its most terrific outbursts. However, a plague of the first rank followed in London and elsewhere in the summer and autumn of 1625.

The cucumber-theory, above mentioned, shows how puzzled people must have been to account for the spotted fever, or “spotted ague” as it was also called, in 1624. Sir Theodore Mayerne did not think contagion from person to person could explain it, but referred it to “some universal disposing cause.” It is conceivable that the famine-fever of 1622 and 1623 in Scotland and the Marches may have spread by contagion into England in the latter year; but in 1624 there is nothing said of fever in Scotland or of scarcity as a primary cause in England.

Besides the famine-fever of Scotland in 1622-23, there was another associated thing which should not be left out of account. Before the famine and fever had begun in that country, the notorious Hungarian fever was raging in the Palatinate, and continued to rage for four years. “Hungarian fever” had become the dreaded name for war-typhus of a peculiar malignity and diffusive power. It had been so often engendered since the 16th century in campaigns upon Hungarian soil as to have become known everywhere under the name of that country. Its infection spread, also, everywhere through Europe; thus it is said to have even reached England in 1566, and again in 1589, although it is not easy to find English evidence of it for either year. It was this type of fever which broke out in the Upper Palatinate, occupied by troops of the Catholic powers, in 1620, and continued through the years 1621, 1622 and 1623; as the title of one of the essays upon this outbreak somewhat fantastically declares, it spread “ex castris ad rastra, ex rastris ad rostra, ab his ad aras et focos[52].” Was the epidemic constitution of “spotted ague” in England in 1623 and 1624 derived from the centre of famine-fever in Scotland, or from the centre of camp-fever in the Palatinate? In the last years of James I. communications were frequent with the latter country, and there was of course much intercourse with Scotland.

The spotted fever or spotted ague of 1623-24, the plague of 1625, and the country agues of the same autumn make really a more instructive series of epidemic constitutions than any that fell under Sydenham’s observation, so instructive, indeed, that it has seemed worth while to revert to it for the sake of illustrating the doctrine of epidemics then in vogue. That doctrine made little of contagion from person to person; yet the idea of contagion was familiar, and had been so since medieval times. If we might assume contagion to explain such cases as those that occurred in the houses of squires and nobles, we might find a source of it either in the famine-fever of Scotland or in the war-fever of the Palatinate. But the teaching of the time was that it was in the air; and if the infective principle had been generated either in Scotland or on the upper Rhine it had diffused itself in some inscrutable way. The doctrine of epidemic constitutions seems strange to us; but some of the facts that it was meant to embrace are also strange to us. Were it not for an occasional reminder from influenza, we should hardly believe that any fevers could have travelled as the Hungarian fevers, the spotted fevers or “spotted agues” of former times are said to have done.

On the other hand, we have now a scientific doctrine of the effects of great fluctuations of the ground-water upon the production of telluric miasmata, which may be used to rationalize the theory of emanations adopted by Sydenham and Boyle. From this modern point of view the remarkable droughts preceding the pestilential fevers and plagues of 1624-25 and 1665, and preceding the fever of 1685-86, which is the one that immediately concerns us, may be not without significance.

The London fever of 1685-86 having been suspected at the time to be the forerunner of a plague, as other such fevers in the earlier part of the century had been, and no plague having ensued, the question arises most naturally at this stage, why the plague should have never come back in London or elsewhere in Britain after the great outbreak of 1665-66.

The extinction of Plague in Britain.

Plague had been the grand infective disease of Britain from the year of the Black Death, 1348-9, for more than three centuries, down to 1666. The last of plague in Scotland was in 1647-8, in the west and north-west of England about 1650 (in Wales probably in 1636-8), in Ireland in 1650, and in all other parts of the kingdom including London in 1666, the absolute last of its provincial prevalence having been at Peterborough in the first months of 1667[53], while two or three occasional deaths continued to occur annually in London down to 1679. False reports of plague, contradicted by public advertisement, were circulated for Bath in 1675[54], and for Newcastle in 1710[55]; while in London as late as 1799, during a bad time of typhus fever, the occurrence of plague was alleged[56].

It is not easy to say why the plague should have died out. It had been continuous in England from 1348, at first in general epidemics, all over the country in certain years, thereafter mostly in the towns, either in great explosions at long intervals or at a moderate level for years together. The final outburst in 1665, which was one of the most severe in its whole history, had followed an unusually long period of freedom from plague in London, and was followed, as it were, by a still longer period of freedom until at last it could be said that the plague was extinct. In some large towns it had been extinct, as the event showed, at a much earlier date; thus at York the last known epidemic was in 1604, and it can hardly be doubted that many other towns in England, Scotland and Ireland would have closed their records of plague earlier than they did had not the sieges and military occupations of the Civil Wars given especial occasion for the seeds of the infection to spring into life. Plague seemed to be dying out all over England and Scotland (in Ireland it is little heard of except in connexion with the Elizabethan and Cromwellian conquests) for some time before its final grand explosion in London in 1665.

In seeking for the causes of its decline and extinction we must keep prominently in view the fact that the virus was brought into the country from abroad as the Black Death of 1348-9. But for that importation it is conceivable that there would have been no signal history of plague in Britain. Its original prevalence was on a great scale, and there were several other widespread epidemics throughout the rest of the 14th century. In the first volume of this history I have collected evidence that plague was endemic or steady for long periods of the 15th and 16th centuries in London, with greater outbursts at intervals, and that in the 17th century it came chiefly in great explosions. Something must have served to keep the virus in the country, and more especially in the towns, until at length it was exhausted. An exotic infection, or one that had not arisen from indigenous conditions, and would probably never have so arisen, does not remain indefinitely in the country to which it is imported. Thus Asiatic cholera, imported into Europe on six, or perhaps five, occasions in the 19th century, has never become domesticated; and yellow fever had a career in the southern provinces of Spain during some twenty years only. Plague did become domesticated for about three centuries in England, and for longer in some other countries of Europe; but it died out at length, and it would almost certainly have died out sooner had it not found in all European countries some conditions not altogether unsuited to it. What were the favouring conditions?

If, as I believe, the virus of plague had its habitat in the soil, from which it rose in emanations, and if it depended therein, both remotely for its origin in some distant country, as well as immediately for its continuance in all countries, upon the decomposition of human bodies, then it is easy to understand that the immense mortalities caused by each epidemic would preserve the seeds of the disease, or the crude matters of the disease, in the soil. Buried plague-bodies would be the most obvious sources of future plagues. But if the theory given of the Black Death be correct, bodies dead of famine or famine-fever would also favour in an especial way the continuance of the plague-virus in certain spots of ground, although they would probably never have originated it in this country. Moreover, the products of ordinary cadaveric decomposition would be so much pabulum or nutriment for the continuance of the virus. But all those things being constant, the continuance of plague would largely depend upon the manner in which the dead, after plague, or after famine and fever, or in general, were disposed of. The soil of all England in 1348-9 was filled with multitudes of the dead laid in trenches, and there were several general revivals of plague in the fifty or sixty years following. In London there were plague-pits opened in the suburbs in many great epidemics during three centuries. Even when there was no epidemic the dead were laid in the ground in such a manner that their resolution was speedy, and the diffusion of the products unchecked. But it is undoubted that greater care in the disposal of the dead did at length come into vogue. Thus, in the Black Book of the Corporation of Tewkesbury there is an entry under the year 1603, that all those dead of plague, “to avoid the perill, were buried in coffins of bourde,” the disease having carried off no fewer than 560 the year before (1602) and being then in its second season.[57]. The reason given is “to avoid the peril,” and it is beyond question that burial in a coffin did in fact delay decomposition (unless in peculiar circumstances which need not be particularized), and kept the cadaveric products from passing quickly and freely into the pores of the ground. Again, if the burial were in such coffins as the Chinese commonly use, the decomposition would proceed almost as slowly as if the body had been embalmed, and with as little risk of befouling the soil. For a long time in England such burials were the privilege only of the rich; but as wealth increased by commerce they became the privilege of all classes; and in the last great plague of London, as I said in my former volume, “even at the worst time coffins would seem to have been got for most.” Defoe’s account of the burials in heaps in plague-pits is so exactly like that of Dekker for the plague of 1603, and of other contemporaries for the plague of 1625, that one may reasonably suspect him to have used these earlier accounts as his authority for the practice in 1665, which he had no direct knowledge of. However, I do not contend that there were no such burials in 1665; just as one learns from Dekker that the coffin-makers in 1603 were busily employed and grew rich, although he also describes how a husband “saw his wife and his deadly enemy whom he hated” launched into the pit “within a pair of sheets.” In ordinary times, as we learn from the tables of burial-dues, there were poorer interments without coffins as late as 1628, according to a document printed by Spelman, the name of the parish being withheld, and even as late as 1672 in the parish of St Giles’s, Cripplegate. Spelman’s object in writing in 1641 was to protest against the mercenary practices of the clergy in the matter of burial, recalling the numerous canons of the medieval Church directed against all such forms of simony; and incidentally he mentions that it was testified before the Commissioners that a certain parson “had made forty pound of one grave in ten yeeres, by ten pounds at a time”[58]--a “tenancy of the soil” short enough to satisfy even the so-called Church of England Burial Reform Association. The use of coffins in the burial of the very poorest is now so universal that we hardly realize how gradually it was introduced. I am unable to say when burial in a sheet or cerecloth ceased; but it became less and less the rule for the poorer classes throughout the 17th century. In 1666 was passed the Act for burial in woollen, which was re-enacted more strictly in 1678[59]. The motive of it was to encourage the native woollen manufactures, or to prevent the money of the country from being expended on foreign-made linen; and its clauses ordained that woollen should be substituted for linen in the lining of the coffin and in the shrouding of the corpse, but that no penalty should be exacted for burying in linen any that shall die of the plague. Whether it prohibited in effect the use of linen cerecloths to enshroud corpses where no coffin was used does not appear clearly from the terms of the Act; but, as the intention was to discourage the use of linen, and to bring in the use of woollen, for all purposes of burial, it is probable that it served to put an end to coffinless burials altogether, wherever it was enforced, inasmuch as the prescribed material was wholly unsuited for the purpose of a cerecloth.

The history of the London plague-pit between Soho and the present Regent Street shows that, after the last great plague of 1665-66, more caution was used against infection from the buried plague-bodies. Macaulay says it was popularly believed that the earth was deeply tainted with infection, and could not be disturbed without imminent risk to human life; and he asserts that no foundations were laid in the pest-field till two generations had passed and till the spot had long been surrounded with buildings, the space being left blank in maps of London as late as the end of George I.’s reign[60].

After 1666 the old churchyards were not less crowded than before, but more crowded, perhaps because coffined corpses occupied more space and decayed more slowly. On 17 October, 1672, Evelyn paid a visit to Norwich: “I observed that most of the churchyards (tho’ some of them large enough) were filled up with earth, or rather the congestion of dead bodys one upon another, for want of earth, even to the very top of the walls, and some above the walls, so as the churches seemed to be built in pitts.” The same day he had visited Sir Thomas Browne, the author of the famous essay on urn burial or cremation, (suggested to him by the digging up of forty or fifty funeral urns in a field at Old Walsingham). The essay is full of curious learning and equally curious moralizing. But Sir Thomas, though a physician, has not a word to say on so proximate a topic as the state of the Norwich churchyards, which came under his eyes and perhaps under his nose every day of his life[61].

The practice of burying in coffins, which came at length within the means of all classes, may seem too paltry a cause to assign, even in part, for so remarkable an effect as the absolute disappearance of plague after a duration of more than three centuries. My view of the matter is that the virus would have died out of itself had it not been continually augmented, or fed by its appropriate pabulum, and that the gradual change in the mode of interment helped to check such augmentation or feeding.

But the more elaborate interment of the dead was itself an index of the greater spending power of the community, and it may be said that it was the better condition of the people, and not this one particular thing in it, which put an end to the periodical recurrences of plague. In all but its earliest outbursts in the fourteenth, and perhaps the fifteenth century, plague had been peculiarly an infection of the poor, being known as “the poor’s plague.” Perhaps the chief reason why the richer classes usually escaped it was that they fled from the plague-tainted place, leaving the poorer classes unable to stir from their homes, exposed to the infectious air, and all the more exposed that their habitual employments and wages would cease, their sustenance become precarious, their condition lowered, and their manners reckless. Again, it was not unusual for the plague to break out in a season of famine or scarcity, during which the ordinary risks of the labouring class would be aggravated. Famines ceased (except in Ireland, where there had been comparatively little plague), and scarcities became less common. The sieges and occupations of the Civil Wars in the middle of the 17th century, which undoubtedly were the occasion of the last outbursts of plague in many of the towns, were a brief experience, followed by unbroken tranquillity. Whatever things were tending to the removal of plague in all its old seats had free course thereafter.

On the other hand, one may make too much of the increase of well-being among the labouring class which coincided with the cessation of plague. As a check upon population plague worked in a very remarkable way. In London, as well as in towns like Newcastle and Chester, plague towards the end of its reign arose perhaps once in a generation and made a clean sweep of a fifth or a fourth part of the inhabitants, including hardly any of the well-to-do. It destroyed, of course, many bread-winners and many that were not absolutely sunk in poverty; but its broad effect was to cut off the margin of poverty as if by a periodical process of pruning. The Lord Mayor of London wrote to the Privy Council at the end of the great plague of 1625: “The great mortality, although it had taken many poor people away, yet had made more poverty by decay of tradesmen”--a decay of trade which they might reasonably expect to recover from before long. No such ruthless shears was ever applied at intervals to the growing fringe of poverty in after times. The poor were a more permanent residue, pressing more upon each other; but they did not press more upon the rich, except through the poor rate; on the contrary, the separation of classes became more marked.

Perhaps I ought to give an illustration of this, so as not to leave so radical a change in the vague and disputable form of a generality. I shall take the instance of Chester; its circuit of walls, remaining from the Roman conquest, is something fixed for the imagination to rest upon amidst changes within and without them.

Passing over its medieval and its not infrequent Tudor experiences of epidemic sickness, let us come to the beginning of the 17th century. In two or three successive seasons from 1602 to 1605 it lost 1,313 persons by plague, as well as about 250 from other causes. The population was then mostly within the walls, and probably did not exceed 5000. There was a shipping quarter on the west side, with egress by the Water-gate to the landing-places on the Dee; a millers’ quarter, with corn-market and hostelries, on the south, connecting by the South gate and bridge with a hamlet across the river along the road to Wales; a Liberty or Freedom of the city outside the walls on the east, along the road to Warrington and Manchester, with a Bar, a short distance out, as in London, to mark the limit of the mayor’s jurisdiction; and on the north side, within the walls, the cattle-market and shambles, with the market for country produce, and a few straggling houses without the gate on the road leading to Liverpool. Chester was a characteristic county town, with its cathedral clergy, its garrison, its resident nobility and gentry, its professional classes, its tradesmen, market people and populace, with the addition of a shipping trade to Ireland and afterwards to foreign and colonial ports. Plague continuing from 1602 to 1605 cut off a fourth or a fifth of its population, and these the poorest. The gaps in the population would gradually have filled up, and the fringe of poverty grown again[62].

The plague came again in 1647, and cut off 2053 in the short space of twenty-three weeks from 22 June to 30 November. The bills of it are extant[63], and show on what parishes the plague fell most. All the parishes were originally within the walls but one, St John’s, the ancient collegiate church of Mercia, built upon a rocky knoll in the south-east angle made by the walls with the river. The other nine parish churches and their graveyards were within the walls; but the parishes of three of them extended beyond the gates, just as the three parishes dedicated to St Botolph at the gates of London did. These three were St Oswald’s, which included the Liberty on the east side, Trinity, which included the shipping quarter on the west as well as the houses along the Liverpool road on the north, and St Mary’s, which included the millers’ suburb across the Dee on the south. Hollar’s map, made a few years after the plague of 1647, shows very few houses beyond the walls, except in the ancient Liberty on the east. But it will appear from the following table that the parishes which had extended beyond the walls must either have been very crowded close up to the walls (as the Gate parishes were always apt to be), or there must have actually been a greater population outside the gates than the contemporary map shows:

Burials from Plague in the several Parishes of Chester in 23 weeks, June 22-Nov. 30, 1647.

5 parishes wholly within the walls.

Total. First Worst (7th) week. week.

St Peter 75 0 14 St Bridget 85 7 9 St Martin 173 9 23 St Michael 133 26 9 St Olave 59 3 5

3 parishes extending beyond the walls.

St Oswald 396 11 37 St Mary 314 5 20 Trinity 232 1 32

1 parish wholly without the walls.

St John 358 2 26 Pesthouse 228 0 34 ---- -- --- 2053 64 209

This was the last plague of Chester, but for a small outbreak in 1654. The next vital statistics that we get for the city are more than a century after, in 1774[64]. The population of 14,713 was then divided into two almost distinct parts, separated by the wall. The old city was being rebuilt, all but some ancient blocks of buildings held in the dead hand of the cathedral chapter; it was becoming a model 18th century place of residence for a wealthy and refined class, who were remarkably healthy and not very prolific, the parishes wholly within the walls having 3502 inhabitants. The poorer class had gone to live mostly outside the walls in new and mean suburbs, the three parishes at the Gates and extending now far beyond the walls, together with the original extramural parish of St John’s, having a population of 11,211. There was no town in Britain where the separation of the rich from the poor was more complete; there was hardly another town of the size where the health of the rich was better; and although the health of the populace was not so bad as in the manufacturing towns of Lancashire and Cumberland, close at hand, yet it is hardly possible to find so great a contrast as that between the clean and wholesome residential quarter within the walls and the mean fever-stricken suburbs as described by Haygarth in 1774:

“The inhabitants of the suburbs,” he says, “are generally of the lowest rank; they want most of the conveniences and comforts of life; their houses are small, close, crowded and dirty; their diet affords very bad nourishment, and their cloaths are seldom changed or washed.... These miserable wretches, even when they go abroad, carry a poisonous atmosphere round their bodies that is distinguished by a noisome and offensive smell, which is peculiarly disgustful even to the healthy and vigorous, exciting sickness and a sense of general debility. It cannot therefore be wondered that diseases should be produced where such poison is inspired with every breath.”

The case of Chester shows by broader contrasts than anywhere else the change from the public health of plague-times to that of more modern times. But it can hardly be said to show the populace better off than before; it shows them changed into a proletariat, and separated from the richer classes by walls several feet thick. Such, at least, was the result after four generations of immunity from plague, a result which indicates, as I have said, that we may easily make too much of the improved well-being of the poorer classes as a cause of the cessation of plague.

An easy explanation of plague ceasing in London has long been current, and just because it is an easy explanation it will probably hold the field for many years to come. It is that the fire of 1666 burnt out the seeds of plague. Defoe, writing in 1723, ascribed this opinion to certain “quacking philosophers,” but he would hardly have said so if he could have foreseen the respectable authority for it in after times. The plague had ceased in most of its provincial centres after the Civil Wars, and in some of them, such as York, from as early a date as 1604. It ceased in all the principal cities of Western Europe within a few years of its cessation in London. In London itself it ceased after 1666, not only in the City which was the part burned down in September of that year, but in St Giles’s, where the Great Plague began, in Cripplegate, Whitechapel and Stepney, where it was always worst, in Southwark, Bermondsey and Newington, in Lambeth and Westminster. Nor can it be said that the City was the source from which the infection used to spread to the Liberties and out-parishes. All the later plagues of London, perhaps even that of 1563, began in the Liberties or out-parishes and at length invaded the City. The part of London that was rebuilt after 1666 contained many finer dwelling-houses than before, built of stone, with substantial carpentry, and elegantly finished in fine and rare woods. The fronts of the new houses did not overhang so as to obstruct the ventilation of the streets and lanes; but the streets, lanes, alleys and courts were somewhat closely reproduced on the old foundations. A side walk in some streets was secured for foot-passengers by means of massive posts, which, with the projecting signs of houses and shops, were at length removed in 1766. The improvements in the City after the fire were mostly in the houses of the richer citizens. The City was the place of residence of the rich, with perhaps as many poorer purlieus in close proximity as the residential districts of London now have. But four-fifths of London at the time of the fire were beyond the walls of the City. It is in these extramural regions that the interest mostly lies for epidemical diseases. They remain, says Defoe in 1723, “still in the same condition they were in before.” Unfortunately we know little of their condition, whether in the 17th century or in the 18th. But there must have been something in it most unfavourable to health; for we find from the Bills of Mortality that the cessation of plague made hardly any difference to the annual average of deaths, the increase of population being allowed for. This fact makes the disappearance of plague all the more remarkable.

Fevers to the end of the 17th century.

The epidemical seasons of 1685-86 were the last that Sydenham recorded; he was shortly after laid aside from active work by gout, and died in 1689. Morton, who made notes of fevers and smallpox until 1694, is more a clinical observer than a student of “epidemic constitutions”; and although his writings are of value to the epidemiologist, he does not help us to understand the circumstances in which epidemic diseases prevailed more at one time than another. To the end of the century there is no other medical source of information, and little besides generalities to be collected from any source. It is known that the years from 1693 to 1699 were years of scarcity all over the kingdom, that the fever-deaths in London reached the high figure of 5036 in 1694, and that there was a high mortality in many country parishes and market towns during the scarcity. But there are few particular illustrations of the type of epidemic sickness. There is, therefore, little left to do but to give the figures, and to add some remarks.

Fever Deaths in the London Bills, 1687-1700.

Spotted Deaths Fever fever from all Year deaths deaths causes

1687 2847 144 21460 1688 3196 139 22921 1689 3313 129 23502 1690 3350 203 21461 1691 3490 193 22691 1692 3205 161 20874 1693 3211 199 20959 1694 5036 423 24109 1695 3019 105 19047 1696 2775 102 18638 1697 3111 137 20292 1698 3343 274 20183 1699 3505 306 20795 1700 3675 189 19443

Tables from Short’s Abstracts of Parish Registers.

Registers Registers with Deaths Births Year examined excess of death in them in them

Country Parishes.

1689 144 27 828 692 1690 146 17 532 324 1691 147 16 336 180 1692 147 10 207 146 1693 146 27 650 426 1694 148 18 465 348 1695 149 23 649 492 1696 150 19 503 344 1697 150 21 559 409 1698 152 12 397 289 1699 151 20 433 318 1700 160 29 890 739

Market Towns.

1689 25 12 1965 1415 1693 25 5 417 338 1694 25 6 1307 681 1695 25 3 309 246 1696 26 4 1020 708 1697 26 2 109 80 1698 26 4 575 423 1699 26 7 1181 867 1700 27 4 726 587

In the London figures the year 1694 stands out conspicuous by its deaths from all causes, and by its high total of fevers. The fever-deaths began to rise from their steady weekly level a little before Christmas, 1693, and remained high all through the year 1694, with a good many deaths from “spotted fever” in the worst weeks. Among the victims in London in February was Sir William Phipps, Governor of New England: his illness appeared at first to be a cold, which obliged him to keep his chamber; but it proved “a sort of malignant fever, whereof many about this time died in the city[65].” Pepys, writing to Evelyn on 10 August, 1694, calls it “the fever of the season,” three being down with it at his house, but well advanced in their recovery. In that week and in the week following, the deaths in London from all causes touched the highest points of the year, the deaths from fever and spotted fever being a full quarter of them. Fever at its worst in London never made more than a quarter of the annual deaths from all causes; so that, if we take it to have been the successor of the plague, it operated in a very different way--with a greatly lessened fatality of all that were attacked, with only a reminder of the old special incidence upon the summer and autumn seasons, but with a steadiness from year to year, and throughout each year, that made the fever-deaths of a generation little short of one of those enormous totals of plague-deaths that were rapidly piled up during a few months, perhaps once or twice in a generation.

The following table from the London weekly Bills shows the progress of the fever from the end of April, 1694, with the number of deaths specially assigned to “spotted fever”:--

London: Weekly Mortalities from fever and all causes, epidemic of 1694.

Week Spotted All ending Fever fever deaths

April 24 90 15 427 May 1 77 10 369 8 89 9 413 15 80 5 395 22 101 3 428 29 72 8 430 June 5 112 12 469 12 113 12 434 19 113 11 430 26 99 14 396 July 3 94 11 423 17 86 10 445 24 115 13 507 31 84 13 484 Aug. 7 99 10 462 14 110 20 530 21 135 19 583 28 111 20 510 Sept. 5 115 16 505 12 112 12 462 18 98 9 504 25 106 4 490 Oct. 2 124 8 533 9 125 10 553 16 114 9 552 23 104 3 511 30 118 3 528 Nov. 6 70 3 439 10 89 7 453 13 106 2 471 20 117 13 538 27 79 6 456 Dec. 4 87 6 475 11 87 3 407 18 78 4 445 25 66 3 394

The year 1694, to which the epidemic of malignant fever (as well as malignant smallpox) belongs, was one of the series of “seven ill years” at the end of the 17th century (1693-99). They were long noted, says Thorold Rogers, “for the distress of the people and for the exalted profits of the farmer.” The price of wheat in the autumn and winter of 1693 was the highest since the famine of 1661. In 1697-8 corn was again dear and much of it was spoilt. At Norwich in 1698 wheat was sold at 44_s._ a comb.

Harvests spoiled by wet weather or unseasonable cold appear to have been the most general cause of the high prices of food. In London there was no unusual sickness except in 1694; indeed the other years to the end of the century show a somewhat low mortality, the year 1696, which Macaulay marks as a time of severe distress among the common people owing to the calling in of the debased coinage[66], had the smallest number of deaths from all causes (18,638) since many years before, and for a century after allowing for the increase of population. But the deaths from “fever” were some three thousand every year, and the births, so far as registered, were, as usual, far below the deaths.

It was in the country at large that the effects of the “seven ill years” were chiefly felt. According to Short’s abstracts of parish registers, there was unusual mortality at the beginning of the period and at the end of it; in his Chronology he mentions spotted fever, bloody flux and agues in 1693 (besides an influenza or universal slight fever recorded by Molyneux of Dublin), and again in 1697 and 1698 “purples, quinsies, Hungarian and spotted fever, universal pestilential spotted fever,” from famine and bad food.

When we look for the evidence of this in England we shall have difficulty in finding it. Short’s own abstracts give almost no colour to it; but there are other figures from the parish registers, scattered through the county histories and statistical works, which prove that the seven ill years must have checked population. Thus at Sheffield in the ten years 1691-1700 there was the greatest excess of burials over baptisms in the whole history of the town from 1561--namely, 2856 burials to 2221 baptisms (688 marriages). At Minehead, Somerset, a parish of some 1200 people occupied in weaving, the deaths and births were as follows in four years of the decennium:

Baptised. Buried.

1691 57 75 1694 34 55 1695 47 48 1697 35 65

A glimpse of spotted or pestilential fever in Bristol during the years of distress at the end of the 17th century comes from Dr Dover, a man of no academical repute, but at all events an articulate voice. Passing from an account of the spotted pestilential fever at Guayaquil, “when I took it by storm,” he goes on[67]:

“About thirty-seven years since [written in 1732], this fever raged much in Bristol, so that I visited from twenty-five to thirty patients a day for a considerable time, besides their poor children taken into their workhouse, where I engaged myself, for the encouragement of so good and charitable an undertaking, to find them physick and give them advice at my own expense and trouble for the two first years. All these poor children in general had this fever, yet no more than one of them died of it of the whole number, which was near two hundred.”

--an experience of typhus in children which was strictly according to rule. This had clearly been the occasion of a memorial addressed to the Mayor and Aldermen of Bristol, in 1696, praying that a capacious workhouse should be erected for children and the aged, which “will prevent children from being smothered or starved by the neglect of the parish officers and poverty of their parents, which is now a great loss to the nation[68].”

The year 1698 was the climax of the seven ill years. The spring was the most backward for forty-seven years, the first wheat in the ear being seen near London on 16th June. For four months to the end of August the days were almost all rainy, except from the 18th to the 26th July. Whole fields of corn were spoilt. In Kent there was barley standing uncut on 29th September, and some lay in the swathe until December. Much of the corn in the north of England was not got in until Christmas, and in Scotland they were reaping the green empty corn in January[69].

Fevers of the seven ill years in Scotland.

It is from Scotland that we hear most of the effects of the seven ill years in the way of famine and fever. Scotland was then in a backward state compared with England; and its northern climate, making the harvest always a few weeks later than in England, told especially against it in the ill years. Fynes Morryson, in the beginning of the 17th century, contrasts the Scotch manner of life unfavourably with the English, and Sir Robert Sibbald’s account towards the end of that century is little better. Morryson says, “the excesse of drinking was then farre greater in generall among the Scots than the English.” Sibbald remarks[70] on the drinking habits of the Scots common people: their potations of ale or spirits on an empty stomach, especially in the morning, relaxed the fibres and induced “erratic fevers of a bad type, bastard pleurisies, ... dropsies, stupors, lethargies and apoplexies.” Morryson says: “Their bedsteads were then like cubbards in the wall, with doores to be opened and shut at pleasure, so as we climbed up to our beds. They used but one sheete, open at the sides and top, but close at the feete, and so doubled[71].” Sibbald says the peasantry had poor food and hard work, and were subject to many diseases--“heartburn, sleeplessness, ravings, hypochondriac affections, mania, dysentery, scrophula, cancer, and a dire troop of diseases which everywhere now invades the husbandmen that were formerly free from diseases.” Causa a victu est. Therefore consumption was common enough. He has much to say of fevers,--of intermittents, especially in spring and autumn, catarrhal fevers, nervous fevers, comatose fevers, with delirium, spasms and the like symptoms, malignant, spotted, pestilential, hectic, &c. The continued fevers ranged in duration from fifteen to thirty-one days, recovery being ushered in with sweats, alvine flux and salivation. Purple fevers had sometimes livid or black spots mixed with the purple (mottling); in a case given, there were suppurations which appear to have been bubonic. There had been no plague in Scotland since 1647-48; but fevers, unless Sibbald has given undue prominence to them, would appear to have filled its place among the adults.

Another writer of this period, from whom some information is got as to fevers, was Dr Andrew Brown of Edinburgh. He is mainly a controversialist, and is on the whole of little use save for the history of the treatment of fevers. He came to London on a visit in 1687, attracted by the fame of Sydenham’s method of curing fevers by antimonial emetics and by purgation: “Returning home as much overjoyed as I had gotten a treasure, I presently set myself to that practice”--of which he gave an account in his ‘Vindicatory Schedule concerning the New Cure of Fever[72].’ Continual fever, he says, takes up, with its pendicles, the half of all the diseases that men are afflicted with; and some part of what he calls continual fever must have been spotted: “As concerning the eruption of spots in fevers, these altogether resemble the marks made by stroaks on the skin, and these marks are also made by the stagnation and coagulation of the blood in the small channels [according to the doctrine of obstructions].... They tinge the skin with blewness or redness.”

The bitter controversy as to the treatment of fevers led Brown into another writing in 1699[73].

“The fevers that reign at this time [it was towards the end of the seven ill years] are for the most part quick and peracute, and cut off in a few days persons of impure bodies. And as I have used this method by vomiting and purging in many, and most successfully at this time, so I have had lately considerable experience thereof in my own family: wherein four of my children and ten servants had the fever, and blessed be God, are all recovered, by repeated vomiting with antimonial vomits and frequent purgings, except two servants, the one having gotten a great stress at work, who bragging of his strength did contend with his neighbour at the mowing of hay, and presently sickened and died the sixth day, and whom I saw not till the day before he died, and found him in such a condition that I could not give him either vomit or purge: and the other was his neighbour who strove with him, being a man of most impure and emaciate body, who had endured want and stress before he came to my service, and who got not all was necessary because he had not the occasion of due attendance, all my servants being sick at the time[74].”

This account of the experience which Dr Andrew Brown had lately had among his children and domestics in or near Edinburgh was written in 1699, and may be taken as relating to part of the wide-spread sickliness of the seven ill years in Scotland. Fletcher of Saltoun gives us a general view of the deplorable state of Scotland at the end of the 17th century, which was intensified by the succession of bad harvests[75]. The rents of cultivated farms were paid, not in money, but in corn, which gave occasion to many inequalities, to the traditional fraudulent practices of millers and to usury. The pasture lands for sheep and black cattle had no shelters from the weather, and no winter provision of hay or straw (roots were unheard of until long after), “so that the beasts are in a dying condition.” The country swarmed with vagrants (a hundred thousand, he estimates, in ordinary times, but doubled in the dear years), who lived and multiplied in incest, rioted in swarms in the nearest hills in times of plenty, and in times of distress fell upon farmhouses in gangs of forty or more, demanding food. Besides these there were a great many poor families very meanly provided for by the Church boxes, who lived wholly upon bad food and fell into various diseases. He had been credibly informed that some families in the years of mere scarcity preceding the climax of 1698-99 had eaten grains, for want of bread. “In the worst time, from unwholesome food diseases are so multiplied among poor people that, if some course be not taken, the famine may very probably be followed by a plague[76].”

We owe some details of these calamities in Scotland to Patrick Walker, the Covenanter, who records them to show how the prophecies of Divine vengeance on the land, uttered during the Stuart persecutions by Cargill and Peden, had been in due time fulfilled[77]:

“In the year 1694, in the month of August, that crop got such a stroke in one night by east mist or fog standing like mountains (and where it remained longest and thickest the badder were the effects, which all our old men, that had seen frost, blasting and mildewing, had never seen the like) that it got little more good of the ground. In November that winter many were smitten with wasting sore fluxes and strange fevers (which carried many off the stage) of such a nature and manner that all our old physicians had never seen the like and could make no help; for all things that used to be proper remedies proved destructive. And this was not to be imputed to bad unwholesome victual; for severals who had plenty of old victual did send to Glasgow for Irish meal, and yet were smitten with fluxes and fevers in a more violent and infectious nature and manner than the poorest in the land, whose names and places where they dwelt I could instance.

“These unheard-of manifold judgments continued seven years, not always alike, but the seasons, summer and winter, so cold and barren, and the wonted heat of the sun so much withholden, that it was discernible upon the cattle, flying fowls and insects decaying, that seldom a fly or gleg was to be seen. Our harvests not in the ordinary months, many shearing in November and December, yea some in January and February; the names of the places I can instruct. Many contracting their deaths, and losing the use of their feet and hands, shearing and working amongst it in frost and snow; and after all some of it standing still, and rotting upon the ground, and much of it for little use either to man or beast, and which had no taste or colour of meal. Meal became so scarce that it was at two shillings a peck, and many could not get it.

“Through the long continuance of these manifold judgments deaths and burials were so many and common that the living were wearied with burying of the dead. I have seen corpses drawn in sleds. Many got neither coffins nor winding-sheet.

“I was one of four who carried the corpse of a young woman a mile of way; and when we came to the grave, an honest poor man came and said, ‘You must go and help me to bury my son, he is lien dead this two days; otherwise I will be obliged to bury him in my own yard.’ We went, and there were eight of us had two miles to carry the corpse of that young man, many neighbours looking on us, but none to help us. I was credibly informed, that in the North, two sisters on a Monday’s morning were found carrying the corpse of their brother on a barrow with bearing-ropes, resting themselves many times, and none offering to help them.

“I have seen some walking about at sunsetting, and next day at six o’clock in the summer morning found dead in their houses, without making any stir at their death, their head lying upon their hand, with as great a smell as if they had been four days dead; the mice or rats having eaten a great part of their hands and arms.

“The nearer and sorer these plagues seized, the sadder were their effects, that took away all natural and relative affections, so that husbands had no sympathy with their wives, nor wives with their husbands, parents with their children, nor children with their parents. These and other things have made me to doubt if ever any of Adam’s race were in a more deplorable condition, their bodies and spirits more low, than many were in these years.”

In the parish of West Calder, 300 out of 900 “examinable” persons wasted away.

Some facts and traditions of the Seven Ill Years were recorded nearly a century after in the Statistical Account of Scotland. From the Kirk Session records of the parish of Fordyce, Banffshire, it did not appear “that any public measures were pursued for the supply of the poor, nor anything uncommon done by the Session except towards the end. The common distribution of the collections of the church amounted only to about 1_s._ 2_d._ or 1_s._ 4_d._ weekly.” The Kirk Session records bore witness to the numerous cases of immorality in the years before the famine that had been dealt with ecclesiastically, and to the entire and speedy cessation of such cases thereafter[78].

The account for the parish of Keithhall and Kinkell, Aberdeenshire, says that “many died of want, in particular ten Highlanders in a neighbouring parish, that of Kemnay; so that the Session got a bier made to carry them to the grave, not being able to afford coffins for such a number[79].” In the upland parish of Montquhitter, in the same county, the dear years reduced the population by one half or more. Until 1709 many farms were waste. Of sixteen families that resided on the estate of Lettertie, thirteen were extinguished. The account of this parish contains several stories of the distress, with the names of individuals[80]. It is clear, however, that all the parishes of Scotland were not equally distressed. The county of Moray and “some of the best land along the east coast of Buchan and Formartine [Aberdeenshire] abounded with seed and bread;” but transport to the upland parishes was difficult[81].

We may take it that these experiences in the reign of William III. were peculiar to Scotland; even Ireland, which had troubles enough of the same kind in the 18th and 19th centuries, was at that time resorted to as a place of refuge by the distressed Scots. Among the special and temporary causes in Scotland were antiquated agricultural usage, an almost incredible proportion of the people in a state of lawless vagrancy, such as Henry VIII. and Elizabeth had to deal with a century and a half before, a low state of morals, both commercial and private, a tyrannical disposition of the employers, a sullen attitude of the labourers, and a total decay of the spirit of charity. An ancient elder of the parish of Fordyce, who kept some traditions of the dear years, remarked to the minister: “If the same precautions had been taken at that time which he had seen taken more lately in times of scarcity, the famine would not have done so much hurt, nor would so many have perished.”

The evil of vagrancy, for which Fletcher of Saltoun saw no remedy but a state of slavery not unlike that which Protector Somerset had actually made the law of England for a couple of years, 1547-49, in somewhat similar circumstances, gradually cured itself without a resort to the practices of antiquity or of barbarism.

The union with England in 1707, by removing the customs duties and opening the Colonial trade to Scots shipping (they had a share in the East India trade already) gave a remarkable impulse to the manufacture of linen and to commerce. Such was the demand for Scots linen that, it seemed to De Foe, “the poor could want no employment”; and it may certainly be taken as a fact that the establishment on a free basis of industries and foreign markets gave Scotland relief from the pauperism and vagrancy, like those of Ireland in the 18th and 19th centuries, that threatened for a time, and especially in the Seven Ill Years, to retard the developement of the nation.

* * * * *

For several years after the period of scarcity or famine from 1693 to 1699, the history of fever in Britain presents little for special remark.

A book of the time was Dr George Cheyne’s New Theory of Continual Fever, London, 1701. His theory is that of Bellini and Borelli, which accounted for everything in fevers on mechanical principles, and ignored the infective element in them. Cheyne does not even describe what the fevers were; but in showing how the theory applies, he mentions incidentally the symptoms--quick pulse, pain in the head, burning heat, want of sleep, raving, clear or flame-coloured urine, and morbid strength. Equally theoretical is the handling of the subject by Pitcairn. Freind, in his essays on fevers[82], is mainly occupied with controversial matters of treatment, except in connexion with Lord Peterborough’s expedition to Spain in 1705, as we shall see in a section on sickness of camps and fleets.

In the absence of clinical details from the medical profession, the following from letters of the time will serve a purpose:

On 18 September, 1700, Thomas Bennett writes to Thomas Coke from Paris giving an account of the fever of Coke’s brother: His fever is very violent upon him, and he has a hickup and twitchings in his face; he is especially ill in the night, and has now and then violent sweats. He raved for eight days together and in all that time did not get an hour’s sleep. He was attended by Dr Helvetius and other physicians. Lady Eastes, her son, and most of her servants are sick, but they are all on the mending hand; her steward is dead of a high fever, having been sick but five days[83]. These are Paris fevers, the symptoms suggesting typhus, especially the prolonged vigil in one of the cases. It is to be remarked that they occurred among the upper classes; and it appears that the universal fevers “of a bad type” in France in 1712 did not spare noble houses nor even the palace of Louis the Great[84].

The following from the London Bills will show the prevalence of fever from year to year[85].

Dead of Dead of Dead of Year Fever Spotted Fever all diseases

1701 2902 68 20,471 1702 2682 53 19,481 1703 3162 74 20,720 1704 3243 61 22,684 1705 3290 41 22,097 1706 2662 54 19,847 1707 2947 42 21,600 1708 2738 62 21,291 1709 3140 118 21,800 1710 4397 343 24,620 1711 3461 142 19,833 1712 3131 96 21,198 1713 3039 102 21,057 1714 4631 150 26,569 1715 3588 161 22,232 1716 3078 100 24,436 1717 2940 137 23,446 1718 3475 132 26,523 1719 3803 124 28,347 1720 3910 66 25,454

The London fever of 1709-10.

The “seven ill years” were followed by the fine summer and abundant harvest (although hardly more than half the breadth was sown) of 1699. Scarcity was not a cause of excessive sickness again until 1709-10; although the harvest of 1703 was unfavourable. The price of wheat in 1702 was 25_s._ 6_d._ per quarter, and continued low for a number of years, notwithstanding the war with France. In Marlborough’s wars there were no war-prices for farmers, as in the corresponding circumstances a century after; on the contrary, corn and produce of all kinds were so cheap that farmers had difficulty in paying their rents. The bounty of five shillings per quarter on exported wheat had given a great impulse to corn-growing, so that the acreage of wheat sown was much more than the country in an ordinary year required, partly, no doubt, because the bread of the poorer classes was largely made from the coarser cereals. The period of abundance was broken by the excessively severe winter of 1708-9, one of three memorable winters in the 18th century. The frost lasted all over Europe from October to March, and was followed by a greatly deficient crop in 1709. The following shows the rise of the price of the quarter of wheat in England:

s. d.

1708 Lady-day 27 3 " Michaelmas 46 3 1709 Lady-day 57 6 " Michaelmas 81 9 1710 Lady-day 81 9

The export of corn was prohibited in 1709 and again in 1710.

An epidemic of fever began in London in the autumn of 1709 and continued throughout 1710, in which year the fever-deaths reached the highest total since 1694. But it was not altogether a fever of starvation or distress among the poor, and perhaps not mainly so. There is always the dual question in connexion with fever following bad seasons and high prices: how much of it was due to the scarcity, and how much to those states of soil and atmosphere upon which the failure of the crop itself depended. An authentic case of the malignant fever which began to rage in London in the autumn of 1709 will both serve to show the remarkable type of at least a portion, if not the whole of the epidemic, and to prove its incidence upon the houses of the rich.

The case is recorded by Sir David Hamilton[86]:

“About the 5th of October, 1709, the son of that worthy gentleman, William Morison, esquire, was seized with a fever; at which time, and for some weeks before, a malignant fever raged in London.” He had a quick and weak pulse, great difficulty or hindrance of speech, and a stupidity; “whereto were added tremors, and startings of the tendons, a dry and blackish tongue, a high-coloured but transparent urine and coming away for the most part involuntarily, and a hot and dry skin.” Dr Grew was called in, and prescribed alexipharmac remedies (cordials, sudorifics, etc.) “A few days after the patient’s skin was stained or marked with red and purple spots, and especially upon his breast, legs and thighs. These symptoms, although a little milder now and then, prevailed for fourteen days; after that the spots vanished, and the convulsive motions so increased that the young gentleman seemed ready to sink under them for several days together.” He was treated with the application of blisters, and with doses of bark. His strength and flesh were so wasted that the hip whereon he lay was seized with a gangrene. For ten or twelve days before his death, “he breathed and perspired so offensive a smell that they were obliged to smoke his chamber with perfumes; and even myself, whilst I inclined my body a little too near him, was, by receiving his breath into my mouth, seized all on a sudden with such a sickness and faintness that I was obliged to take the air in the open fields, and returning thence to drink plentifully of mountain wine at dinner.” The examination after death was made by the celebrated anatomist Dr Douglas. There was still a heap of brown-coloured spots visible on the breast; “there was nothing contained in the more conspicuous vessels of the abdomen but grumes or clots of blackish blood, without any serum in the interstices.” Hamilton adds: “We too seldom dissect the bodies of those dying in fevers.”

The tremors, offensive sweats and offensive breath are distinctive of a form of typhus that became common towards the middle of the century, and was called putrid fever (not in the sense of Willis) or miliary fever from the watery vesicles of the skin that often attended it. But although Hamilton was writing on miliary fever (of the factitious variety) this case is not given as an example, but is appended to his sixteen cases of the latter, as an example of “a deadly fever with loss of speech from the beginning.” Among earlier cases, those belonging to the epidemic of 1661 as described by Willis correspond closely with this case, which we may take as representing part of the malignant fever that then raged in London. We have an anatomical record from each; but in neither was there sloughing of the lymph-follicles of the intestine, or of the mesenteric glands, as in the enteric fever of our own time; while in both there were red or purple spots on the breast or neck, and on the limbs. The “loss of speech from the beginning” suggests Sydenham’s “absolute aphonia” in the comatose fever of 1673-76, which resembled in other respects Willis’s fever of the brain and nervous stock (mostly of children) in 1661. One of the synonyms of “infantile remittent” was “an acute fever with dumbness[87].” This seems to have been a common type of fever in the latter part of the 17th century and early part of the 18th. Some likeness to enteric fever may be found in it, but there is no warrant for identifying it with that fever. Its main features may be said to have been its incidence upon the earlier years of life, but not to the exclusion of adult cases, its remarkable ataxic symptoms, which led Willis to refer it to “the brain and nervous stock” (spinal cord), its comatose character, its spots, occasional miliary eruption, ill-smelling sweats and other foetid evacuations, its protracted course, and its hectic sequelae.

The weekly bills of mortality in London bear little evidence of unusual prevalence of fever in 1709, except in the weeks ending 13 and 20 September, when the fever-deaths were 96 and 75 (including “spotted fever”). But the unusual entry of “malignant fever” appears in three weekly bills, 19 July, 9 August and 23 August, one death being referred to it on each occasion. It was in the summer and autumn of 1710 that the fever reached a height in London, being attended with a very fatal smallpox. An essay on the London epidemic of 1710[88] is interesting chiefly for recording a probable case of relapsing fever, a form which was almost certainly part of the great febrile epidemic in London in 1727-29.

Mrs Simon, aged 20, had a burning fever, stifling of her breath, frequent vomiting and looseness, foul tongue, loss of sleep, restlessness, intermitting, low and irregular pulse. This terrible fever disappeared on the fourth day, and she thought herself recovered. But on the seventh day from her being taken ill the fever returned, she was light-headed, did not know her relatives, and was fevered in the highest degree. It looked like a malignant fever, but there were no spots.

The following table shows the very high mortality from fever (as well as from smallpox) in the epidemic to which the above case belonged.

London: Weekly deaths from fever, smallpox and all causes.

1710.

Week Dead of Dead of Dead of Dead of ending fever spotted fever smallpox all diseases

May 2 103 [illegible] 99 571 9 90 6 60 517 16 84 7 71 502 23 93 15 71 503 30 106 11 83 550 June 6 93 2 98 508 13 79 8 84 509 20 106 12 99 574 27 105 15 86 503 July 4 106 7 99 482 11 107 13 97 467 18 126 16 89 509 25 109 13 105 562 Aug. 1 91 12 79 444 8 92 11 72 463 15 98 10 58 459 22 105 10 63 463 29 111 16 71 495 Sept. 5 76 4 63 414 12[89] 107 12 57 520 19 115 9 83 548 26 81 11 46 456 Oct. 3 98 9 45 469 10 79 10 49 480 17 90 5 41 477 24 107 5 45 470 31 106 14 51 421 Nov. 7 71 6 55 425 14 92 2 41 390 21 70 4 25 345

Throughout England, in country parishes and in towns, the first ten years of the 18th century were on the whole a period of good public health. In Short’s abstracts of the parish registers to show the excess of deaths over the births, those years are as little conspicuous as any in the long series. It was a time when there was a great lull in smallpox, and probably also in fevers. The figures for Sheffield may serve as an example[90]. It will be seen from the Table that the burials exceeded the baptisms in every decade from the Restoration to the end of the century; after that for twenty years the baptisms exceeded the burials, the marriages having increased greatly.

Vital Statistics of Sheffield.

Ten-year periods Marriages Baptisms Burials

1661-70 585 2086 2266 1671-80 537 2240 2387 1681-90 540 2595 2856 1691-1700 688 2221 2856 1701-10 942 3033 2613 1711-20 991 3304 2765

Of particular epidemics, we hear of a malignant fever at Harwich in 1709. Harwich was then an important naval station, and the fever may have arisen in connexion with the transport of troops to and from the seat of war, just as camp- and war-fevers appeared at various ports in the next war, 1742-48.

There were rumours of a plague at Newcastle in 1710, which were contradicted by advertisement in the London Gazette[91]. But, as there was so much plague in the Baltic ports in 1710 it is possible that the Newcastle rumour may have been one of plague imported, and not a rumour suggested by the mortality from some other disease.

To the same period of epidemic fever in London, about 1709-10, belongs also a curiously localized epidemic in an Oxford college, which reminds one somewhat of the circumstances of enteric fever in our time. It was told to Dr Rogers of Cork twenty-five or twenty-six years before the date of his writing (1734), by one who was a student at Oxford then: “There broke out amongst the scholars of Wadham College a fever very malignant, that swept away great numbers, whilst the rest of the colleges remained unvisited. All agreed that the contagious infection arose from the putrefaction of a vast quantity of cabbages thrown into a heap out of the several gardens near Wadham College[92].”

The next epidemic of fever in London was in 1714. Like that of 1710, it followed a great rise in the price of wheat, or perhaps it followed the unseasonable weather which caused the deficient harvest. Before the Peace of Utrecht wheat in England was as low as 33_s._ 9_d._ per quarter, in 1712, the peace next year sending it no lower than 30_s._ But at Michaelmas, 1713, it rose with a bound to 56_s._ 11_d._, doubtless owing to a bad harvest. The fever-deaths in London began to rise in the spring of 1714, reaching a weekly total of 103 in the week ending 20 April. All through the summer and autumn they continued very high, the weekly totals exceeding, on an average, those of the year 1710, as in the foregoing table, and having corresponding large additions of “spotted fever.” The deaths from all causes in 1714 were a quarter more than those of the year before, the epidemic of fever being the chief contributor to the rise. This happened to be a very slack time in medical writing[93]; but, even in the absence of such testimony as we have for earlier and later epidemics of fever in London, we may safely conclude that the fever of 1714 was of the type of pestilential or malignant typhus, beginning in early summer and reaching a height in the old plague season of autumn.

A singular instance of what may be considered war-typhus belongs to the winter of 1715-16. The political intrigues preceding and following the death of Queen Anne in 1714 culminated in the Jacobite rising in Scotland and the North of England in 1715. The Jacobites having been defeated at Preston on 13 November, prisoners to the number of 450 were brought to Chester Castle on the Sunday night before December 1st. A fortnight later (December 15th), Lady Otway writes of the 450 prisoners in the Castle:

“They all lie upon straw, the better and the worse alike. The king’s allowance is a groat a day for each man for meat, but they are almost starved for want of some covering, though many persons are charitable to the sick.” The winter was unusually severe, the snow lying “a yard deep.” Many prisoners died in the Castle by “the severity of the season,” many were carried off by “a very malignant fever.” On February 16th Lady Otway writes again:--“So much sickness now in our Castle that they dye in droves like rotten sheep, and be 4 or 5 in a night throne into the Castle ditch ffor ther graves. The feavour and sickness increaseth dayly, is begun to spread much into the citty, and many of the guard solidyers is sick, it is thought by inffection. The Lord preserve us ffrom plague and pestilence[94]!”

Prosperity of Britain, 1715-65.

The fifty years from 1715 to 1765 were, with two or three exceptions, marked by abundant harvests, low prices and heavy exports of corn. This was undoubtedly a great time in the expansion of England, a time of fortune-making for the monied class, and of cheapness of the necessaries of life.

The well-being and comfort of the middle class were undoubtedly great; also there was something peculiar to England in the prosperity of towns and villages throughout all classes. In the very worst year of the period, the year 1741, Horace Walpole landed at Dover on the 13th September, having completed the grand tour of Europe. Like many others, he was delighted with the pleasant county of Kent as he posted towards London; and on stopping for the night at Sittingbourne, he wrote as follows in a letter:

“The country town delights me: the populousness, the ease, the gaiety, and well-dressed everybody, amaze me. Canterbury, which on my setting out I thought deplorable, is a paradise to Modena, Reggio, Parma, etc. I had before discovered that there was nowhere but in England the distinction of middling people. I perceive now that there is peculiar to us middling houses; how snug they are[95]!”

Our history henceforth has little to record of malignant typhus fevers, or of smallpox, in these snug houses of the middle class, although not only the middle class, but also the highest class had a considerable share of those troubles all through the 17th century. But the 18th century, even the most prosperous part of it, from the accession of George I. to the beginning of the Industrial Revolution in the last quarter or third of it, was none the less a most unwholesome period in the history of England. The health of London was never worse than in those years, and the vital statistics of some other towns, such as Norwich, are little more satisfactory. This was the time which gave us the saying, that God made the country and man made the town. Praise of rural felicity was a common theme in the poetry of the time, as in Johnson’s London:

“There every bush with nature’s music rings, There every breeze bears health upon its wings.”

Both for the country and the town the history of the public health does not harmonize well with the optimist views of the 18th century. The historians are agreed that, under the two first Georges, during the ministries of Walpole, the Pelhams and Pitt, the prosperity of Britain was general. Adam Smith speaks of “the peculiarly happy circumstances of the country” during the reign of George II. (1727-60). Hallam characterizes the same reign as “the most prosperous that England had ever experienced.” The most recent historian of England in the 18th century is of the same opinion[96]. The novels of Fielding give us the concrete picture of the period with epic fidelity, and the picture is of abundance and prodigality. Agriculture and commerce with the Colonies, India and the continent of Europe, were the sources of the country’s wealth. Farming and stock-raising had been greatly improved by the introduction of roots and sown grasses. In some country parishes the baptisms were three times the burials. But the public health during this period will not appear in a favourable light from what follows. More particularly there were three occasions, about the years 1718, 1728 and 1741, when a single bad harvest in the midst of many abundant ones brought wide-spread distress, with epidemics of typhus and relapsing fever; from which fact it would appear that the common people had little in hand. Thorold Rogers, among economists, was of the opinion that the prosperity was all on the side of the governing and capitalist classes, that the labourers were in “irremediable poverty” and “without hope,” and that the law of parochial settlement, with the artificial fixing of wages by the Quarter Sessions and the bonuses out of the poor-rates, had the effect of keeping the mass of the people on the land “in a condition wherein existence could just be maintained[97].” I shall not attempt an independent judgment in economics, but proceed to those illustrations of national well-being which belong to my subject, leaving the latter to have their due weight on the one side of economical opinion or on the other. Besides the economical question there is of course also an ethical one. When the pinch came about 1766, there was the usual diversity of opinion expressed on the “condition of England” problem, one holding that the labourers were unfairly paid, another that the nation had been made “splendid and flourishing by keeping wages low,” and that the distress was due to “want of industry, want of frugality, want of sobriety, want of principle” among the common people at large. “If in a time of plenty,” wrote one austere moralist, “the labourers would abate of their drunkenness, sloth, and bad economy, and make a reserve against times of scarcity, they would have no reason to complain of want or distress at any time[98].” But there must have been something wrong in the economics and morals of their betters if it were the case that the working class as a whole, and not merely a certain number of individuals in it, was drunken, thriftless and slothful. The familiar proof of this is the apathy of the Church, broken by the Methodist revival of religion.

The epidemic fevers of 1718-19.

In the fifty years from 1715 to 1765, the three worst periods of epidemic fever in England and Scotland correspond closely to the three periods of actual famine and its attendant train of sicknesses in Ireland, namely, the years 1718-19, 1727-29, and 1740-42. The three divisions of the kingdom suffered in common, Ireland suffering most. The first period, 1718-19, was an extremely slack tide in medical writing, insomuch that hardly any accounts of the reigning maladies remain, except those by Wintringham, of York, and Rogers, of Cork. The whole of the Irish history of fevers and the allied maladies is dealt with in a chapter apart. Of the Scots history, little is known for the first of the three periods beyond a statement that there was a malignant fever and dysentery in Lorn, Argyllshire, in January and February, 1717[99].

Wintringham gives the following account of the synochus, afterwards called typhus, which attracted notice in the summer of 1718 and became more common in the warm season of 1719: in each year it began about May, reached its height in July and lasted all August, carrying off many of those who fell into it.

It began with rigors, nausea and bilious vomiting, followed by alternate heats and chills, with great lassitude and a feeling of heaviness: then thirst and pungent heat, a dry and brown tongue, sometimes black. The patient slept little, did not sweat, and was mostly delirious, or anxious and restless, tossing continually in bed. About the 12th day it was not unusual for profuse and exhausting diarrhœa to come on. In a favourable case the fever ended in a crisis of sweating about the 16th day. Those who were of lax habit, unhealthy, hysteric, or cachectic, were apt to have tremors, spasms and delirium, while others were so prostrated as to have no control over their evacuations, lying in a stupor and raving when roused out of it. In these the fever would continue to the 20th day; in some few it ended without a manifest crisis, and with a slow convalescence[100].

This applies to the city of York, but in what special circumstances we are not told. However, it happens that a physician of York, two generations after, in giving an account of the great improvement that had taken place in its public health, throws some light on its old-world state: “The streets have been widened in many places by taking down a number of old houses built in such a manner as almost to meet in the upper stories, by which the sun and air were almost excluded in the streets and inferior apartments[101].”

In London the fever-deaths, with the deaths from all causes, rose decidedly in 1718, and reached a very high figure in 1719, of which the summer was excessively hot. One cause, at least, was want of employment, especially among weavers in the East End[102]. But the epidemic fever of 1718-19 was not limited to the distressed classes; we have a glimpse of it, under the name of “spotted fever,” in the family of the archbishop of Canterbury:

“On Friday night the archbishop of Canterbury’s sixth daughter was interred in our chancel, with four others preceding, she dying on Monday after three days of the spotted fever. The fourth and seventh are recovered, and hoped past danger[103].”

The following table shows the fever-mortalities for London, from 1718 onwards, and, for comparison, the excessive mortalities in the epidemics of 1710 and 1714:

London Mortalities from Fever, &c.

Year Fevers Spotted fevers Smallpox All causes

1710 4397 343 3138 24620 1714 4631 150 2810 26569 1718 3475 132 1884 26523 1719 3803 124 3229 28347 1720 3910 46 1442 25454 1721 3331 84 2375 26142 1722 3088 22 2167 25750 1723 3321 51 3271 29197 1724 3262 84 1227 25952 1725 3277 59 3188 25523 1726 4666 84 1569 29647 1727 4728 102 2379 28418 1728 4716 94 2105 27810 1729 5235 [The entry 2849 29722 1730 4011 ends.] 1914 26761 1731 3225 2640 25262 1732 2939 1197 23358 1733 3831 1370 29233 1734 3116 2688 26062 1735 2544 1594 23538 1736 3361 3014 27581 1737 4580 2084 27823 1738 3890 1590 25825 1739 3334 1690 25432 1740 4003 2725 30811

In country parishes, according to Short’s abstracts of registers, there was no unusual sickness in 1718 and 1719. But in market towns the mortality rose greatly in 1719, which had an excessively hot summer; and that was the year when the synochus or typhus described by Wintringham reached its worst at York. The mortality kept high for several years after 1719.

Market Towns.

Registers Registers with Deaths Births Year examined excess of deaths in same in same

1716 30 8 1060 845 1717 30 9 1485 1290 1718 30 3 249 169 1719 30 6 1737 1320 1720 30 10 2186 1461 1721 33 9 1294 952 1722 33 11 1664 1345 1723 33 14 2532 2176

The high mortalities in 1721-23 were mostly from smallpox, exact figures of many of the epidemics in Yorkshire and elsewhere being given in the chapter on that disease. The country parishes shared in its prevalence:

Country Parishes.

Registers Registers with Deaths Births Year examined excess of deaths in same in same

1721 174 35 793 586 1722 175 35 1015 775 1723 174 63 2021 1583

Besides smallpox, diarrhoeas and dysenteries in the autumn are given by Wintringham as the reigning maladies, fever not being mentioned.

The Epidemic Fevers of 1726-29: evidence of Relapsing Fever.

The four years 1726-29 were a great fever-period in London, the deaths having been as follows:

Year Fever deaths All deaths

1726 4666 29,647 1727 4728 28,418 1728 4716 27,810 1729 5335 29,722

In the last of those years the entry in the annual bills becomes “fever, malignant fever, spotted fever and purples.”

The following are the weekly maxima of fever deaths and deaths from all causes during the four years, 1726-29; in nearly all the weeks the deaths from “convulsions” (generic name for most of the maladies of infants) contribute from a fourth to a third, or even more, of the whole mortality.

Week Fever All ending deaths deaths 1726 Jan. 18 71 633 March 15 81 678 May 31 103 611 June 7 106 607 Aug. 30 102 711 Sept. 6 116 680 13 109 643 20 109 648 1727 Aug. 8 103 577 15 123 698 22 132 730 29 130 789 Sept. 5 150 764 12 134 795 19 165 798 26 163 715 Oct. 3 150 684 1728 Feb. 6 112 748 13 131 889 20 121 850 27 145 927 March 5 93 733 Aug. 27 138 525 Sept. 3 131 562 Dec. 10 122 734 1729 Sept. 9 109 676 Nov. 4 213 908[104] 11 267 993[104] 18 166 783 Dec. 9 132 779

These are high mortalities, whatever were the types of fever that caused them. That the old pestilential fever of London was one of them we need have no doubt. Dr John Arbuthnot, writing two or three years after, said, “I believe one may safely affirm that there is hardly any year in which there are not in London fevers with buboes and carbuncles [the distinctive pestilential marks]; and that there are many petechial or spotted fevers is certain[105].”

The essay of Strother also has a reference to “spotted fever” in its title, although the text throws very little light upon it[106]. But, for the rest, the “constitution” of 1727-29 is more than usually perplexing. There was an influenza at the end of 1729, which can be separated from the rest easily enough by the help of the London weekly bills of mortality; and it is probable, unless Arbuthnot, Huxham and Rutty have erred in their dates, that one or more epidemics of catarrhal fever had occurred before that, in the years 1727 and 1728. The greatest difficulty is with a certain “little fever,” or “hysteric fever,” or “febricula,” which gave rise to some writing and a good deal of talk. Strother does not specially treat of it, at least under that name, although he says that “many, especially women, have been subject to fits of vapours, cold sweats, apprehensions, and unaccountable fears of death; every small disappointment dejected them, tremblings and weakness attended them,” etc. (p. 116); and again, “never was a season when apoplexies, palsies and other obstructions of the nerves did prevail so much as they do at present, and have done for some time past” (p. 102); while he had frequently seen hysterical and hypochondriacal symptoms, dejection of spirits and the like remaining behind the fever (p. 109). For some years before this, much had been heard in London of the vapours, the “hypo,” the spleen, and the like, an essay by Dr Mandeville, better known by his ‘Fable of the Bees,’ having first made these maladies fashionable in the year 1711[107].

In due time it began to be noticed that symptoms which many physicians made light of as a “fit of vapours” were really the beginning of a fever. Dr Blackmore, in an essay on the Plague written in 1721, admitted the ambiguity:

“For several days a malignant fever has so near a resemblance to one that is only hysterick, that many physicians and standers by, I am apt to believe, mistake the first for the last, and look upon a great and dangerous disease to be only the spleen, or a fit of the vapors, to the great hazard of the patient[108].”

In 1730, Dr William Cockburn, in a polemic against the physicians whom he styles “the academical cabal” (because they objected to his secret electuary for dysentery), professes to give a history of the mistakes of the faculty in London over this “little fever,” or “hysteric fever,” which often became dangerous[109]:

“The present fever, with a variation in some of its symptoms, has now subsisted twelve years [or since 1718] not in England only, but all over Europe [Manningham says it was peculiarly English]. Few or no physicians suspected the reigning and popular disease to be a fever. Vapours, a nervous disease, and such general appellations it had from sundry physicians. Others, who discovered the fever, knew it was the low or slow fever, first mentioned by Hippocrates.... The last were represented as ignorant for calling the distemper a fever, and affixing to it the name ‘low’ or ‘slow,’ a slow fever being, in their adversaries’ opinion, altogether unheard of among physicians and never recorded in their books. Nothing was more monstrous than calling this distemper a fever, or confining persons afflicted with it to their bed, and dieting them with broth, or other liquid food of good nourishment, and what is easily concocted.... ‘You are not hot, you are not dry; you are in good temper; and therefore you have no fever’ was the common language of the town.... They might have seen physicians practising for a destroying distemper, and yet, after seven years, they confess themselves ignorant of its very name.”

At length, he continues, Blackmore admitted the ambiguity of diagnosis, while Mead, Freind and others, recognized that there was really such a thing as a slow, nervous fever, by no means free from danger to life. It is probably to this insidious fever that Strother refers:

“Thus, having gone on for six or seven days in a train of indolence, they have been surprized on the seventh day, and have died on the eighth lethargick or delirious, whereas, if they had taken due care, the fever would have run its course in fifteen days or more.” It was the remissions, or intermissions, he explains, that often misled patients, by which he seems to mean the clear intervals between relapses. “Others, wearied out with relapses, have hoped their recovery would as certainly ensue as it had hitherto, and have deferred asking advice until it was too late.” These relapses, he thought, were brought on by venturing too soon into the air: “it is too well known that the fever has been cured, and patients have soon, after they have ventured into the air, relapsed and have again run the same circle of ill symptoms, if not worse than before.” Bark failed conspicuously in these “remittents:” “it is therefore incumbent on me to examine into the reason of this new phenomenon. I call it new,” he explains, because bark had hitherto succeeded. “Perhaps we may find reason to lay some blame on the air for the frequent relapses.... Periodical comas have of late been common; so soon as the fit was over, the drowsiness abated till the fit returned.”

Elsewhere he speaks of the frequent relapses as belonging to a “quartan,” under which diagnosis bark had been tried. The fevers were less apt to “relapse” when treated by mild cathartics. Another symptom of this fever was jaundice: “If jaundice breaks forth on the fourth day of a fever, it is much better than if it comes at the conclusion of a fever.... Jaundices are now very common after the cure of these fevers.”

These indications, dispersed throughout the rambling essay of Strother, point somewhat plainly to relapsing fever[110]. But his theoretical pathology comes in to obscure the whole matter. He explains everything by obstructions. The jaundice was due to obstruction of the liver by “styptics,” the hysteric symptoms to obstructions of the nerves; there were also theoretical obstructions of the mesentery, part of the matter being sometimes “thrown off into the mesenteric glands”; also “congestions” or phlegmons of the liver, spleen and pancreas. But it is when he comes to the bowels that his subjective morbid anatomy becomes truly misleading. There is nothing to show that Strother examined a single body dead of this fever. He says, however, in his à priori way: “The crisis of these slow fevers is generally deposited on the bowels.... The lent fever is a symptomatical fever, arising from an inflammation, or an ulcer fixed on some of the bowels. A lent fever, depending on some fixed cause of the bowels, must be cured by having regard to those causes some of which I shall enumerate”:--the first supposition being that the fever depends on phlegmons by congestion of “the liver, spleen, pancreas, or the mesentery”; the second, if it depends on extravasations in an equally comprehensive range of viscera; the third, “if it depends on an ulcer, then all vulneraries must be administered internally; but to speak truth, when the viscera are ulcerated, there remains but small hope of life”; the fourth supposition is worms, the fifth corruption of the humours. All this is paper pathology. There is not a single precise fact relating to ulcerated Peyer’s patches, or to swollen mesenteric glands, or to enlarged spleen, which last would have been equally distinctive of relapsing as of enteric fever; it is “the viscera” that are ulcerated, or congested, or extravasated, or it is “some of the bowels,” or the pancreas and liver obstructed as well as the spleen, the obstruction of the liver being invoked to explain the highly significant jaundice.

It is not quite clear whether Strother’s fever with relapses and jaundice corresponded exactly to the little fever, hysteric fever, or nervous fever of the same years; but it is worthy of note that relapsing fever in Ireland a century later was called febricula or the “short fever.” It was not until 1746 that the excellent essay upon it by Sir Richard Manningham was written. By that time a good deal was being said in various parts of Britain of a slow, nervous, or putrid fever, Huxham, in particular, identifying the nervous fever with Manningham’s febricula or little fever[111]. Some have supposed that the nervous fever of the 18th century included cases of enteric fever, if it did not stand for that disease exclusively. Murchison takes Manningham’s essay to be “an excellent description of enteric fever, under the title of febricula or little fever, etc.[112]” The following are brief extracts from his description, by which the reader will be able to form his own opinion on the question of identity[113].

At the beginning patients feel merely languid or uneasy, with flying pains, dryness of the lips and tongue but no thirst; in a day or two they find themselves often giddy, dispirited and anxious without apparent reason, and passing pale urine. They have transient fits of chilliness, a low, quick and unequal pulse, sometimes cold clammy sweats and risings in the throat. They go about until more violent symptoms come on, simulating those of quotidian, tertian or quartan fever; sometimes the malady simulates pleurisy. There may be attacks of dyspnoea, nausea and haemorrhage; the menses in women are checked. A loss of memory and a delirium occur at intervals for short periods. The malady is very difficult to cure and too often becomes fatal in the end. It will last thirty or forty days, unless it end fatally in stupor or syncope. A form of mania is a consequence of it, where it has been neglected or badly treated; “of late years this species of madness has been more than ordinarily frequent.” All sorts were liable to it, but mostly valetudinarians, delicate persons, and those in the decline of life; the fatalities were “especially among the opulent families of this great metropolis[114].”

This fever-period in London corresponds on the whole closely with a series of unhealthy years in Short’s tables from the registers of market towns and country parishes, and with high mortalities in the Norwich register. It was not specially a smallpox period, as the last unhealthy year, 1723, was. On the other hand the epidemiographists in Yorkshire, Devonshire and Ireland dwell most upon fevers of the nature of typhus, some of which were due to famine or dearth, and upon “agues.”

Market Towns.

Registers No. with excess Deaths Births Year examined of deaths in same in same

1727 33 19 3606 2441 1728 34 23 4972 2355 1729 36 27 6673 3494 1730 36 16 3445 2529

Norwich.

Year Buried Baptized

1728 1417 774 1729 1731 843

Country Parishes.

Registers With excess Burials Baptisms Year examined of burials in same in same

1726 181 22 542 495 1727 180 55 1368 1091 1728 180 80 2429 1536 1729 178 62 2015 1442 1730 176 39 1302 1022 1731 175 24 700 614

The best epidemiologists of the time were not in London, but at York, Ripon, Plymouth, Cork and Dublin. Leaving the Irish history to a separate chapter, we shall find in the annals of Wintringham, Hillary and Huxham a somewhat detailed account of the fevers which caused the very high mortalities of the years 1727-29, with an occasional glimpse of the circumstances in which the fevers arose. Much of what follows relates to the same nervous, hysteric or “putrid” fever, with or without relapses, that has been described for London. Going back a little, Wintringham says[115] that the continued fevers of 1720 were milder than those of the year before (which were synochus or typhus) and were often languid or nervous, with giddiness, stupor and nervous tremblings, a quick pulse, a whitish tongue, no thirst, and sweats of the head, neck and chest: this fever lasted twenty days or more, and ended in a general sweat. He had mentioned the “languid nervous fevers” first in the years 1716 and 1717, and he mentions them again as mixed with or following the synochus or typhus of 1727-28.

In April, 1727, there were fevers prevalent, remitting and intermitting, but with uncertain paroxysms; in May, a fever with pleuritic pains; in July, a putrid fever in some, but the chief diseases of that month were “remittents and intermittents,” which were often attended by cutaneous eruptions, sometimes of dusky colour and dry, at other times full of clear serum; which, “as they depended upon a scorbutic taint, tormented the sick with pruritus.” The sick persons in these remittents were for the most part drowsy and stupid, especially during the paroxysm; the fevers were followed by lassitude, debility, languor of spirits and hysteric symptoms.

Hillary[116], who practised at Ripon, not far from Wintringham, at York, records in 1726 the prevalence of remittents and intermittents: “some had exanthematous eruptions towards the latter end of the disease, filled with a clear or yellowish water, which went or dried away without any other inconvenience to the sick but an uneasy itching for a few days”--just as Wintringham had described a miliary fever for 1727. It is also under 1726 that he describes the same drowsy and nervous symptoms of Wintringham’s summer fever of 1727:

“Ancient and weak hysterical people had nervous twitchings and catchings, and were comatous and delirious; some were very languid, sick and faint, and had tremors; the young and robust, who had more full pulses, were generally delirious, unless it was prevented or taken off by proper evacuations and cooling medicines. I found blistering to be of very great service in this fever, and the sick were more relieved by it than ever I observed in any other fever whatever. People of lax, weak constitutions were very low and faint, and had frequent, profuse, partial sweatings, which most commonly were cold and clammy.” Huxham also, at the other end of England, says that in October and November, 1727, a slow nervous fever attacked not a few; and under the date of January, 1728, he confirms the Yorkshire experiences of the prevalence of angina.

There can be little doubt that England in 1727 was already suffering in a measure from the distress that was acutely felt in Ireland; it was much aggravated by the hard winter of 1728-29[117], but it had begun before that and was doubtless the indirect cause of the great prevalence of sickness. The exports of corn under the bounty system used to bring two or three millions of money into the country in a year. But in 1727 there was a debt balance of 70,757 quarters of wheat imported, and in 1728 the import exceeded the export by 21,322 quarters, the price rising at the same time from 4_s._ to 8_s._ per bushel[118]. Under the year 1727 Hillary says:

“Many of the labouring and poor people, who used a low diet, and were much exposed to the injuries and changes of the weather, died; many of whom probably wanted the necessary assistance of diet and medicines.” And after referring, under the winter of 1727-28, to the prevalence of a fatal suffocative angina, which fell, by a kind of metastasis, on the diaphragm or pleura, and sometimes on the peritoneum, he proceeds (p. 16):--

“Nor did any other method, which art could afford, relieve them: insomuch that many of the little country towns and villages were almost stripped of their poor people, not only in the country adjacent to Ripon, but all over the northern parts of the kingdom: indeed I had no certain account of what distempers those who were at a distance died of, but suppose they were the same as those which I have mentioned, which were nearer to us. Bleeding, pectorals with volatiles, and antiphlogistic diluters and blistering, were the most successful. I observed that very few of the richer people, who used a more generous way of living, and were not exposed to the inclemencies of the weather, were seized with any of these diseases at this time.... The quartans were very subject to turn into quotidians, and sometimes to continual, in which the sick were frequently delirious.”

The Yorkshire accounts by Wintringham and Hillary for the second year of this epidemic period, the year 1728, are very full, as regards the symptoms or types of the fevers; but it would be tedious to cite them at length, and unnecessary to do so unless to answer the not inconceivable cavil that the fevers were not of the nature of typhus in one or other of its forms. The chief point is that the second year, towards Midsummer, brought a fever with the symptoms of synochus, and not rarely marked with small red spots like fleabites or with purple petechiae. In the autumn of 1729, Hillary noticed a fever of a slow type, which might go on as long as thirty days and end without a perfect crisis--the nearest approach to enteric fever in any of the descriptions. For the same years, 1727-29, Huxham, of Plymouth, describes languid fevers of the “putrid” type, with profuse sweating, followed by typhus of a more spotted type. Like the Yorkshire observer, Huxham mentions also “intermittents” as mixed with the continued fevers.

The great prevalence of these fevers, “intermittents and other fevers,” in the west of England in 1728-29 was known to Dr Rutty of Dublin, who speaks especially of “the neighbourhoods of Gloucester and London, and very mortal in the country places, but less in the cities.” This is confirmed by Dover:

“I happened to live in Gloucestershire in the years 1728 and 1729, when a very fatal epidemical fever raged to such a degree as to sweep off whole families, nay almost whole villages. I was called to several houses where eight or nine persons were down at a time; and yet did not so much as lose one patient where I was concerned[119].”

Some of the cases of nervous or putrid fever in the epidemics of 1727-29 appear to have been marked by relapses in the country districts as well as in London. Huxham says under date of April, 1728, that those who had wholly got rid of the putrid fever were exceedingly apt to have relapses. Hillary does not mention relapses until March, 1733, when a fever, with many hysterical symptoms, which succeeded the influenza of that year, relapsed in several, “though seemingly perfectly recovered before.” But he seems really to be contrasting relapsing fever and typhus when he points out that, whereas the inflammatory type of fever in the first year of the epidemic (1727) was greatly benefited by enormous phlebotomies, the fever patients in the two seasons following, when the fever was more of the nature of spotted typhus, could not stand the loss of so much blood, or, it might be, the loss of any blood[120]. This was precisely the remark made by Christison and others a century later, when the inflammatory synocha, which often had the relapsing type very marked, changed to the spotted typhus.

From the year 1731 we begin to have annual accounts (soon discontinued) of the reigning maladies in Edinburgh, on the same plan as Wintringham’s, Hillary’s and Huxham’s, with which, indeed, they are sometimes collated and compared[121]. The fevers of Edinburgh and the villages near were as various as those of Plymouth, according to Huxham, and singularly like the latter. Thus, in the winter of 1731-32, there was much worm fever, comatose fever, or convulsive fever among children, but not limited to children, marked by intense pain in the head, raving in some, stupor in others, tremulous movements, leaping of the tendons, and all the other symptoms described by Willis for the fever of 1661, a fatal case of October, 1732, in a boy of ten, recorded by St Clair one of the Edinburgh professors, reading exactly like the cases of Willis already given[122]. St Clair’s case, which was soon fatal, had no worms; but in the general accounts, both for the winter of 1731-32 and the autumn of 1732, it is said that many of the younger sort passed worms, both teretes and ascarides, and recovered, the fatalities among children being, as usual, few. In March and April, 1735, there were again “very irregular fevers of children.” Huxham records exactly the same “worm-fever” of children at Plymouth in the spring of 1734--a fever with pains in the head, languor, anxiety, oppression of the breast, vomiting, diarrhoea, and a comatose state (affectus soporosus), which attacked the young mostly, and was often attended by the passage of worms. He gives the same account of the seasons as Gilchrist--the years 1734 and 1735 marked by almost continual rains, the country more squalid than had been known for some years[123].

But it is the nervous fever that chiefly engrosses attention both in Scotland and in England. In 1735, Dr Gilchrist, of Dumfries, made it the subject of an essay, returning to the subject a few years after[124]. “As our fever,” he says, “seems to be peculiar to this age, it is not a little surprising that much more has not been said upon it.” He is not sure whether its frequency of late years may not be owing to the manner of living (it was the time of the great drink-craze, which Huxham also connects with the reigning maladies) and to a long course of warm, rainy seasons; the winters for some years had been warm and open, and the summers and harvests rainy. It was only the poorer sort and those a degree above them who were subject to this fever; he knew but few instances of it amongst those who lived well, and none amongst wine-drinkers. It was in some insidious in its approach; those who seemed to be in no danger the first days for the most part died. In others the onset was violent, with nausea, heat, thirst and delirium. Among the symptoms were looseness, pains in the belly, local sweating, tickling cough, leaping of the tendons. Sometimes they were in continual cold clammy sweats; at other times profuse sweats ran from them, as if water were sprinkled upon them, the skin feeling death cold.

At Edinburgh, from October, 1735, to February, 1736, the fever became very common, and was often a relapsing fever.

“The sick had generally a low pulse on the first two or three days, with great anxiety and uneasiness, and thin, crude urine. Delirium began about the fourth day, and continued until the fever went off on the seventh day. Sometimes the disease was lengthened to the fourteenth day. The approach of the delirium could always be foretold by the urine becoming more limpid, and without sediment.... A large plentiful sweat was the crisis in some. Others were exposed to relapses, which were very frequent, and rather more dangerous than the former fever[125].”

These evidences, beginning with Strother’s for London in 1728 and extending to the Edinburgh record of 1735, must suffice to identify true relapsing fever. In the chapter on Irish fevers we shall find clear evidence of relapsing fever in Dublin in 1739, before the great famine had begun.

Huxham’s account of the fevers at Plymouth, in Devonshire generally, and in Cornwall about the years 1734-36 is of the first importance. It is highly complex, owing to the prevalence of an affection of the throat, so that one part of the constitution is “anginose fever.” This has been dealt with in the chapter on Scarlatina and Diphtheria. Another part was true typhus. In his account of the nervous fever we are introduced, as in the Yorkshire annals, 1726-27, to a phenomenon that was almost distinctive of the low, nervous or putrid fever from about 1750 to 1760 or longer, namely, the eruption of red, or purple, or white watery vesicles, from which it got the name of miliary fever. Huxham’s annals are full of this phenomenon about the years 1734-36[126]. The red pustules, or white pustules, with attendant ill-smelling sweats, are mentioned over and over again. He thought them critical or relieving: “Happy was then the patient who broke out in sweats or in red pustules.” These fevers are said to have extended to the country parts of Devonshire, after they had ceased in Plymouth, and to Cornwall in August, 1736. In Plymouth itself the type of fever changed after a time to malignant spotted fever, synochus, or true typhus.

The malignant epidemic seemed to have been brought in by the fleet; it had raged for a long time among the sailors of the fleet lying at Portsmouth, and had destroyed many of them. In March, 1735, it was raging among the lower classes of Plymouth. About the 10th day of the fever, previously marked by various head symptoms, there appeared petechiae, red or purple, or livid or black, up to the size of vibices or blotches, or the eruption might be more minute, like fleabites. A profuse, clammy, stinking sweat, or a most foetid diarrhoea wasted the miserable patients. A black tongue, spasms, hiccup, and livid hands presaged death about the 11th to 14th day. So extensive and rapid was the putrefaction of the bodies that they had to be buried at once or within twenty-four hours. It was fortunate for many to have had a mild sweat and a red miliary eruption about the 4th or 5th day; but for others the course of the disease was attended with great risk. In April the type became worse, and the disease more general. There was rarely now any constriction of the throat. Few pustules broke out; but in place of them there were dusky or purple and black petechiae, and too often livid blotches, with which symptoms very many died both in April and May. In July this contagious fever had decreased much in Plymouth, and in September it was only sporadic there. With a mere reference to Hillary’s account of somewhat similar fevers at Ripon in 1734-5 (with profuse sweats, sometimes foetid, great fainting and sinking of spirits, starting of the limbs and beating of the tendons, hiccup for days, etc.[127]) we may pass to a more signal historical event, the great epidemic of fever in 1741-42, of which the Irish part alone has hitherto received sufficient notice[128].

The epidemic fever of 1741-42.

The harvest of 1739 had been an abundant one, and the export of grain had been large. At Lady-day the price of wheat had been 31_s._ 6_d._ per quarter, and it rose 10_s._ before Lady-day, 1740. An extremely severe winter had intervened, one of the three memorable winters of the 18th century. The autumn-sown wheat was destroyed by the prolonged and intense frost, and the price at Michaelmas, 1740, rose to 56_s._ per quarter, the exportation being at the same time prohibited, but not until every available bushel had been sold to the foreigners. The long cold of the winter of 1739-40 had produced much distress and want in London, Norwich, Edinburgh and other towns. In London the mortality for 1740 rose to a very high figure, 30,811, of which 4003 deaths were from fever and 2725 from smallpox. In mid-winter, 1739-40, coals rose to £3. 10_s._ per chaldron, owing to the navigation of the Thames being closed by ice; the streets were impassable by snow, there was a “frost-fair” on the Thames, and in other respects a repetition of the events preceding the London typhus of 1685-86. The Gentleman’s Magazine of January, 1740, tells in verse how the poor were “unable to sustain oppressive want and hunger’s urgent pain,” and reproaches the rich,--“colder their hearts than snow, and harder than the frost”; while in its prose columns it announces that “the hearts of the rich have been opened in consideration of the hard fate of the poor[129].” The long, hard winter was followed by the dry spring and hot summer of 1740, during which the sickness (in Ireland at least) was of the dysenteric type. In the autumn of 1740 the epidemic is said to have taken origin both at Plymouth and Bristol from ships arriving with infection among the men--at the former port the king’s ships ‘Panther’ and ‘Canterbury,’ at the latter a merchant ship. At Plymouth it was certainly raging enormously from June to the end of the year--“febris nautica pestilentialis jam saevit maxime,” says Huxham; it continued there all through the first half of 1741, “when it seemed to become lost in a fever of the bilious kind.” It was in the dry spring and very hot summer of 1741 that the fever became general over England. Wall says that it appeared at Worcester at the Spring Assizes among a few; at Exeter also it was traced to the gaol delivery; and it was commonly said that the turmoil of the General Election (which resulted in driving Walpole from his long term of power) helped its diffusion. But undoubtedly the great occasion of its universality was a widely felt scarcity. The rise in the price of wheat was small beside the enormous leaps that prices used to take in the medieval period, having been at no time double the average low price of that generation. It was rather the want of employment that made the pinch so sharp in 1741. The weaving towns of the west of England were losing their trade; of “most trades,” also, it was said that they were in apparent decay, “except those which supply luxury[130].” Dr Barker, of Sarum, the best medical writer upon the epidemic, says:

“The general poverty which has of late prevailed over a great part of this nation, and particularly amongst the woollen manufacturers in the west, where the fever has raged and still continues to rage with the greatest violence, affords but too great reason to believe that this has been one principal source of the disease[131].”

He explains that the price of wheat had driven the poor to live on bad bread. This is borne out by a letter from Wolverhampton, 27 November, 1741[132]. The writer speaks of the extraordinary havoc made among the poorer sort by the terrible fever that has for some time raged in most parts of England and Ireland. At first it seldom fixed on any but the poor people, and especially such as lived in large towns, workhouses, or prisons. Country people and farmers seemed for the most part exempt from it, “though we have observed it frequently in villages near market towns”; whereas, says the writer, the epidemic fevers of 1727, 1728 and 1729 were first observed to begin among the country people, and to be some time in advancing to large towns. This writer’s theory was that the fever was caused by bad bread, and he alleges that horse-beans, pease and coarse unsound barley were almost the only food of the poor. To this a Birmingham surgeon took exception[133]. Great numbers of the poor had, to his knowledge, lived almost entirely upon bean-bread, but had been very little afflicted with the fever. Besides, every practitioner knew that the fever was not confined to the poor. He pointed out that in Wolverhampton, whence the bad-bread theory emanated, the proportion of poor to those in easier circumstances was as six to one, poverty having increased so much by decay of trade that many wanted even the necessaries of life. The Birmingham surgeon was on the whole inclined to the theory of “the ingenious Sydenham, that the disease may be ascribed to a contagious quality in the air, arising from some secret and hidden alterations in the bowels of the earth, passing through the whole atmosphere, or to some malign influence in the heavenly bodies”--these being Sydenham’s words as applied to the fever of 1685-6.

Barker, also, draws a parallel between the epidemic of 1741 and that of 1685-86: the Thames was frozen in each of the two winters preceding the respective epidemics, and the spring and summer of 1740 and 1741 were as remarkable for drought and heat as those of 1684 and 1685.

In London the deaths from fever in 1741 reached the enormous figure of 7528, the highest total in the bills of mortality from first to last, while the deaths from all causes were 32,119, in a population of some 700,000, also the highest total from the year of the great plague until the new registration of the whole metropolitan area in 1838. It will be seen from the following table (on p. 81) of the weekly mortalities that the fever-deaths rose greatly in the autumn, but, unlike the old plague, reached a maximum in the winter.

The effects of the epidemic of typhus upon the weaving towns of the west of England, in which the fever lasted, as in London, into the spring of 1742, were seen at their worst in the instance of Tiverton. It was then a town of about 8000 inhabitants, having increased little during the last hundred years. Judged by the burials and baptisms in the parish register it was a more unhealthy place since the extinction of plague than it had been before that. It was mostly a community of weavers, who had not been in prosperous circumstances for sometime past. In 1735 the town had been burned down, and in 1738 it was the scene of riots. The hard winter of 1739-40 brought acute distress, and in 1741 spotted fever was so prevalent that 636 persons were buried in that year, being 1 in 12 of the inhabitants. At the height of the epidemic ten or eleven funerals were seen at one time in St Peter’s churchyard. Its population twenty years after is estimated to have declined by two thousand, and at the end of the 18th century it was a less populous place than at the beginning[134].

Mortality by Fever in London, 1741-42.

Week All ending Fever causes 1741 March 10 123 660 17 103 564 24 112 624 31 105 573 April 7 123 670 14 128 687 21 89 580 28 123 622 May 5 104 495 12 141 587 19 129 573 26 153 600 June 2 138 512 9 138 483 16 115 536 23 127 494 30 154 513 July 7 149 523 14 162 551 21 130 485 28 151 621 Aug. 4 128 512 11 142 541 18 172 636 25 192 665 Sept. 1 171 675 8 190 691 15 182 760 22 199 748 29 189 733 Oct. 6 207 784 13 192 787 20 232 793 27 234 850 Nov. 3 250 835 10 228 772 17 182 670 24 214 806 Dec. 1 224 768 8 203 748 15 191 761 22 179 775 29 180 702 1742 Jan. 5 221 893 12 184 760 19 151 724 Feb. 2 132 675 9 103 533 16 108 675 25 103 641

Effects of the Epidemic of 1741-42 on Provincial Towns. (Short’s Abstracts of Parish Registers.)

With burials Registers more than Baptisms in Burials in Year examined baptisms the same the same

1740 27 6 1409 1940 1741 27 14 3787 6205 1742 26 6 1721 3345

Other parts of the kingdom may be represented by Norwich, Newcastle and Edinburgh. The record of baptisms in Norwich is almost certainly defective; in only two years from 1719 to 1741, is a small excess of baptisms over burials recorded, namely, in 1722 and 1726, while in a third year, 1736, the figures are exactly equal. In 1740 there are 916 baptisms to 1173 burials, and in 1741, 851 baptisms to 1456 burials; while in 1742, owing to an epidemic of smallpox, the deaths rose to 1953, or to more than double the recorded births[135]. The distress was felt most in East Anglia in 1740. Blomefield, who ends his history in that year, says there was much rioting throughout the kingdom, “on the pretence of the scarcity and dearness of grain.” At Wisbech Assizes fourteen were found guilty, but were not all executed. In Norfolk two were convicted and executed accordingly. At Norwich the military fired upon the mob and killed seven persons, of whom only one was truly a rioter[136]. It was also in the severe winter of 1739-40 that the distress began in Edinburgh. The mills were stopped by ice and snow, causing a scarcity of meal; the harvest of 1740 was bad, riots took place in October, and granaries were plundered[137]. The deaths from fever were many in 1740, but were nearly doubled in 1741, with a significant accompaniment of fatal dysentery[138]:

Edinburgh Mortalities, 1740-41.

(Population in 1732, estimated at 32,000.)[139]

1740 1741 All causes 1237 1611 ---- ---- Consumption 278 349 Fever 161 304 Flux 3 36 Smallpox 274 206 Measles 100 112 Chincough 26 101 Convulsions 22 16

The last four items are of children’s maladies, for which Edinburgh was worse reputed even than London.

At Newcastle the deaths in the register in 1741 were 320 more than in 1740, in which year they were doubtless excessive, as elsewhere. But there is a significant addition: “There have also been buried upwards of 400 upon the Ballast Hills near this town[140].”

The symptoms of the epidemic fever of 1741-42 are described by Barker, of Salisbury, and Wall, of Worcester[141]. It began like a common cold, as was remarked also in Ireland. On the seventh day spots appeared like fleabites on the breast and arms; in some there were broad purple spots like those of scurvy. Miliary eruptions were apt to come out about the eleventh day, especially in women. In most, after the first six or seven days, there was a wonderful propensity to diarrhoea, which might end in dysentery. The cough, which had appeared at the outset, went off about the ninth day, when stupor and delirium came on. Gilchrist, of Dumfries, describes the fever there in November, 1741, as more malignant than the “nervous fever” which he had described in 1735. It came to an end about the fourteenth day; the sick were almost constantly under a coma or raving, and they died of an absolute oppression of the brain; a profuse sweat about the seventh day was followed by an aggravation of all the symptoms[142]. An anonymous writer, dating from Sherborne, uses the occasion to make an onslaught upon blood-letting[143].

Sanitary Condition of London under George II.

The great epidemic of fever in 1741-42 was the climax of a series of years in London all marked by high fever mortalities. If there had not been something peculiarly favourable to contagious fever in the then state of the capital, it is not likely that a temporary distress caused by a hard winter and a deficient harvest following should have had such effects. This was the time when the population is supposed to have stood still or even declined in London. Drunkenness was so prevalent that the College of Physicians on 19 January, 1726, made a representation on it to the House of Commons through Dr Freind, one of their fellows and member for Launceston:

“We have with concern observed for some years past the fatal effects of the frequent use of several sorts of distilled spirituous liquor upon great numbers of both sexes, rendering them diseased, not fit for business, poor, a burthen to themselves and neighbours, and too often the cause of weak, feeble and distempered children, who must be, instead of an advantage and strength, a charge to their country[144].”

“This state of things,” said the College, “doth every year increase.” Fielding guessed that a hundred thousand in London lived upon drink alone; six gallons per head of the population per annum is an estimate for this period, against one gallon at present. The enormous duty of 20_s._ per gallon served only to develope the trade in smuggled Hollands gin and Nantes brandy. In the harvest of 1733 farmers in several parts of Kent were obliged to offer higher wages, although the price of grain was low, and could hardly get hands on any terms, “which is attributed to the great numbers who employ themselves in smuggling along the coast[145].”

The mean annual deaths were never higher in London, not even in plague times over a series of years, the fever deaths keeping pace with the mortality from all causes, and, in the great epidemic of typhus in 1741, making about a fourth part of the whole. The populace lived in a bad atmosphere, physical and moral. As Arbuthnot said in 1733, they “breathed their own steams”; and he works out the following curious sum:

“The perspiration of a man is about 1/34 of an inch in 24 hours, consequently one inch in 34 days. The surface of the skin of a middle-sized man is about 15 square feet; consequently the surface of the skin of 2904 such men would cover an acre of ground, and the perspir’d matter would cover an acre of ground 1 inch deep in 34 days, which, rarefi’d into air, would make over that acre an atmosphere of the steams of their bodies near 71 foot high.” This, he explains, would turn pestiferous unless carried away by the wind; “from whence it may be inferred that the very first consideration in building of cities is to make them open, airy, and well perflated[146].”

In the growth of London from a medieval walled city of some forty or sixty thousand inhabitants to the “great wen” of Cobbett’s time, these considerations had been little attended to so far as concerned the quarters of the populace. The Liberties of the City and the out-parishes were covered with aggregates of houses all on the same plan, or rather want of plan. In the medieval period the extramural population built rude shelters against the town walls or in the fosse, if it were dry, or along the side of the ditch. The same process of squatting at length extended farther afield, with more regular building along the sides of the great highways leading from the gates. Queen Elizabeth’s proclamation of 1580 was designed to check the growth of London after this irregular fashion; but as neither the original edict nor the numerous copies of it, reissued for near a hundred years, made any provision for an orderly expansion of the capital, these prohibitions had merely the effect of adding to the hugger-mugger of building, “in odd corners and over stables.” The outparishes were covered with houses and tenements of all kinds, to which access was got by an endless maze of narrow passages or alleys; regular streets were few in them, and it would appear from the account given by John Stow in 1598 of the parish of Whitechapel that even the old country highway, one of the great roads into Essex and the eastern counties, had been “pestered[147].” The “pestering” of the field lanes in the suburban parishes with poor cottages is Stow’s frequent theme[148]. The borough of Southwark, as part of the City, may have been better than most: “Then from the Bridge straight towards the south a continual street called Long Southwark, built on both sides with divers lanes and alleys up to St George’s Church, and beyond it through Blackman Street towards New Town or Newington”--the mazes of courts and alleys on either side of the Borough Road which may be traced in the maps long after Stow’s time. So again in St Olave’s parish along the river bank eastwards from London Bridge--“continual building on both sides, with lanes and alleys, up to Battle Bridge, to Horsedown, and towards Rotherhithe.” In the Western Liberty, the lanes that had been laid out in Henry VIII.’s time, Shoe Lane, Fetter Lane and Chancery Lane, served as three main arteries to the densely populated area between Fleet Street and Holborn, but for the rest it was reached by a plexus or rete mirabile of alleys and courts, notorious even in the 19th century. In like manner Drury Lane and St Martin’s Lane were the main arteries between High Holborn and the Strand. One piazza of Covent Garden was a new centre of regular streets, to which the haberdashers and other trades were beginning to remove from the City, for greater room, about 1662. The Seven Dials were a wonder when they were new, about 1694, and had the same intention of openness and regularity as in Wren’s unused design for the City after the fire. The great speculative builder of the Restoration was Nicholas Barbone, son of Praise-God Barbones. He built over Red Lion Fields, much to the annoyance of the gentlemen of Gray’s Inn[149], and his manner of building may be inferred from the following:

“He was the inventor of this new method of building by casting of ground into streets and small houses, and to augment their number with as little front as possible, and selling the ground to workmen by so much per foot front, and what he could not sell build himself. This has made ground-rents high for the sake of mortgaging; and others, following his steps, have refined and improved upon it, and made a superfoetation of houses about London[150].”

In these mazes of alleys, courts, or “rents” the people were for the most part closely packed. Overcrowding had been the rule since the Elizabethan proclamation of 1580, and it seems to have become worse under the Stuarts. On February 24, 1623, certain householders of Chancery Lane were indicted at the Middlesex Sessions for subletting, “to the great danger of infectious disease, with plague and other diseases.” In May, 1637, one house was found to contain eleven married couples and fifteen single persons; another house harboured eighteen lodgers. In the most crowded parishes the houses had no sufficient curtilage, standing as they did in alleys and courts. When we begin to have some sanitary information long after, it appears that their vaults, or privies, were indoors, at the foot of the common stair[151]. In 1710, Swift’s lodging in Bury Street, St James’s, for which he paid eight shillings a week (“plaguy deep” he thought), had a “thousand stinks in it,” so that he left it after three months. The House of Commons appears to have been ill reputed for smells, which were specially remembered in connexion with the hot summer of the great fever-year 1685[152].

The newer parts of London were built over cesspools, which were probably more dangerous than the visible nuisances of the streets satirized by Swift and Gay. There were also the “intramural” graveyards; of one of these, the Green Ground, Portugal Street, it was said by Walker, as late as 1839; “The effluvia from this ground are so offensive that persons living in the back of Clement’s Lane are compelled to keep their windows closed.” But that which helped most of all to make a foul atmosphere in the houses of the working class, an atmosphere in which the contagion of fever could thrive, was the window-tax. It is hardly possible that those who devised it can have foreseen how detrimental it would be to the public health; it took nearly a century to realize the simple truth that it was in effect a tax upon light and air.

The Window-Tax.

Willan, writing of fever in London in 1799, mentions that even the passages of tenement houses were “kept dark in order to lessen the window-tax,” and the air therefore kept foul[153]. Ferriar, writing of Manchester in the last years of the 18th century, mentions, among other fever-dens, a large house in an airy situation which had been built for a poor’s-house, but abandoned: having been let to poor families for a very trifling rent, many of the windows and the principal entrance were built up, and the fever then became universal in it[154]. The Carlisle typhus described by Heysham for 1781 began in a house near one of the gates, tenanted by five or six very poor families; they had “blocked up every window to lessen the burden of the window-tax[155].” John Howard’s interest having been excited in the question of gaol-fever, he noted the effects of the window-tax not only in prisons but in other houses. The magistrates of Kent appear to have paid the tax for the gaols in that county from the county funds; but in most cases the burden fell on the keepers of the gaols.

“The gaolers,” says Howard, “have to pay it; this tempts them to stop the windows and stifle their prisoners;” and he appends the following note: “This is also the case in many work-houses and farm-houses, where the poor and the labourers are lodged in rooms that have no light nor fresh air; which may be a cause of our peasants not having the healthy ruddy complexions one used to see so common twenty or thirty years ago. The difference has often struck me in my various journeys[156].”

Such impressions are known to be often fallacious; but in the history of the window-tax, which we shall now follow, it will appear that there was a new law, with increased stringency, in the years 1746-1748, corresponding to the “twenty or thirty years ago” of Howard’s recollection.

The window-tax was originally a device of the statesmen of the Revolution “for making good the deficiency of the clipped money.” By the Act of 7 and 8 William and Mary, cap. 18, taking effect from the 25th March, 1696, every inhabited house owed duty of two shillings per annum, and, over and above such duty on all inhabited houses, every dwelling-house with ten windows owed four shillings per annum, and every house with twenty windows eight shillings. In 1710 houses with from twenty to thirty windows were made to pay ten shillings, and those with more than thirty windows twenty shillings. Various devices were resorted to to check the evasions of bachelors, widows and others. A farmer had to pay for his servants, recouping himself from their wages. A house subdivided into tenements was to count as one; which would have made the tax difficult to gather except from the landlord. The machinery of collection was a board of commissioners, receivers-general and collectors.

But in the 20th of George II. (1746) the basis of the law was changed. The tax was levied upon the several windows of a house, so much per window, so that it fell more decisively than before upon the tenants of tenement-houses, and not on the landlords. The two-shillings house duty was continued; but the window-tax became sixpence per annum for every window of a house with ten, eleven, twelve, thirteen or fourteen windows, or lights, ninepence for every window of a house with fifteen, sixteen, seventeen, eighteen or nineteen windows, and one shilling for every window of a house with twenty or more windows. An exemption in the Act in favour of those receiving parochial relief was decided by the law officers of the Crown not to apply to houses with ten or more windows or lights, which would have included most tenement-houses; on the other hand they ruled that hospitals, poor-houses, workhouses, and infirmaries were not chargeable with the window duty. To remove doubts and check evasions another Act was made in 21 George II. cap. 10. All skylights, and lights of staircases, garrets, cellars and passages were to count for the purpose of the tax; also certain outhouses, but not others, were to count as part of the main dwelling whether they were contiguous or not. The 11th paragraph of the Amendment Act shows how the law had been working in the course of its first year: “No window or light shall be deemed to be stopped up unless such window or light shall be stopped up effectually with stone or brick or plaister upon lath,” etc.

This remained the law down to 1803, when a change was made back to the original basis of rating houses as a whole, according to the number of their windows, the rate being considerably raised and fixed according to a schedule. The tax for tenement houses was at the same time made recoverable from the landlord. The window-tax thus became a form of the modern house-tax, rated upon windows instead of upon rental, and so lost a great part of its obnoxious character.

The law of 1747-48, which taxed each window separately, and was enforced by a galling and corrupt machinery of commissioners, receivers-general and collectors paid by results, could not fail to work injuriously; for light and air, two of the primary necessaries of life, were in effect taxed. Even rich men appear to have taken pleasure in circumventing the collectors[157]. But it was among the poor, and especially the inhabitants of tenement houses, that the effect was truly disastrous; a tax on the skylights of garrets and on the lights of cellars, staircases and passages, taught the people to dispense with them altogether. Towards the end of the 18th century the grievance became now and then the subject of a pamphlet or a sermon.

Gaol-Fever.

Besides these ordinary things favouring contagious epidemic fever both in town and country, there were two special sources of contagion, the gaols and the fleets and armies. I shall take first the state of the gaols, which has been already indicated in speaking of the window-tax. In the opinion of Lind, a great part of the fever, which was a constant trouble in ships of the navy, came direct from the gaols through the pressing of newly discharged convicts.

The state of the prisons in the first half of the 18th century was certainly not better than Howard found it to be a generation after; it was probably worse, for the administration of justice was more savage. About the beginning of the century, many petitions were made to Parliament by imprisoned debtors, complaining of their treatment, and a Bill was introduced in 1702. Sixty thousand were said to be in prison for debt[158]. On 25 February, 1729, the House of Commons appointed a committee “to inquire into the state of the gaols of this Kingdom”; but only two prisons were reported on, the Fleet and the Marshalsea, in London, the inquiries upon these being due to the energy of Oglethorpe, then at the beginning of his useful career. The committee found a disgraceful state of things:--wardens, tip-staffs and turnkeys making their offices so lucrative by extortion that the reversion of them was worth large sums, prisoners abused or neglected if they could not pay, some prisoners kept for years after their term was expired, the penniless crowded three in a bed, or forty in one small room, while some rooms stood empty to await the arrival of a prisoner with a well-filled purse. On the common side of the Fleet Prison, ninety-three prisoners were confined in three wards, having to find their own bedding, or pay a shilling a week, or else sleep on the floor. The “Lyons Den” and women’s ward, which contained about eighteen, were very noisome and in very ill repair. Those who were well had to lie on the floor beside the sick. A Portuguese debtor had been kept two months in a damp stinking dungeon over the common sewer and adjoining to the sink and dunghill; he was taken elsewhere on payment of five guineas. In the Marshalsea there were 330 prisoners on the common side, crowded in small rooms. George’s ward, sixteen feet by fourteen and about eight feet high, had never less than thirty-two in it “all last year,” and sometimes forty; there was no room for them all to lie down, about one-half of the number sleeping over the others in hammocks; they were locked in from 9 p.m. to 5 a.m. in summer (longer hours in winter), and as they were forced to ease nature within the room, the stench was noisome beyond expression, and it seemed surprising that it had not caused a contagion; several in the heat of summer perished for want of air. Meanwhile the room above was let to a tailor to work in, and no one allowed to lie in it. Unless the prisoners were relieved by their friends, they perished by famine. There was an allowance of pease from a casual donor who concealed his name, and 30 lbs. of beef three times a week from another charitable source. The starving person falls into a kind of hectic, lingers for a month or two and then dies, the right of his corpse to a coroner’s inquest being often scandalously refused[159]. The prison scenes in Fielding’s Amelia are obviously faithful and correct.

Oglethorpe’s committee had done some good since they first met at the Marshalsea on 25th March, 1729, not above nine having died from that date to the 14th May; whereas before that a day seldom passed without a death, “and upon the advancing of the spring not less than eight or ten usually died every twenty-four hours.” Two of the chief personages concerned were found by a unanimous vote of the House of Commons to have committed high crimes and misdemeanours; but when they were tried before a jury on a charge of felony they were found not guilty.

About a year after these reports to the Commons there was a tragic occurrence among the Judges and the Bar of the Western Circuit during the Lent Assizes of 1730. The Bridewell at Taunton was filled for the occasion of the Assizes with drafts of prisoners from other gaols in Somerset, among whom several from Ilchester were said to have been more than ordinarily noisome. Over a hundred prisoners were tried, of whom eight were sentenced to death (six executed), and seventeen to transportation. As the Assize Court continued its circuit through Devon and Dorset several of its members sickened of the gaol fever and died: Piggot, the high-sheriff, on the 11th April, Sir James Sheppard, serjeant-at-law, on 13th April at Honiton, the crier of the court and two of the Judge’s servants at Exeter, the Judge himself, chief baron Pengelly, at Blandford, and serjeant-at-law Rous, on his return to London, whither he had posted from Exeter as soon as he felt ill[160]. It is said that the infection afterwards spread within the town of Taunton, where it arose, “and carried off some hundreds”; but the local histories make no mention of such an epidemic in 1730, and no authority is cited for it[161]. Something of the same kind is believed to have happened at a gaol delivery at Launceston in 1742, but the circumstances are vaguely related, and it does not appear that any prominent personage in the Assize Court died on the occasion[162].

The great instance of a Black Assize in the 18th century, comparable to those of Cambridge, Oxford and Exeter in the 16th[163], was that of the Old Bailey Sessions in London in April, 1750. It has been fully related by Sir Michael Foster, one of the justices of the King’s Bench, who had himself been on the bench at the January sessions preceding, and was the intimate friend of Sir Thomas Abney, the presiding judge who lost his life from the contagion of the April sessions[164].

“At the Old Bailey sessions in April, 1750, one Mr Clarke was brought to his trial; and it being a case of great expectation, the court and all the passages to it were extremely crowded; the weather too was hotter than is usual at that time of the year[165]. Many people who were in court at this time were sensibly affected with a very noisome smell; and it appeared soon afterwards, upon an enquiry ordered by the court of aldermen, that the whole prison of Newgate and all the passages leading thence into the court were in a very filthy condition, and had long been so. What made these circumstances to be at all attended to was, that within a week or ten days at most, after the session, many people who were present at Mr Clarke’s trial were seized with a fever of the malignant kind; and few who were seized recovered. The symptoms were much alike in all the patients, and in less than six weeks time the distemper entirely ceased. It was remarked by some, and I mention it because the same remark hath formerly been made on a like occasion [Oxford, 1577], that women were very little affected: I did not hear of more than one woman who took the fever in court, though doubtless many women were there.

“It ought to be remembered that at the time this disaster happened there was no sickness in the gaol more than is common in such places. This circumstance, which distinguisheth this from most of the cases of the like kind which we have heard of, suggesteth a very proper caution: not to presume too far upon the health of the gaol, barely because the gaol-fever is not among the prisoners. For without doubt, if the points of cleanliness and free air have been greatly neglected, the putrid effluvia which the prisoners bring with them in their clothes etc., especially where too many are brought into a crowded court together, may have fatal effects on people who are accustomed to breathe better air; though the poor wretches, who are in some measure habituated to the fumes of a prison, may not always be sensible of any great inconvenience from them.

“The persons of chief note who were in court at this time and died of the fever were Sir Samuel Pennant, lord mayor for that year, Sir Thomas Abney, one of the justices of the Common Pleas, Charles Clarke, esquire, one of the barons of the exchequer, and Sir Daniel Lambert, one of the aldermen of London. Of less note, a gentleman of the bar, two or three students, one of the under-sheriffs, an officer of Lord Chief Justice Lee, who attended his lordship in court at that time, several of the jury on the Middlesex side, and about forty other persons whom business or curiosity had brought thither.”

The same thing was remarked here as at Exeter in 1586 that those who sat on the side of the Court nearest to the dock were most attacked by the infection[166]. When the cases of fever began to occur, after the usual incubation of “a week or ten days,” there was much fear of the infection spreading, so that many families, it is said, retired into the country[167]. But Pringle wrote on 24 May, “However fatal it has been since the Sessions, it is highly probable that the calamity will be in a great measure confined to those who were present at the tryal[168];” and Justice Foster gives no hint of anyone having taken the fever who was not present in court.

The tragedy of gaol-fever at the Old Bailey in 1750 secured increased attention to the subject of scientific ventilation. The great bar to fresh air indoors throughout the 18th century was the window-tax. It bore particularly hard on prisoners, for the gaolers had to pay the window-tax out of their profits, and they naturally preferred to build up the windows. Scientific ventilation of gaols was something of a mockery in these circumstances; but it is the business of science to find out cunning contrivances, and ingenious ventilators were devised for Newgate, the leading spirit in this work being the Rev. Dr Hales, rector of a parish near London, and an amateur in physiology at the meetings of the Royal Society.

A ventilating apparatus had been erected at Newgate about a year before the fatal sessions of 1650, but it does not seem to have answered. It consisted of tubes from the various wards meeting in a great trunk which opened on the roof. A committee of the Court of Aldermen in October 1750 resolved, after consulting Pringle and Hales, to add a windmill on the leads over the vent, and that was done about two years after. Pringle, who inspected the ventilator on 11 July, 1752, says that a considerable stream of air of a most offensive smell issued from the vent; and it appeared that no fewer than seven of the eleven carpenters who were working at the alterations on the old ventilator caught gaol-fever (of the petechial kind), which spread among the families of some of them[169]. Pringle and Hales were of opinion that the wards furnished with tubes were less foul than the others; and they claimed, on the evidence of the man who took care of the apparatus, that only one person had died in the gaol in two months, whereas, before the windmill was used, there died six or seven in a week[170]. But Oglethorpe had claimed an improvement of the same kind at the Marshalsea in 1729 merely from having the prisoners saved from hunger; and Lind, who was a most matter-of-fact person, did not think that the ingenious contrivances for ventilation had answered their end[171].

Howard’s visitations of the prisons, which began in 1773 and were continued or repeated during several years following, brought to light many instances of epidemic sickness therein, which was nearly always of the nature of gaol-typhus. The following is a list compiled from his various reports, the two or three instances of smallpox infection being given elsewhere.

Wood Street Compter, London. About 100 in it, chiefly debtors. Eleven died in beginning of 1773; since then it has been visited by Dr Lettsom at the request of the aldermen.

Savoy, London. On 15 March, 1776, 119 prisoners. Many sick and dying. Between that date and next visit, 25 May, 1776, the gaol-fever has been caught by many.

Hertford. Inmates range from 20 to 30. In the interval of two visits, the gaol-fever prevailed and carried off seven or eight prisoners and two turnkeys. (The interval probably corresponded to the admission of an unusual number of debtors.)

Chelmsford. Number of inmates varies from 20 to 60, about one-half debtors. A close prison frequently infected with the gaol-distemper.

Dartford, County Bridewell. A small prison. About two years before visit of 1774 there was a bad fever, which affected the keeper and his family and every fresh prisoner. Two died of it.

Horsham, Bridewell. The keeper a widow: her husband dead of the gaol-fever.

Petworth, Bridewell. Allowance per diem a penny loaf (7½ oz.). Th. Draper and Wm. Godfrey committed 6 Jan., 1776: the former died on 11 Jan., the other on 16th. Wm. Cox, committed 13 Jan., died 23rd. “None of these had the gaol-fever. I do not affirm that these men were famished to death; it was extreme cold weather.” After this the allowance of bread was doubled, thanks to the Duke of Richmond.

Southwark, the new gaol. Holds up to 90 debtors and felons. “In so close a prison I did not wonder to see, in March, 1776, several felons sick on the floors.” No bedding, nor straw. The Act for preserving the health of prisoners is on a painted board.

Aylesbury. About 20 prisoners. First visit Nov., 1773, second Nov., 1774: in the interval six or seven died of the gaol-distemper.

Bedford. About twenty years ago the gaol-fever was in this prison; some died there, and many in the town, among whom was Mr Daniel, the surgeon who attended the prisoners. The new surgeon changed the medicines from sudorifics to bark and cordials; and a sail-ventilator being put up the gaol has been free from the fever almost ever since. (This was the gaol which is often said to have started Howard on his inquiries when he was High Sheriff.)

Warwick. Holds up to fifty-seven. The late gaoler died in 1772 of the gaol-distemper, and so did some of his prisoners. No water then; plenty now.

Southwell, Bridewell. A small prison. A few years ago seven died here of the gaol-fever within two years.

Worcester. Has a ventilator. Mr Hallward the surgeon caught the gaol-fever some years ago, and has ever since been fearful of going into the dungeon; when any felon is sick, he orders him to be brought out.

Shrewsbury. Gaol-fever has prevailed here more than once of late years.

Monmouth. At first visit in 1774, they had the gaol-fever, of which died the gaoler, several of his prisoners, and some of their friends.

Usk (Monmouth) Bridewell. The keeper’s wife said that many years ago the prison was crowded, and that herself, her father who was then keeper, and many others of the family had the gaol-fever, three of whom, and several of the prisoners, died of it.

Gloucester, the Castle. Many prisoners died here in 1773; and always except at Howard’s last visit, he saw some sick in this gaol. A large dunghill near the stone steps. The prisoners miserable objects: Mr Raikes and others took pity on them.

Winchester. The former destructive dungeon was down eleven steps, and darker than the present. Mr Lipscomb said that more than twenty prisoners had died in it of the gaol-fever in one year, and that the surgeon before him had died of it.

Liverpool. Holds about sixty, offensive, crowded. Howard in March, 1774, told the keeper his prisoners were in danger of the gaol-fever. Between that date and Nov., 1775, twenty-eight had been ill of it at one time.

Chester, the Castle. Dungeon used to imprison military deserters. Two of them brought by a sergeant and two men to Worcester, of which party three died a few days after they came to their quarters. (For fever in this prison in 1716 see the text, p. 60.)

Cowbridge. The keeper said, on 19 August, 1774, that many had died of the gaol-fever, among them a man and a woman a year before, at which time himself and daughter were ill of it.

Cambridge, the Town Bridewell. In the spring of 1779, seventeen women were confined in the daytime, and some of them at night, in the workroom, which has no fireplace or sewer. This made it extremely offensive, and occasioned a fever or sickness among them, which so alarmed the Vice-Chancellor that he ordered all of them to be discharged. Two or three of them died within a few days.

Exeter, the County Bridewell. Between first visit in 1775 and next on 5 Feb., 1779, the surgeon and two or three prisoners have died of the gaol-fever. In 1755 a prisoner discharged from the gaol went home to Axminster, and infected his family, of whom two died, and many others in that town afterwards.

Exeter, the High Gaol for felons. Mr Bull, the surgeon, stated that he was by contract excused from attending in the dungeons any prisoners that should have the gaol-fever.

Winchester, Bridewell. Close and small. Receives many prisoners from other gaols at Quarter Sessions. It has been fatal to vast numbers. The misery of the prisoners induced the Duke of Chandos to send them for some years 30 lbs. of beef and 2 gallon loaves a week.

Devizes, Bridewell. Two or three years ago the gaol-fever carried off many. An infirmary added since then.

Marlborough. The rooms offensive. Saw one dying on the floor of the gaol-fever. One had died just before, and another soon after his discharge.

Launceston. Small, with offensive dungeons. No windows, chimneys, or drains. No water. Damp earthen floor. Those who serve there often catch the gaol-fever. At first visit, found the keeper, his assistant and all the prisoners but one sick of it (on 19 Feb., 1774, eleven felons in it). Heard that, a few years before, many prisoners had died of it, and the keeper and his wife in one night. A woman confined three years by the Ecclesiastical Court had three children born in the gaol.

Bodmin, Bridewell. Much out of repair. The night rooms are two garrets with small close-glazed skylight 17 in. × 12 in. A few years ago the gaol-fever was very fatal, not only in the prison but also in the town.

Taunton, Bridewell. Six years ago, when there was no infirmary provided, the gaol-fever spread over the whole prison, so that eight died out of nineteen prisoners.

Shepton Mallet. Men’s night room close, with small window. So unhealthy some years ago that the keeper buried three or four in a week.

Thirsk. Prisoners had the gaol-fever not long ago.

Carlisle. During the gaol-fever which some years ago carried off many of the prisoners, Mr Farish, the chaplain, visited the sick every day.

I shall add some medical experiences of gaol-fever in London from the notes of Lettsom[172]:--

May, 1773. A person released from Newgate “in a malignant or jail-fever” was brought into a house in a court off Long Lane, Aldersgate Street; soon after which fourteen persons in the same confined court were attacked with a similar fever: one died before Lettsom was called in, one was sent to hospital, eleven attended by him all recovered, though with difficulty. Two deaths in Wood Street Compter: 1. Rowell, an industrious, sober workman, who had supported for many years a wife and three children; some of these having been lately sick, he fell behind with his rent, a little over three guineas; he offered all he had (more than enough) to the landlord, but the latter preferred to throw the man and his family into the Compter, where Rowell died of fever. 2. Russell, once a reputable tradesman on Ludgate Hill, fell into a debt of under three guineas, sent to the Compter with his wife and five children, took fever and died; attended in his sickness in a bare room by his eldest daughter, elegant and refined, aged seventeen; his son, aged fourteen, took the fever and recovered.

There was one Black Assize at this period, at Dublin in April 1776. A criminal, brought into the Court of Sessions without cleansing, infected the court and alarmed the whole city. Among others who died of the contagion were Fielding Ould, High Sheriff, the counsellors Derby, Palmer, Spring and Ridge, Mr Caldwell, Messrs Bolton and Eriven, and several attorneys and others whose business it was to attend the court[173].

There were two notorious outbreaks of malignant fever among foreign prisoners of war, one in 1761[174] and another in 1780[175], the first among French and Spaniards at Winchester and Portchester, the second among Spaniards at Winchester.

Howard found so little typhus in the gaols in his later visits that it seemed as if banished for good. But it was heard of frequently about 1780-85--at Maidstone, at Aylesbury, at Worcester, costing the lives of some of the visiting physicians.

Circumstances of severe and mild Typhus.

The circumstances of the gaol distemper bring out one grand character of typhus which will have to be stated formally before we go farther. Ordinary domestic typhus was not a very fatal disease. Haygarth says that of 285 attacked by it in the poorer quarters of Chester in the autumn of 1774, only twenty-eight died. Ferriar, in Manchester, had sometimes an even more favourable experience than that: “The mortality of the epidemic was not great, ... out of the first ninety patients whom I attended, only two died.” This was before the House of Recovery was opened; so that the low mortality was of typhus in the homes of the people.

The fever was often an insidious languishing, without great heat, and marked most by tossing and wakefulness, which might pass into delirium; when it went through the members of a family or the inmates of a house, there would be some cases concerning which it was hard to say whether they were cases of typhus or not. Misery and starvation brought it on, and often it was itself but a degree of misery and starvation. “I have found,” says Ferriar, “that for three or four days before the appearance of typhus in a family consisting of several children, they had subsisted on little more than cold water.” “It has been observed,” says Langrish, “that those who have died of hunger and thirst, as at sieges and at sea, etc., have always died delirious and feverish.” The fever was on the whole a distinct episode, but in many cases it had no marked crisis. “Those women who recovered,” says Ferriar, “were commonly affected with hysterical symptoms after the fever disappeared;” and again: “Fevers often terminate in hysterical disorders, especially in women; men, too, are sometimes hysterically inclined upon recovering from typhus, for they experience a capricious disposition to laugh or cry, and a degree of the globus hystericus.” These were probably the more case-hardened people, inured to their circumstances, their healthy appetite dulled by the practice of fasting or “clemming,” or by opium, and their blood accustomed to be renovated by foul air. If the limit of subsistence be approached gradually, life may be sustained thereat without any sharp crisis of fever, or with only such an interlude of fever as differs but little from a habit of body unnamed in the nosology.

The worst kind of typhus, often attended with delirium, crying and raving, intolerable pains in the head, and livid spots on the skin, ending fatally perhaps in two or three days, or after a longer respite of stupor or waking insensibility, was commonly the typhus of those not accustomed to the minimum of well-being--the typhus of hardy felons newly thrown into gaol, of soldiers in a campaign crowded into a hospital after a season in the open air, of sailors on board ship mixing with newly pressed men having the prison atmosphere clinging to them, of judges, counsel, officials of the court and gentlemen of the grand jury brought into the same atmosphere with prisoners at a gaol-delivery, of the wife and children of a discharged prisoner returned to his home, of the gaol-keeper, gaol-chaplain, or gaol-doctor, of the religious and charitable who visited in poor localities even where no fever was known to be, and most of all of country people who crowded to the towns in search of work or of higher wages or of a more exciting life.

It was in these circumstances that the most fatal infections of typhus took place. Such extraordinary malignancy of typhus happened often when the type of sickness (if indeed there was definite disease at all) among the originally ailing failed to account for it; it was the great disparity of condition that accounted for it. There were, however, more special occasions when a higher degree of malignancy than ordinary was bred or cultivated among the classes at large who were habitually liable to typhus. But even the old pestilential spotted fever which used to precede, accompany, and follow the plague itself, was fatal to a comparatively small proportion of all who had it. Thus, towards the end of the great London plague of 1625, on 18th October, Sir John Coke writes to Lord Brooke: “In London now the tenth person dieth not of those that are sick, and generally the plague seems changed into an ague[176].” One in ten is probably too small a fatality for the old pestilential fever; but that is the usually accepted proportion of deaths to attacks in the typhus fever of later times. The rate of fatality is got, naturally, by striking an average. But in truth an aggregate of typhus cases, however homogeneous in conventional symptoms or type-characters, was not always really homogeneous. We have seen that ninety cases of typhus could occur in the slums of Manchester with only two deaths. On the other hand there were outbreaks of gaol-fever in which half or more of all that were attacked died; and I suspect that the average fatality in typhus of one in ten was often brought up by an admixture of cases of healthy and well-conditioned people who caught a much more malignant type of fever from their contact with those inured to misery. To strike an average is in many instances a convenience and a help to the apprehension of a truth; but for the average to be instructive, the members of the aggregate must be more or less comparable in their circumstances. It has been truly said that there is no common measure between Lazarus and Dives as regards their subjective views of things; it is not a little strange to find that they are just as incommensurable in their risk of dying from the infection of typhus fever. The rule seems to be that the degree of acuteness or violence of an attack of typhus was inversely as the habitual poor condition of the victim. In adducing evidence of the tragic nature of typhus infection conveyed across the gulf of misery to the other side, I shall endeavour to keep strictly to the scientific facts, leaving the moral, if there be a moral (and it is not always obvious), to point itself.

Let us take first the common case of country-bred people migrating to the towns. Any lodging in a crowded centre of industry and trade would be high-rented compared with the country cottage which they had left, and they would naturally gravitate to the slums of the city.

“Great numbers of the labouring poor,” says Ferriar of Manchester, “who are tempted by the prospect of large wages to flock into the principal manufacturing towns, become diseased by getting into dirty infected houses on their arrival. Others waste their small stock of money without procuring employment, and sink under the pressure of want and despair.... The number of such victims sacrificed to the present abuses is incredible.” And again:

“It must be observed that persons newly arrived from the country are most liable to suffer from these causes, and as they are often taken ill within a few days after entering an infected house, there arises a double injury to the town, from the loss of their labour, and the expense of supporting them in their illness. A great number of the home-patients of the Infirmary are of this description. The horror of these houses cannot easily be described; a lodger fresh from the country often lies down in a bed filled with infection by its last tenant, or from which the corpse of a victim to fever has only been removed a few hours before[177].”

Two instances from the same author will show the severe type of the fever.

The tenant of a house in Manchester, who was herself ill of typhus along with her three children, took in a lodger, a girl named Jane Jones, fresh from the country. The lodger fell ill, but the fact was kept concealed from the visiting physician until her screams discovered her: “She was found delirious, with a black fur on the lips and teeth, her cheeks extremely flushed, and her pulse low, creeping, and scarcely to be counted.” Treatment was of no use; she “passed whole nights in shrieking,” and in her extremity, she was saved, as Ferriar believed, by affusions of cold water. Another case, exactly parallel, proved fatal in three days:

“In 1792 I had two patients ill of typhus in an infected lodging-house. I desired that they might be washed with cold water; and a healthy, ruddy young woman of the neighbourhood undertook the office. Though apparently in perfect health before she went into the sick chamber, she complained of the intolerable smell of the patients, and said she felt a head-ache when she came down stairs. She sickened, and died of the fever in three days[178].”

These are instances of country-bred people, plunging abruptly into the fever-dens of cities and catching a typhus severe in the direct ratio of their ruddy, healthy condition. Another class of cases is that of persons carrying the atmosphere of a gaol into the company of healthy and otherwise favourably situated people. Howard gives a case: at Axminster a prisoner discharged from Exeter gaol in 1755 infected his family with the gaol-distemper, of which two of them died, and many others in that town. The best illustrations of the greater severity and fatality of typhus among the well-to-do come from Ireland, in times of famine, and will be found in another chapter. But it may be said here, so that this point in the natural history of typhus fever may not be suspected of exaggeration, that the enormously greater fatality of typhus (of course, in a smaller number of cases) among the richer classes in the Irish famines, who had exposed themselves in the work of administration, of justice, or of charity, rests upon the unimpeachable authority of such men as Graves, and upon the concurrent evidence of many.

Ship-Fever.

The prevalence of fevers in ships of war and transports from the Restoration onwards can be learned but imperfectly, and learned at all only with much trouble. Sir Gilbert Blane, who was not wanting in aptitude and had the archives of the Navy Office at his service, goes no farther back than 1779, from which date an account was kept of the causes of death in the naval hospitals. But the deaths on board ships of the fleet were not systematically recorded until 1811, when the Board of Admiralty instructed all commanders of ships of war to send to the Naval Office an annual account of all the deaths of men on board[179]. The sources of information for earlier periods are more casual.

The war with France, which dated from the accession of William III. and continued until the Peace of Ryswick in 1697, led to numerous conflicts with French and Spaniards in the West Indies, and to naval expeditions year after year. The loss of life from sickness in the British ships for a few years at the end of the century was such as can hardly be realized by us. Some part of it happened on the outward voyages, but by far the greater part of it was from the poison of yellow fever which had entered the ships in the anchorages of West Indian colonies. It was probably to that cause that the enormous mortality in the fleet under Sir Francis Wheeler was owing. After some ineffective operations against the French in the Windward Islands in the winter of 1693-4, he sailed for North America with the intention of attacking Quebec. This he failed to do, having sailed from Boston for home on the 3rd of August without entering the St Lawrence. The reason of the failure was probably the extraordinary fatality which Cotton Mather, of Boston, professes to have heard from the admiral himself, namely, that he lost by a malignant fever on the passage from Barbados to Boston 1300 sailors out of 2100, and 1800 soldiers out of 2400[180].

Another instance comes from Carlisle Bay, Barbados. The slave ship ‘Hannibal’ arrived there in November, 1694, during a disastrous epidemic of yellow fever. Phillips, the captain, whose journal of the voyage is published[181], had great difficulty in saving his crew from being pressed into the king’s ships, which were short of men owing to the yellow fever. Captain Sherman, of the ‘Tiger,’ who convoyed the ‘Hannibal’ and other merchantmen back to England in April, 1695, told Phillips that he buried six hundred men out of his ship during the two years that he lay at Barbados, though his complement was but 220, “still pressing men out of the merchant ships that came in, to recruit his number in the room of those that died daily.”

These and other similar experiences of yellow fever in the West Indies, which might be collected from the naval history, do not come properly into this chapter; and I pass from them to ship-fever proper, having indicated how much of the loss of life abroad was due to yellow fever.

Some light is thrown upon the state of health on board ships of war on the home station by Dr William Cockburn, physician to the fleet, afterwards the friend of Swift, who calls him “honest Dr Cockburn.” He had a secret remedy for dysentery, which he succeeded in getting adopted by the Admiralty, greatly to his own emolument for many years after. Dining on board one of the ships at Portsmouth, in 1696, with Lord Berkeley of Stratton, he brought up the subject of his electuary, and arranged for a public trial of it next day on board the ‘Sandwich.’ An uncertain number, which looks to have been about seven in Cockburn’s own account, but became seventy in the pamphlet which advertised the electuary after his death, were available for the trial and were speedily cured. Cockburn’s three essays on the health of seamen[182] leave no doubt as to the extensive prevalence of scurvy and the causes thereof; while his references to “malignant fever,” although they are, as usual, brought in to illustrate some doctrinal or theoretical point, give colour to the belief that ship-typhus may have been as common then as we know it to have been in the ships at Portsmouth and Plymouth, on the more direct testimony of Huxham in 1736, and of Lind twenty years later.

A naval surgeon of the time of William III. and Anne, was induced by his enthusiasm for blood-letting in fevers to record some of his experiences on board ship[183]. It was usually the lustiest, both of the young, strong and healthy people, and likewise of the elder sort, that died of fevers, the symptoms which proved so mortal having been delirium, phrenitis, coma or stupor, whether they occurred in the συνόχοι (of Sydenham) or in the συνεχεῖς (of the same author):

“I had observed in a ship of war whose complement was near 500, in a Mediterranean voyage in the year 1694, where we lost about 90 or 100 men, mostly by fevers, that those who died were commonly the young, but almost always the strongest, lustiest, handsomest persons, and that two or three escaped by means of such [natural] haemorrhagies, which were five or six pounds of blood”--the point being that the amount of blood drawn by phlebotomy should be in proportion to the robustness and body-weight of the patient.

In 1703 and 1704 he was surgeon to two of Her Majesty’s ships “where a delirium, stupor and phrenitis” were found as symptoms of the fevers. In the summer of 1704, cruising in the latitudes of Portugal and Spain, the men brought on board from Lisbon unripe lemons with which they made great quantities of punch. This was the evident cause of a cholera morbus and dysentery: “after this we had a pretty many taken with the synochus putris, and some with the causus” [malignant fever]. Most of these fevers went off by a crisis in sweating, “which was so large I had good reason to believe it judicatory.” In several the fevers left on the 9th, 10th or 11th day, and in almost all by the 14th. “About the latter end of July, and in August, there were many taken with a delirium and stupor or coma, and some with the phrenitis in their fever.” Among the symptoms was one which we find described for fevers on board ship on the West Coast of Africa at the same time--“soreness all over as if from blows with a cane,” a symptom afterwards associated with dengue. “Sometimes the bones (as they term it) don’t pain them much.” In some cases there were petechial spots as well as a stupor. In the month of August “the fevers with a stupor and phrenitis” came on apace. The treatment was to take ten ounces of blood every day from the second to the eighth day of the fever, to give tartar emetic in five-grain doses at the outset, and to administer cathartic glysters in the second half of the fever. “Seeing the lustiest men now ran no more hazard of their lives than any other who were usually taken with this fever, nor indeed so much, in the beginning of September I resolved, after all the phlebotomy was done in these fevers, to try the cathartic sooner.” Many of these who had accustomed themselves to the liberal use of spirituous liquors miscarried in the phrenitis.

White left the navy in 1704 and settled in practice at Lisbon, where he saw much fever. He had seen epidemics break out in British ships of war at anchor in the Tagus, crowded with men and prisoners. One case he mentions in a Lisbon woman, with continual synochus, stupor, and petechiae on the fifth day: “This was contagious, for she got it by going often to assist a gunner of a man-of-war, who came to her house with this distemper upon him: for many at the same time on board that ship were sick of that disease.” Among the causes of fever on board ship he mentions the effluvia of the bilge-water.

Exposed to these emanations were “a multitude of people breathing and constantly perspiring in a close place, such as a ship’s allop or lower deck next the hould, where is the entry to a certain vacant space near the ship’s center, which leadeth to the bottom, for gathering all the water together which the ship draweth by leakage, and is called the well. Several times there is occasion for some people to go down to examine the quantity of the water, and in some ships to bore an augur hole to let in as much as will preserve a good air. I have often known two or three men killed at a time, as it is said; and the reason may be understood from what I said of the general effects of that fluid in ordinary fever [he is now writing on heat apoplexy], where there is not above two or three inches, but just as much as may make a surface, almost equal to the square of the well, of stagnant salt water which had been a long while in gathering; and the air over the whole allop extremely rarified, and here not at all ventilated[184].”

We owe it to the accident of the celebrated Dr Freind having accompanied Lord Peterborough’s expedition to Spain in 1705 that some account has been preserved of the sickness among the troops ashore and afloat[185].

The expedition of some 8000 men being then in its second year, fever and dysentery were by far the most common diseases, so common that “we can hardly turn, whether at sea or in camp, without finding them as if our inseparable companions and as if domesticated among us.” In the summer of the previous year there had been much fever both in the ships of the fleet and in the camp before Barcelona: “It was of the continual kind, though it usually remitted in the day time, and seemed to approach nearly to the stationary one which Sydenham has described in the years 1685 and 1686.” He then gives symptoms, which were on the whole those of the hospital fever to be afterwards described from Pringle’s medical account of the campaigns in 1743-48. Persons of a robust habit were affected more than others, and more severely, and carried off sooner. The others were generally taken away by a lingering death. “Some, when the fever seemed to have been wholly gone off lay four or five days without pain or sickness, though weak; afterwards being suddenly seized with convulsions of the nerves they in a short time expired”--perhaps the phenomenon of relapse, which Lind recorded for ship-fever fifty years after and was seen among the troops landed from Corunna in 1809. In some few the parotids, or abscesses formed about the groin, carried off the disease.

He then gives the case of a lieutenant on board the ‘Barfleur.’ At first he was restless and delirious; on the 7th and 8th days he had subsultus tendinum; on the 8th day his tongue was sometimes fixed, and his eyes sparkled; on the 9th day, he was wholly deprived of his understanding; he pulled off the fringe of the bed and plucked the flocks; when he had before faultered in his speech, he was sometimes seized with hiccough. But on the 10th day, after 12 oz. of blood had been drawn from the jugular vein, his delirium went off on a sudden, and he began to mend, making a perfect recovery.

Until the middle of the 18th century there are few other notices of ship-fever, but it is probable that Huxham’s accounts of a very malignant typhus among the crews of ships of war at Plymouth in 1735 (as well as at Portsmouth according to report), and again in 1741, are to be taken as samples of what might have been recorded on many occasions[186].

Fever and Dysentery of Campaigns: War Typhus, 1742-63.

The war in Ireland after the accession of William III. produced two remarkable instances of war-sickness, which are fully given in another chapter. The campaigns of Marlborough against the armies of Louis XIV., from 1704 to the Treaty of Utrecht in 1713, appear to have found no historian from the medical side, nor does the duke refer to these matters in his dispatches or letters, beyond a remark in a letter to his wife from near Munich, 30 July, 1704, a fortnight before the battle of Blenheim: “There having been no war in this country for above sixty years, these towns and villages are so clean that you would be pleased with them[187].”

The war of 1742-48, in which George II. joined Austria against France, produced the first good accounts of war typhus, on land and on board ship, in the writings of Pringle[188]. After the battle of Dettingen, 27 June, 1743, the men were exposed all night in the wet fields; during the next eight days five hundred of them were attacked with dysentery, and in a few weeks near half the army were either ill of it or had recovered from it. The dysentery continued all July and part of August, while the army lay at Hanau. The village of Feckenheim, a league from the camp, was used as a hospital, some 1500 being quartered in it, most of them ill at first of dysentery. The latrines appear to have been ill designed and badly kept. “A malignant fever began among the men, from which few escaped: for however mild or bad soever the flux was for which the person was sent to hospital, this fever almost surely supervened. The petechial spots, blotches, parotids, frequent mortifications, and the great mortality, characterized a pestilential malignity: in this it was worse than the true plague.... Of 14 mates employed about the hospital five died; and, excepting one or two, all the rest had been ill and in danger. The hospital lost nearly half of the patients; but the inhabitants of the village of Feckenheim, where the sick were, having first received the bloody flux, and afterwards the fever by contagion, were almost utterly destroyed[189].” The survivors from the sick troops in Feckenheim were removed to Neuwied, where they were relieved; “but the rest, who were mixed with them, caught the infection.” The mixed troops were sent still down the Rhine in bilanders, during which voyage “the fever became so virulent that above half the number died in the boats, and many of the remnant soon after their arrival.” A parcel of tents sent in these bilanders to the Low Countries were given to a Ghent tradesman to refit; he employed twenty-three journeymen upon them, “but these unhappy men were quickly seized with this fever, whereof seventeen died.” They had no other communication with the infected but through the tents.

“These,” says Pringle, “are instances of high malignity. The common course of the infection is slow, and only catching to those constantly confined to the bad air. Sometimes one will have this fever about him for several days before it confines him to his bed; others I have known complain for weeks of the same symptoms without any regular fever at all; and some, after leaving the infectious place, have afterwards fallen ill of it[190].”

After the battle of Fontenoy on 11 May, 1745, the army was in good health: “the smallpox was the only new disease; it came with the recruits from England, but did not spread; and indeed we have never known it of any consequence in the field.”

On the Jacobite rebellion breaking out in Scotland later in the same year, some of the returning troops were ordered to disembark at Newcastle, Holy Island and Berwick. They had a long voyage, so that a kind of remitting fever which some of them had acquired in the autumn in the Low Countries was “by the crowds and the foul air of the hold soon converted into the jail distemper and became infectious.” At Newcastle most of the nurses and medical attendants of the extemporized hospital were seized with it, of whom three apothecaries, four apprentices and two journeymen died. But the most remarkable experience was on Holy Island. Of ninety-seven men taken out of the ships there, ill of the gaol-fever, forty died, “and the people of the place receiving the infection, in a few weeks buried fifty, the sixth part of the inhabitants of that island.” At Nairn and Inverness there was a singular experience in the spring of 1746. The ships which brought Houghton’s brigade to Nairn carried also thirty-six deserters to be tried by court-martial at the headquarters at Inverness: these men had deserted to the French in Flanders, had been found on board of a captured French transport carrying men to aid the Pretender, and had been thrown into gaol in England till an opportunity arose of sending them to their trial. Three days after the landing at Nairn of the force with which these deserters sailed, six of the officers were seized with fever and many of the men, of whom eighty were left sick at Nairn; in the ten days that the regiment remained at Inverness it sent one hundred and twenty more to hospital, ill of the same fever, which became frequent also among the inhabitants of the town. “Though the virulence of the distemper diminished afterwards in their march to Fort Augustus and Fort William, yet the corps continued sickly for some time.” From the middle of February, 1746, when the army crossed the Forth, to the end of the campaign, there were two thousand sick in hospital, including wounded, of which number near three hundred died, mostly of the contagious fever[191].

After the Peace of Aix-la-Chapelle in 1748, the English troops embarked at Willemstad for home; “but the wind being contrary, several of the ships lay above a month at anchor, and, after all, meeting with a tedious and stormy passage, during which the men kept mostly below deck, the air was corrupted and produced the jail or hospital fever.” The ships that came to Ipswich were in the worst state, about four hundred men having been landed sick there, most of them ill of this contagious fever. The infection was at first as active and the mortality as great on shore as on board; but the virulence of the fever was at length subdued by dispersing the sick and convalescents as much as possible[192].

Monro gives a similar account of the camp sickness among the British troops during the campaigns in North Germany in 1760-63. In the autumn of 1760, before he joined the forces, there had been much malignant fever and dysentery: the camp at Warburg was near the battlefield (31 July, 1760), where many of the dead were scarce covered with earth; there were also many dead horses, and in a time of heavy rains, the camp, with the neighbouring villages and fields, was filled with the excrements of a numerous army. Not only the soldiers, but the inhabitants of the country, who were reduced to the greatest misery and want, were infected, and whole villages almost laid waste. When Monro joined at Paderborn in January, 1761, he found the hospitals overcrowded, and the malignancy of the fever thereby much increased, so that a great many died. “The 1st and 3rd regiments suffered most, owing to all the sick of each regiment being put into a particular hospital by themselves, which kept up the infection, so that they lost one-third of those left ill of this fever, and many of the nurses and people who attended them were seized with it.” He distributed the sick men of the Coldstreams among the houses in the town, and lost few in comparison with the 1st and 3rd regiments. The contagion, under this bold policy, did not spread.

Two points in the symptoms are noteworthy: first the occurrence of suppurating buboes of the groins and armpits in several; and, secondly, the frequency of round worms.

“In this fever it was common for patients to vomit worms, or to pass them by stool, or, what was more frequent, to have them come up into the throat or mouth, and sometimes into their nostrils, while they were asleep in bed, and to pull them out with their fingers. The same thing happened to most of the British soldiers brought to the hospitals for other feverish disorders as well as this.”

He cannot explain the commonness of round worms in the sick, unless it was from the great quantity of crude vegetables and fruits eaten, and the bad water. Patients in convalescence often suffered from deafness, and from suppurating parotids. Some had frequent relapses into the fever, “which seemed to be owing to the irritation of these insects,” namely the worms. Most of those who fell into profuse, kindly, warm sweats recovered, the sweats lasting from twelve to forty-eight hours, and carrying off the fever. He never saw any miliary eruptions, and only sometimes petechiae, or small spots, or marbling as in measles[193].

Ship-Fever in the Seven Years’ War and American War.

Ship-fever would appear to have been at its worst after the middle of the 18th century. Dr James Lind joined Haslar Hospital in 1758, and brought to the naval medical service the same high qualities which Pringle and Monro brought to that of the army[194]. The smaller ships, such as the ‘Saltash’ sloop, the ‘Richmond’ frigate, and the ‘Infernal’ bomb were full of fever of the most malignant kind; of 120 men in the ‘Saltash,’ 80 were infected with a contagion much more virulent and dangerous than that in the guard-ships. The explanation was that the smaller ships were receiving vessels for the larger ships, and were manned from the gaols; drafts from them carried the infection to the guard-ships and to the ships fitting out for foreign service. Malignant fever also arose on the voyage home from America[195]. In September and October 1758, after the reduction of Louisburg, several of the ships arriving at Spithead were infected with a malignant fever; three hundred men were received from them at Haslar Hospital (some with scurvy), of whom twenty-eight died. The ‘Edgar,’ having been manned at the Nore from gaols, sailed for the Mediterranean, and lost sixty men from fever and scurvy. The ‘Loestoffe,’ having lain in the St Lawrence for eight months in perfect health, took on board six convalescent men from Point Levi Hospital before sailing for home; in forty-eight hours, fifty out of her two hundred men were seized with fevers and fluxes, and six died on the voyage home. The ‘Dublin’ on the homeward voyage from Quebec buried nineteen, and on her arrival reported ninety men sick of fever, fluxes and scurvy. The ‘Neptune’ was said to have lost one hundred and sixty men in a few months, and reported 136 sick. The ‘Cambridge,’ with 650 men in health, sent three of her crew to the ‘Neptune’ laid up, to prepare her for the dock; of these three, one on the fifth day became spotted and died, and another narrowly escaped with life. The ‘Diana’ developed fever during a rough passage home from America. The ‘St George,’ having sailed from Spithead in 1760, met with rough weather and had to return on account of sickness. On the other hand, Hawke’s fleet of twenty ships of the line with fourteen thousand men, which defeated the French in November 1759, kept the Bay of Biscay for four months in the most perfect health.

From 1 July, 1758, to 1 July, 1760, there were 5743 admissions to Haslar Hospital, the chief diseases being as follows:

Fevers 2174 Scurvy 1146 Consumption 360 Rheumatism 350 Fluxes 245

Of the fevers some were of an intermittent type, but by far the most were continued ship-typhus. Relapses were common, even to the sixth or seventh time. The fever varied a good deal in malignity, but never produced buboes, livid blotches or mortifications, and seldom parotids. Twenty-four men received from January to March 1760 out of the ‘Garland’ had most of them petechial spots accompanied with other symptoms of malignity, and of these, five died or 20 per cent. But of 105 received during the same months from the ‘Postilion’ and ‘Liverpool’ only eight died, and those mostly of a flux. The infection had little tendency to spread among the attendants at Haslar. In the first six months only one nurse died; in 1759, two labourers and two nurses died, one of the nurses by infection, having concealed some infected shirts under her bed, the other by decay of nature. Of more than a hundred persons employed in various offices about the sick there died only those five in the course of eighteen months.

Although Lind’s account of ship-fever in the British navy is bad enough, he has collected some far worse particulars of foreign ships. Febrile contagion destroyed two-thirds of the men in the Duc d’Anville’s fleet at Chebucto (now Halifax), in 1746, the complete destruction of which was afterwards accomplished by the scurvy. It was ship-fever which ravaged the Marquis d’Antin’s squadron in 1741, the Count de Roquesevel’s in 1744, and the Toulon squadron in 1747. He takes the following from Poissonnier’s Traité de Maladies des Gens de Mer: The fleet commanded by M. Dubois de la Mothe sailed in 1757 from Rochefort for Louisburg, Canada, having some men sickly. The ships touched at Brest, and sent 400 ashore sick. They sailed from Brest on 3 May, and arrived at Louisburg on 28 June. There was then sickness in only two ships, but in a short time it appeared in all the fleet. On 14 October the fleet sailed from Louisburg for home, embarking one thousand sick, and leaving four hundred supposed dying. In less than six days from sailing most of the thousand sick were dead. When the fleet arrived at Brest on 22 November there were few seamen well enough to navigate the ships; 4000 men were ill, the holds and decks being crowded with the sick. The hospitals at Brest were already occupied, two ships from Quebec shortly before having sent a thousand men to them. Fifteen hospitals were soon filled, attended by five physicians and one hundred and fifty surgeons. Two hundred almoners and nurses fell victims. The infection passed to the lower class of the citizens, the havoc became general, and houses everywhere were filled with the dying and the dead. At length it got among the prisoners in the hulks. This dreadful infection began to abate in March, 1758, and ceased in April, having carried off in less than five months upwards of 10,000 people in the hospitals alone, besides a great number of the Brest townspeople. The stench was intolerable. No person could enter the hospitals without being immediately seized with headache; and every kind of indisposition quickly turned to fatal fever, as in the old plague times. The state of the bodies showed the degree of malignity that had been engendered: the lungs were engorged with blood, and looked gangrenous; the intestines often contained a green offensive liquor, and sometimes worms. Lind’s other instances are chiefly of the Dutch East Indiamen that anchored at Spithead with fever on board. In Nov., 1770, the ‘Yselmonde’ bound to Batavia, came to anchor at Spithead, and buried a number of men every day; two custom-house officers caught the fever and died. He gives two other instances of Dutch ships bound to Batavia, which came in to Portsmouth with fever[196]. The Dutch were said to send annually 2000 soldiers to Batavia, and to lose three-fourths of them by the ship-fever before they arrived. In 1769 Lind saw ship-fever in the Russian fleet at Spithead.

Brownrigg, of Whitehaven, gives a good instance of the diffusion of typhus in a newly-commissioned ship of war, and thence to the civil population, which bears out Lind’s favourite notion that the gaols and the press-gang had far-reaching effects. In the year 1757 a sloop of war had been hastily manned at the Nore to protect the shipping between the Irish and Cumberland ports. She reached Whitehaven in May, with fever on board. The men were landed and lodged in small houses. Brownrigg found about forty lying on the floor of three small rooms, very close together, many of them in a dying state; seven days after he was himself seized with fever, and had a narrow escape with life. The ship’s surgeon died of it, his mate recovered with difficulty, two surgeons of the town died of it, and two more in Cockermouth. The contagion spread widely among the inhabitants of Whitehaven, Cockermouth and Workington[197].

Lind showed to Howard in one of the wards of Haslar Hospital a number of sailors ill of the gaol fever; it had been brought on board their ship by a man who had been discharged from a prison in London, and it spread so much that the ship had to be laid up[198].

With the outbreak of the American War we begin to hear of still more disastrous epidemics of fever in the English fleets. Some instances from Robertson’s full collection must suffice[199]. The ‘Nonsuch’ left England in March, 1777, and fifty of her men were carried off by fever before December; in that month, the ‘Nonsuch,’ ‘Raisonable’ and ‘Somerset’ had each from 130 to 150 men on the sick list, chiefly fever in the ‘Somerset,’ and scurvy in the other two. In April, 1778, the ‘Venus,’ with a crew of 240, was at Rhode Island very sickly; the surgeon told Robertson that they had lost about fifty men of fever, which still continued to rage on board: they became sickly from being crowded with prisoners and cruising with them on board in bad weather. The ‘Somerset’ had buried 90 men of the fever since she left England, 70 of them being of the best seamen. On arriving at Spithead in October, 1779, Robertson found much fever in the Channel Fleet which had lately come in, especially in the ‘Canada,’ ‘Intrepid,’ ‘Shrewsbury,’ ‘London’ and ‘Namur,’ three or four of which were put past service, so much were they disabled by sickness. At Gibraltar Hospital from 12 January to 31 March, 1780, there were admitted 570 men from twenty-seven ships, of whom 57 died; of 110 sick from the ‘Ajax,’ 18 died; of 437 Spanish prisoners, 37 died. Next year, in May, 1781, at Gibraltar, the ‘Bellona’ had buried 27 men since she left England, and had 108 on the sick list. The ‘Cumberland’ had buried 15; of the ‘Marlborough’s’ men, 40 had died at the hospital. Robertson had to purchase at his own expense vegetable acids, fruit and vegetables for the sick.

Some statistics remain of the loss of men in the navy by sickness in the Seven Years’ War (1756-62) and in the American War[200]. The House of Commons had ordered a return of the number of seamen and marines raised and lost in the former; but the return was too general to be of much use, the number “lost” having included all those men who had been sent to hospital and never returned to their ships, all those who had been discharged as unserviceable, and all deserters. The number raised was 184,899, and the number “lost” 133,708, besides 1512 killed. The Return by the Navy Board for the period of the American War was more specific, showing only the number of the dead and killed.

Seamen and Marines raised, dead or killed, during the American War, 29 Sept., 1774, to 29 Sept., 1780:

Year Raised Dead Killed

1774 345 -- -- 1775 4,735 -- -- 1776 21,565 1679 105 1777 37,457 3247 40 1778 31,847 4801 254 1779 41,831 4726 551 1780 28,210 4092 293 ------- ------ ---- 175,990 18,545 1243

Fully a tenth part of the men raised were lost by sickness. Fever was the chief sickness, and as it happened rarely that more than one in ten cases of fever died, it will be easy to form an approximate estimate of the proportion of all the men raised for the ships that were on the sick list at one time or another with fever--nearly the whole, one might guess.

During the three last years of the period Haslar Hospital was constantly full of typhus fever. Admiral Keppel’s fleet arrived at Spithead on 26 October, 1778, and soon began to be infected with contagious fever; before the end of December, 3600 men had been sent to Haslar, which could make up at a pinch 1800 beds. But the great epidemic at Portsmouth was the next year, 1779, when the very large Channel Fleet under Sir Charles Hardy came in. During the month of September, 2500 men were received into hospital, and more than 1000 ill of fevers remained on board for want of room in the hospitals. In the last four months of 1779, 6064 sick were sent to Haslar, which had 2443 patients on 1 January, 1780. There was an additional hospital at Foston, holding 200, as well as two hospital ships holding 600. The infection was virulent during the winter, when Portsmouth was crowded with ships; and in the first five months of 1780, when 3751 cases of fever were admitted during the decline of the epidemic, one in eight died. The following shows how much fever preponderated at Haslar Hospital in 1780. In 8143 admissions on the medical side, the chief forms of sickness were as follows[201]:

Continued Fevers 5539 Scurvy 1457 Rheumatism 327 Flux 240 Consumption 218 Smallpox 42

Blane gives the instance of the ‘Intrepid,’ one of the Channel Fleet under Hardy in 1779: “Almost the whole of her crew either died at sea or were sent to the hospital upon arriving at Portsmouth. This ship, after refitting, was pretty healthy for a little time; but probably from the operation of the old adhering infection, she became extremely sickly immediately after joining our fleet and sent 200 men to the hospital after arriving in the West Indies. Most of these were ill of dysentery[202].” During a voyage of three weeks of the ‘Alcide’ and ‘Torbay’ from the Windward Islands to New York in September, 1780, nearly a half of the men were unfit. In the ‘Alcide’ it was a fever that raged, in the ‘Torbay’ it was a dysentery[203].

These experiences of fever in the ships of the Royal navy continued to the end of the 18th century. In Trotter’s time, as in Lind’s, receiving ships were a source of contagion to others, one ship of the kind, the ‘Cambridge’ having diffused fever among many ships of the Channel Fleet by men drafted from her[204].

Ship typhus was also an incident of the voyages of the East India Company’s ships, which nearly always carried troops. In the voyage of the ‘Talbot,’ 22 March--25 August, 1768, with 240 persons on board, “towards the end of July a fever of a very bad kind made its appearance, attended with delirium, low pulse, petechiae or livid vibices and hæmorrhages from the nose, of which one died and three or four escaped hard.” The sick were isolated, and the infection did not spread. Such outbreaks of typhus were not uncommon at sea, although the loss of life from them was small beside that from the fevers of Madagascar, Sumatra, Batavia and Bengal. The ship typhus usually began on board among the soldiers. The most notable point is that relapses were common, as Lind also observed at Haslar Hospital; some on board the ‘Lascelles’ in 1783 (150 attacks among 151 soldiers) had relapsed seven times. It does not appear, however, that the best class of merchantmen suffered greatly from fevers. Dr Clark, who compiled a report of the practice in fevers in the ships of the East India Company from 1770 to 1785, had reason to congratulate the Company on the general healthiness of their fleet:

“When ships set out at a proper season, when they are not too much crowded, when the weather is favourable, and no mismanagement appears, fewer lives are lost in these long voyages than in the most healthy country villages. And in perusing the medical journals I have the peculiar pleasure of finding that many ships have arrived in India without the loss of a single life by disease,” e.g. the ‘Valentine’ in 1784, seven months out, with 300 souls, no deaths, and the ‘Barrington’ in 1789, no deaths outward bound[205].

On the other hand, these English reports give incidentally the most unfavourable accounts of the Dutch East Indian ships. Three Dutch ships, then in Praya Bay, St Jago (Cape de Verde Islands), had buried 70 to 80 men each, and had some hundreds of sick on board. Another report says: “Before we left Table Bay several Dutch ships arrived, some of which had buried 80 people in the voyage from Holland. None lost less than 40 men. I am informed that some of their ships last year buried 200 men”--the causes of the sickness being overcrowding, filth, and the slowness of the voyages. One experience of the very worst kind happened to an English expedition consisting of the 100th regiment, the 98th regiment, the second battalion of the 42nd, and four additional companies. They had formed part of the force for the reduction of the Cape of Good Hope, whence they re-embarked for Bombay. During the voyage from Saldanha Bay a contagious fever and scurvy broke out among the troops, who were crowded and badly clothed; dead men were thrown overboard by dozens, and the regiments were reduced to a third of their original numbers. Six officers of the 100th regiment died, and an equal if not greater proportion of those of the 98th and 42nd.

The other chief occasion of ship typhus was the emigration to the American and West Indian colonies from Britain and Ireland. The Irish emigration was especially active from the beginning of the 18th century, owing to rack-renting and other causes. Madden[206] professed to know that one-third of the Irish who went to the West Indies (perhaps he should have included Carolina) perished either on the voyage or by diseases caught in the first weeks after landing; and as we know that typhus attended the Irish emigration in the 19th century, we may infer that the same was the cause of mortality in the 18th.

The trouble from ship-fever in the navy was so great all through the 18th century that many ingenious shifts were tried to overcome it. Towards the end of the century, the favourite device was fumigation with the vapour of mineral acids; one such plan, for which the Admiralty paid a good sum, ended in the burning of several ships to the water’s edge. An earlier plan was ventilation of the hold and ’tween decks by means of Sutton’s pipes[207], which found a strong advocate in the Rev. Stephen Hales, of the Royal Society[208].

Twice in the course of a paper to that learned body[209] he asserts that the noxious, putrid, close, confined, pestilential air of ships’ holds and ’tween decks “has destroyed millions of mankind”; on the other hand, according to the testimony of a captain of the navy, Sutton’s pipes had kept his ship free from fever. Lind caps this with the case of H.M.S. ‘Sheerness,’ bound to the East Indies. She was fitted with Sutton’s pipes, the dietary being at the same time so arranged that the men had salt meat only once a week. After a very long passage of five months and some days she arrived at the Cape of Good Hope without having had one man sick. “As the use of Sutton’s pipes had been then newly introduced into the king’s ships, the captain was willing to ascribe part of such an uncommon healthfulness in so long a run to their beneficial effects; but it was soon discovered that, by the neglect of the carpenter, the cock of the pipes had been all this while kept shut[210].”

Ship-fever was at length got rid of by more homely and more radical means than scientific ingenuity. Lind had shown one root of the evil to lie in the pressing of men just out of gaol. Admiral Boscawen, by his unaided wits, discovered another means of checking it. He avoided the mixing of fresh hands with crews seasoned to their ships, unless when some evident utility or necessity of service made it proper; “and upon this principle he used to resist the solicitation of captains, when they requested to carry men from one ship to another when changing their command[211].” Towards the end of the 18th century many reforms were made in the naval service--in the dietary, in the allowance of soap, in keeping the bilges clean, in the use of iron and lead instead of timber; so that Blane dates from the year 1796 a new era in the health of the navy[212].

The “Putrid Constitution” of Fevers in the middle third of the 18th Century.

Resuming the history of fevers among the people at large from the great typhus epidemic of 1741-42 to the end of the century, we find the conditions somewhat different in the earlier and later divisions of the period. The time of prosperity, when England exported large quantities of wheat in every year except two or three, is reckoned from 1715 to 1765; after the latter date England gradually ceased to be an exporting country, owing to various causes, including the increase of pasture farming and the growth of industrial populations in the northern counties. The year 1765 marks the beginning of what has been called the Industrial Revolution; and it is also an important point of time in the history of the fevers of the country, for it is in the generation after that we obtain all the best information on what may be called industrial typhus, in the writings of a group of physicians who were at once philanthropic and exact. But there was an earlier period of fever, which is somewhat difficult to the historian. It is perhaps the last period in which Sydenham’s language of “epidemic constitutions” seems to be appropriate, whether it be that the writers of the time were still under his influence, or because the prevalent maladies could not well be accounted for in any other way. The constitution in question was a “putrid” one. It coincided with the great outburst of putrid or gangrenous sore-throat, to be described elsewhere; and it included an extensive prevalence of fevers which were also called putrid or nervous, and sometimes called miliary. Fevers of the same kind, and with the same miliary rash, are described by earlier writers, such as Huxham. Perhaps the most correct view of the matter is to consider this type of fever as corresponding roughly to the middle third of the century, and as having been interrupted by the typhus epidemic of 1741-42, during a time of special distress. Besides the great outburst of putrid or malignant sore-throat, there was also a disastrous murrain of cattle for several years; and at Rouen there was a remarkable fever which some English writers of the time took to be the highest manifestation of the same “putrid” constitution that they discovered also in the English and Irish fevers.

The fever at Rouen which Le Cat specially described to the Royal Society was an outbreak from the end of November, 1753, to February, 1754. This outbreak was only one of a series; but as it attacked a great number of persons of distinction and made great havock among them, it attracted unusual notice and was regarded as something new, the rumour spreading over Europe that Rouen had been visited by plague. The same fever, however, had occurred there in previous years; and allied forms of sickness, of the same gangrenous character, including gangrenous sore-throat, could be traced back for twenty or thirty years. It will suffice to mention of these the malignant fever which appeared in 1748 and continued in 1749, 1750 and 1751. There was a fixed pain in the head, pain about the heart, a low fever with delirium, often miliary eruptions, continual faint sweating, drowsiness, scanty or suppressed urine, abdominal distension. After death the stomach was found “inflamed” at places, as well as the small intestine. In some cases there were ulcerations which almost penetrated the coats. The lungs were engorged with blood. In one case, of a young woman aged twenty, the mesentery was filled with obstructed glands and the intestines mortified in different places. In another, almost the whole mesentery was mortified and there was an anthrax or carbuncle at the upper fore part of the armpit. At the same time some cases of smallpox, with miliary eruption, also had ulcerations of the stomach, with inflammatory spots on other parts of it and of the intestine, the mesenteric glands being enlarged and hard. Some of the cases at the Hôtel Dieu in 1750 were traced to infection from bales of horse-hair; but the type of the disease in those cases did not differ essentially from that of other cases. Some rapidly fatal cases in the winter of 1752-53 had suppurative inflammation about the heart. (In 1739 there had been deaths from continued fever at the Hôtel Dieu, after an illness of six or seven days, marked by frequent faintings, small abscesses being found after death in the substance of the heart near the auricles.) The fever among the upper classes in the winter of 1753-54 was marked, in its most mortal form, by lowness, continued fever, pain in the head, cough, sore-throat, nausea, dry black tongue, delirium, sweats, stupor, some oppression of the heart, spitting of blood, sometimes swelling of the belly, these symptoms being followed often by miliary eruption, and sometimes by a slight flux with blood. Many were affected with a dejection of spirits, and with a feeling of terror which made them tremble at the ordinary sound of the voice. The fever ran a full course of thirty or forty days (the miliary eruption coming about the 21st day), while death usually ensued about the 25th. The appearances after death were remarkable (many bodies were opened): “In some a part of the villous coat of the stomach and of the small guts was inflamed; and the rest of these organs were filled with an eruption of the miliary crystalline kind, except that it was larger; and there was likewise an obstruction in the glands of the mesentery. In others a strong inflammation had seized the whole stomach and a small portion of the oesophagus, but the intestines were free.... In those cases where the delirium had continued long and violent, we found either ulceration on the stomach, or its villous coat separated, together with a great inflammation, and even some gangrenous spots, on the other coats of that organ.” Some recovered by critical abscesses. Others who escaped death by the poison carried its terrible effects for many months; their limbs and joints were feeble, and they were troubled with vertigo, lassitude and fears[213].

Exactly covering the period of these fevers at Rouen, there were low putrid fevers in London, in Worcestershire, in Ireland, and among the English colonists in Barbados. It was certainly not a mere fashion in medicine which produced the accounts of a similar fever, for these accounts came from places far apart and were independent of each other. Dr Fothergill, of Lombard Street, published in the Gentleman’s Magazine every month for five years a short account of the weather and prevalent diseases of London, beginning with April, 1751, and ending with December, 1755. He had the weekly bills of mortality before him, and he makes various comments upon them; but his accounts of prevalent diseases are from his own observation and by way of illustrating the bills. His first reference to a fever is under October, 1751: “A slow continual fever, with acute pain in the forehead: not many attacked, few mortally.” The year 1752 was remarkably free from fevers until November, when we read of a fatal fever which had rheumatic symptoms at first (as at Rouen in 1744), attacking the head later, with coma-vigil and a dark-coloured ichor on the tongue and lips. It continued into January and February, 1753, proving fatal to several. In the summer and autumn months there were fevers of the low, depressed kind, sometimes called “remittents,” with copious sweats, or “slow, remitting, dangerous fever,” or “slow, treacherous, remittent fever, too often fatal.” The references to it are most numerous in the months from November, 1753, corresponding to Le Cat’s Rouen narrative. It was slow and imperceptible in its approach, the sick often going about ill for a week before seeking advice; it was attended with profuse sweats which never relieved, and was fatal to many. It continued more or less through the summer, and from August, 1754, it is again prominent. In September, it was the most alarming form of disease, and was then commonly vehement in its access, with lassitude, and pain in the head and back; unrelieving sweats are again mentioned, with dry tongue, delirium, coma-vigil, and death about the 14th-15th day. Fothergill was at a loss to know whether he should order blood to be drawn, owing to the low depressed nature of the fever. In February, 1755, the fever is still “too much of the nature of those which prevailed in the preceding months to allow a repetition of bleeding.” In April it is called the petechial and miliary fever, the miliary eruption being of a white sort with a very noisome scent; the petechial spots turned livid, black and gangrenous; few patients escaped who had been sweated at the beginning. The fever was truly malignant, the patient restless from the outset, the sweats weakening. Fothergill’s last entries of it are important, under the months of May and June, 1755. In May, 1755, the fevers were “for the most part allied to that dangerous remittent which has for some years past more or less prevailed in different places of this kingdom.” In June: “It does not appear that either in the hospitals or any part of the city a disease has broken out of so dangerous a nature as has been reported. The same kind of fever that has long continued in this city with some small variations in its type, still remains, but it is by no means more frequent than it has been in the preceding months, nor is it attended with more unfavourable symptoms.”

It is impossible to say how general over England this fever may have been in the years 1751-57. Our fullest accounts come from Worcestershire; but the putrid fever is heard of more widely. Thus a short Latin piece in the Gentleman’s Magazine, dated 14 April, 1755, is on the putrid fever lately epidemic, and not yet extinct, in some parts of the county of Somerset and adjoining places; its signs were contagiousness, pains of the head and loins, nausea and vomiting, diarrhoea, quick weak pulse, purple spots, delirium and coma[214]. Grainger, writing from Edinburgh in 1753, declares his motive for publishing an account of the anomalous fever of the Netherlands in 1746-48 to be that the same had lately been raging over almost the whole of Britain.

We have some particulars for Kidderminster, which can hardly have been exceptional for an industrial town, and according to the accounts were true also for villages and market towns near. Kidderminster was, in the year 1756, a town of about four thousand inhabitants, mostly hand-loom weavers of worsted and silk. There were no power-looms anywhere in England at that time; and the condition of the Kidderminster weavers’ houses was doubtless what that of the Tiverton community had been fifteen years before. Many of the weavers, we are told, are lodged in small nasty houses, for the most part crowded with looms and other utensils[215]. Many of these houses were built on a low flat of the river Stour, whence rose putrid vapours after floods. Its situation had served to render the town specially unhealthy before, as in the epidemic of 1727-29[216].

The first notice by Dr Johnstone is of a low miliary fever from Midsummer 1752 to the end of the year. This was a comparatively mild affair, although it carried off several. But after Christmas it was succeeded by a fever which would then have been classed as of the putrid kind. The first great season was in 1753, it ceased in the fine years 1754-55, but came back in 1756 and 1757. It began with languor, lowness, flutterings, faintness, vague pains in the limbs, a low quick pulse, giddiness and slight sickness. Some had a propensity to loose stools and to profuse hurtful sweats; some bled at the nose, others coughed and spit blood; some had pain in the throat, and crimson-red tongue, the sweat and breath of the sick had a strong, offensive, putrid smell. In some of the worst cases livid petechiae, large livid blotches, and dark brown spots occurred over the trunk and limbs. The successful treatment was by mineral acids, bark, port wine, and vesication. “This malignant fever was very often (though not constantly) complicated with, and in general bore great analogy to the malignant sore-throat which at this time prevailed in many parts of England.” The fever which prevailed during that remarkable year (1753) was very evidently contagious, for whole families were either all together or one after another seized with it. One of the most distinctive symptoms was a tendency to trembling of the whole body, as well as leaping of the tendons at the wrists. In some the tonsils were beset with aphthous sloughs, and towards the decline there would be aphthae of the mouth, but symptomatic only, and not the dominant lesion as in the ulcerous sore-throat. About the 15th day the fever was generally at its height. The miliary eruptions were critical to the few that had them; the flat livid petechiae appeared at all times of the disorder. Johnstone then compares the fever with that described by Le Cat at Rouen in the winter of the same year; and although he had been unable to satisfy his curiosity by opening any body dead of the fever, he felt sure that these dreadful symptoms arose from some affection of the stomach and small guts, at first erysipelatous, afterwards gangrenous, and at last truly sphacelous.

Johnstone’s statement that the putrid fever in Worcestershire in 1752-53 was often complicated with and bore great analogy to the malignant sore-throat is borne out by Huxham’s accounts for Plymouth during the same season:

“In all sorts of fevers,” he writes, “there was a surprising disposition to eruptions of some kind or other [including miliary], to sweats, soreness of throat and aphthae.” It is hardly possible to make out all his cases of “malignant anginose fever” to have been scarlet fever with sore-throat. Thus there occurred stench, swelling, and samious haemorrhages “commonly in those that died of malignant anginose fever above described. I have known the whole body swell vastly, even to the ends of the fingers and toes, with a cadaveric lividity, though almost quite cold, and an intolerable stench, even before the person was actually dead, blood issuing at the same time from the ears, nose, mouth and guts[217].”

The first years of this putrid or miliary fever were not seasons of scarcity, there having been no failure of the crops since 1741 (unless in Ireland, in the province of Ulster mostly, in 1744); on the contrary, many of the seasons had been unusually fine and abundant, the exports from England of wheat, barley, malt and rye in the three years 1748, 1749 and 1750 amounting to four million quarters. Prices were at the same time favourable to the poorer classes[218]. But there had been a destructive murrain for several years (30,000 cows are said to have died in Cheshire in 1751), and the harvest of 1756 was a failure.

To the month of February, 1756, the season had been very forward, but the early promise of spring was blighted by cold, a wet summer and autumn ensued, the fruit crop was ruined, and the corn harvest spoiled by long, heavy rains. A dearth, bread-riots, &c. ensued[219]; but it is to be noted that the revival of the dangerous malignant contagious fever began at Kidderminster as early as April, becoming much worse after harvest. “Many for weeks or months laboured under an uncommon depression of spirits, felt their strength abate, with great lassitude, and very often a great proneness to faint away.” As the summer advanced the fever became truly epidemic not only in Kidderminster but in many other parts of the West and North-west of England.

It went through whole families, who succumbed either all together or one member after the other, and was carried from place to place by the attendants on the sick. “It prevailed chiefly in poor families, where numbers were lodged in mean houses, not always clean, but sordid and damp. It seemed to affect such poor families most where there was reason to think a sufficiency of the necessaries of life, on account of the dearth, had for some time been scantily supplied; yet the other poor persons, given to the intemperate use of malt liquors and ardent spirits, were observed to be very much liable to its influence. And not a few persons in easy circumstances of life were affected with this fever like others.”

Frost in October checked it, and then measles of a malignant type had its turn among the children, the whooping-cough succeeding the measles. From November to Christmas the putrid fever, which chiefly affected persons from ten to fifty, and more women than men, returned with increased force. In fatal cases, the face was ghastly, sunken and livid (the facies Hippocratica), the patient sweated profusely, but seldom became cold till death was at hand. There was an abominable cadaverous stench in the breath, perspiration and stools. In these cases death took place from the 12th to the 14th day.

The intense and long frost of the opening months of 1757 nearly put a stop to the fever at Kidderminster.

“But in other neighbouring villages and market towns it has since the spring hitherto (Dec. 1757) been very frequent in places that were little affected with it last year. The families of the poorer sort of people universally are the most subject to it. And it is observable that the fever in some places first broke out in the parish workhouses, and from thence spread among the neighbouring people with great malignity. Wherever it has appeared it has given very apparent and fatal evidence of its infectious nature[220].”

Parliament was summoned to meet in December, 1756, on account of the dearth, which formed the topic of the Speech from the throne. The export of corn (which had reached a million quarters a year not long before) was prohibited, and the use of grain in distilling stopped for two months. The distress was more acute in 1757, and was enhanced by the greed of corn-dealers and millers, who used French bolting-mills to grind the mere husks of wheat, pease, rye and barley together into meal. Short, who practised at Sheffield, says that the fever in October and November, 1757, “was neither so rife nor fatal as in 1741[221].” It raged fiercely in several towns at a distance, “where it went by the name of the miliary fever,” and was mostly among the poor, half-starved in the dearth of 1756-57. It is heard of again in the district of Cleveland in the winter of 1759-60, where it seems to have been mostly a disease of children complicated with sore-throat, and allied more to scarlet fever than to the putrid fever of adults[222]. But at Sunderland, near at hand, there was spotted fever at the same time, and in Newcastle there was dysentery.

The accounts of fever in Ireland in the same period as in England (see chapter II.) are not without value, as showing that the “putrid” or nervous type of fever, contrasting with the ordinary typhus of the country, had been remarked there also. Rutty and Sims describe, during a certain period, the symptoms of the low, putrid fever, sometimes with miliary eruptions, identifying it both by name and in character with the fever then prevalent in England. The most significant thing in Rutty’s annals is that there occurred in the midst of the low, putrid fever with miliary pustules in 1746, a more acute fever, ending after five or seven days in a critical sweat, and relapsing. The same fever, not very fatal, reappeared in 1748. Sims brings the history of the nervous or putrid or miliary fever in Ireland (Tyrone) continuously down to the year 1772, as elsewhere related. The remarkable phenomenon of tremors or shakings, which most witness to, was seen by him in perfection in the year 1771:

The tremulousness of the wrists, he says, extended to all the body, “insomuch that I have seen the bed-curtains dancing for three or four days, to the no small terror of the superstitious attendants, who, on first perceiving it, thought some evil spirit shook the bed. This agitation was so constant a concomitant of the fever as to be almost a distinguishing symptom.” These were not the shakings of an ague, for there might be no intermission for days[223].

Perhaps the most surprising testimony to the existence of an “epidemic constitution” of slow, continued nervous fever comes from the island of Barbados. Hillary, who had kept a record of the prevalent diseases at Ripon, continued the same when he settled in Barbados in 1751[224]. There can be no doubt as to the appearance of this fever in February 1753, its prevalence all over the island for eighteen months, and its disappearance in September 1754, when, as he writes, “It now totally disappeared and left the island, and, I think, has not been seen in it since” (1758). He gives the same account of it as the observers in England and Ireland, except that he does not describe miliary eruptions and describes jaundice in convalescent children. It was insidious in its onset (as in London), the patient often keeping afoot five or six days; the symptoms included pains in the head, vertigo, torpor, lassitude, vigil, delirium, faintings, partial sweats, involuntary evacuations, gulpings, tremors, twitchings, catchings, coma and convulsions. Recovery was marked by copious equable sweats and plentiful spitting. “This slow, nervous fever was certainly infectious, for I observed that many of those who visited, and most of them that attended the sick in their fever were infected by it, and got the disease, and especially those who constantly attended them and performed the necessary offices of the sick.” It was last heard of in the remoter parts of the island.

Miliary Fever.

It will have been observed in the foregoing accounts of the predominant fevers of the years (roughly) from 1750 to 1760 that there was often a miliary eruption, but that it was far from constant. The constant things were the lowness, depression, ill-smelling sweats, tremors of the whole body or of the wrist-tendons, and other nervous or ataxic symptoms. But we hear more of a miliary eruption in connexion with that than with any other period of fevers in the history; and this was the time when a controversy arose as to whether there was in reality a distinctive kind of fever marked by miliary eruption. Some of the school of Boerhaave contended that the phenomenon of miliary vesicles was due solely to the heating and sweating treatment of the alexipharmac physicians. De Haën and others answered that miliary fever was a natural form, independent of the mode of treatment. The Boerhaavian contention may be admitted as good for such miliary fevers as were described under that name in 1710 by Sir David Hamilton[225]; nearly the whole of his sixteen cases appear to have been made miliary by treatment, in so far as they became miliary at all. What this physician did was to foretell the approach of miliary symptoms in various maladies (about one-half of the cases being of lying-in women, and the rest various), and then to prescribe Gascoign’s powder, Goa stone, Gutteta powder, Venice treacle or other diaphoretics, along with diluents and the application of blisters; the miliaria appeared about the breast, neck, and clefts of the fingers in due course (tenth to fourteenth day).

So far as his clinical cases are concerned, the late appearance of miliary vesicles, lasting a few days, is sufficiently explained by the powerful drenches administered; and it can hardly be doubted that much of what was called miliary fever was of that factitious kind. But even in Hamilton’s essay we find indications of a real miliary type of fever; thus he mentions a class of cases which look to be the same as those described by Johnstone, Rutty, Sims and others forty years after--cases with wakefulness, depression, tremblings of the tongue and hands, convulsive movements and delirium. He mentions also a complication of this with sore-throat in 1704, which destroyed many.

As to the association of miliary eruption with the low putrid fever so characteristic of the sixth decade of the 18th century, it is asserted by too many and in too various circumstances for any doubt as to its reality. There is nothing to show that the alexipharmac treatment was the one always used; and it is not certain that some in Ireland and elsewhere who had miliary eruption received any medical treatment at all. Again, miliary vesicles, not always with perspiration, were commonly found in the relapsing fever of Irish emigrants in London during the great famine of Ireland in 1846-47, by which time the powerful drenches of the alexipharmac treatment had been long disused[226]. The controversy as to the reality of miliary fever was one of the kind usual in medicine: certain physicians, of whom Hamilton in 1710 was an obvious instance, took up an untenable position; they were answered according to the weakness of their argument; and that has been held in later times to be an answer to all who alleged the existence of a type of fever marked by miliary eruptions. There can be no question as to a low, “putrid” kind of fever in which miliary eruptions were usual; but offensive sweats were perhaps more usual, whence the name of putrid in a literal sense, different from the theoretical sense of Willis; more constant also were the starting of tendons, the tremors and shakings, together with very varied hysteric symptoms, from which the fevers received the name of nervous. Dr John Fordyce in his ‘History of a Miliary Fever’ (1758) really describes under that name the symptoms of the low, nervous, putrid fever, often attended with miliary vesicles, which had been the common type in England in the years immediately preceding, and was a common type for some time after, although less is heard of the miliary eruptions in the later history[227].

About the last quarter of the 18th century medical writers were inclined to drop the names of nervous and putrid as distinctive of certain fevers. Pringle, in his edition of 1775, says he had been careful to avoid the terms nervous, bilious, putrid and malignant, which conveyed either no clear idea or a false one. Armstrong, another army physician, writing in 1773, says: “Nervous, putrid, bilious, petechial or miliary, they are all of the malignant family; and in this great town [London] these are almost the only fevers that have for many years prevailed, and do so still, to the great destruction of mankind. For inflammatory fevers ... have for many years been remarkably rare[228].” Dr John Moore becomes sarcastic over the variety of names given to continued fever, some such generic name as Cullen’s “typhus,” then newly introduced, being what he desired[229].

Haygarth, writing of the Chester fevers in 1772, said that the miliary fever had been “supposed” endemic there for more than thirty years past, but he thought it probable that the eruption had generally, or always, been fabricated “by close, warm rooms, too many bed-cloaths, hot medicines and diet.” He had seen only one case in the epidemic that year, and he believed its rarity at that time was due to the treatment by fresh air and by “such regimen and medicines as are cooling and check putrefaction[230].” We shall see later that Percival, for Manchester, contents himself with saying that miliary fevers, which were formerly very frequent in that town and neighbourhood, now [1772] rarely occur[231]. In Scotland as late as 1782 the type was still nervous or low, and hardly ever inflammatory[232].

Mortalities in London from fever and all causes.

Fever All Year deaths deaths

1741 7528 32169 1742 5108 27483 1743 3837 25700 1744 2670 20606 1745 2690 21296 1746 4167 28157 1747 4779 25494 1748 3981 23069 1749 4458 25516 1750 4294 23727 1751 3219 21028 1752 2070 20485 1753 2292 19276 1754 2964 22696 1755 3042 21917 1756 3579 20872 1757 2564 21313 1758 2471 17576 1759 2314 19604 1760 2136 19830 1761 2475 21063 1762 3742 26326 1763 3414 26148 1764 3942 23202 1765 3921 23230 1766 3738 23911 1767 3765 22612 1768 3596 23639 1769 3430 21847 1770 3214 22434

It is singular to observe that in the five successive years in this period with lowest fever-deaths and deaths from all causes, the years 1757-61 England was at war on the Continent. A similar low fever-mortality corresponded with the wars under Marlborough and Wellington.

The era of agricultural prosperity in England, which had its only considerable interruptions in the years 1727-29 and 1740-42, may be said to have met with a more serious check from the bad harvest of 1756. There was a recurrence of agrarian troubles in 1764-67, partly through actual scarcity caused by the extreme drought of 1764, partly through the pulling down of cottages and the discouragement of country villages, which Goldsmith has pathetically described in his poem of the time. Short says that the country in 1765 was in general very healthy but for children’s diseases. “In some parts the putrid fever roamed about from place to place in the highest degree of putrefaction, so as several dead bodies were obliged to be buried the same day as they died.” The price of provisions was excessive, meal riots broke out, and the export of corn was stopped, Parliament having been summoned for the occasion in November, 1766[233]. In 1769, at the time of the formation of Chatham’s ministry, the same train of incidents recurred,--bread-riots, flour-mills wrecked, corn and bread seized by the populace and sold at low prices, collisions with the military, the gaols full of prisoners[234]. The long period of cheapness, having lasted half a century, was coming to an end. Moralists and economists had much to say as to the meaning of the national distress which began to be felt in the sixties. Want of industry, want of frugality, want of sobriety, want of principle, said one, had brought trouble on the working class. “The tumults that have lately arisen in many counties of England are no other than the murmurs of the people, which have been heard for some years, bursting forth at last into riot and confusion.” The English, it seems, had returned to their old medieval taste for the best food they could get; they would not give up the finest bread, although the Irish lived on potatoes, and the French on turnips and cabbage: “The ploughman, the shepherd, the hedger and ditcher, all eat as white bread as is commonly made in London, which occasions a greater consumption of wheat.” Women must have tea and snuff, though children go naked and starved. Another writes: “The poorest people will have the finest or none.” The enclosures had made a want of tillage. “What must become of our poor, destitute of work for want of tillage?” The country had for the most part been sickly, labourers scarce, and the farmers not able to get their usual quantity threshed out. The profligacy of the poor, profane swearing, etc., are remarked upon[235].

In the last thirty years of the 18th century the accounts of fever in England became more detailed as to its circumstances, and more numerically precise. I shall accordingly bring together all that I can find relevant to fever in London, Liverpool, Newcastle and Chester, and thereafter in those towns, such as Manchester, Leeds, and others in the North, which were specially touched in their public health by the movement known as the Industrial Revolution.

Typhus Fever in London, 1770-1800.

In the London bills of mortality the item of fevers diminishes steadily during the latter part of the 18th century, the deaths from all causes diminish, the births come nearer to the number of the deaths, and in three years of the last decade they exceed them. This statistical result is doubtless roughly correct; but the bills were becoming more and more inadequate to the whole metropolitan area; and even for the original parishes which they included they have not the same value for fever in the later period as they had for plague at their beginning[236]. On the other hand, from about the year 1770 we begin to have more exact medical accounts of fever in London, which are not indeed numerically exhaustive, but good as samples of what was going on. Whatever improvement there was in the prevalence of typhus fever touched the richer classes. The Paving Act of 1766 is credited with having improved the health of the City, and there were many new streets and squares being built in the west end that were, of course, free from typhus. It is to these desirable residential quarters that the eulogies of Sir John Pringle[237], Dr John Moore[238] and others apply. The slums of London were as yet unimproved, and but little known to the physicians. Lettsom, who was one of the first of his class to visit among the poor in their homes, has much to say of typhus fever; but he is emphatic that it was nearly all an infection of the poor. “In the airy parts of this city,” he writes in 1773, “and in large, open streets, fevers of a putrid tendency rarely arise.... In my practice I have attentively observed that at least forty-eight out of fifty of these fevers have existed in narrow courts and alleys.” The same is remarked by Currie for Liverpool, by Clark for Newcastle, by Percival and Ferriar for Manchester, by Haygarth for Chester, and by Heysham for Carlisle.

The quarters of the rich had gradually become detached from those of the poor. I have shown this more especially for Chester, where the old walls made a clear division; but it was general in the second half of the 18th century[239].

Medical practice lay mostly among the richer classes; the physicians knew little of the state of health in the cellars and tenement-houses of large towns. Those physicians who did know how much typhus fever there was in these purlieus had to enter a caveat against the incredulity of the rest. Dr Currie of Liverpool, whose facts I shall give in their place, protested that he was not exaggerating; a protest the more necessary that a contemporary of his own, Mr Moss, a middle-class practitioner, who wrote a book specially on the medical aspects of Liverpool, declares that fever is “rare” in that city, while Currie was treating from his dispensary a steady average of three thousand cases of typhus every year. In the same years, in February, 1779, a physician to the army, Dr John Hunter, who had commenced practice in Mayfair, found on visiting in the homes of the poorer classes in the west of London cases of fever for which he had no other name than the gaol or hospital fever of his military experience; it was so much a novelty to him, apart from campaigns or transport ships, that he gave an account of his discovery of domestic typhus to the College of Physicians[240]. At length he found so many cases steadily winter after winter that he had them sent to the infirmary of the Marylebone Workhouse. The practitioners who knew most of the sicknesses of the poor were such as Robert Levett, Dr Samuel Johnson’s dependant, who lived with the doctor in the house in Gough Square. Levett had been a waiter in a Paris coffee-house frequented by the medical fraternity, and had acquired a taste for and perhaps some knowledge of the healing art. He made his modest living by the small fees or articles of food and drink which his poor patients gave him. He had only to issue from the back of Gough Square by the courts and alleys behind Fleet Street, and he would find in the region between Chancery Lane and Shoe Lane hundreds of families seldom visited by a physician or by a qualified surgeon-apothecary. The good Levett was only one of a class. There had always been such humble medical attendants of the poor in London. An Act of the third year of Henry VIII. was directed against them at the instance of the privileged practitioners; but the regular faculty is said to have proved in the sequel both greedy and incompetent, and after thirty years there came another Act, couched in terms that the bluff king himself might have indited (31-32 Henry VIII.), which asserts those qualities of the profession in so many words, and establishes the right of any subject of the king to practise minor surgery and the medicine of simples upon his or her neighbours. That Act is still part of the law of England, and under it Levett exercised a statutory right, perhaps without knowing it[241]. There were many other regions of courts and alleys all round the City on both sides of the water, which must have been medically served by such as Levett, if served at all. It was there that typhus was found and at length clinically described by competent physicians, among the earliest of whom was Lettsom.

The General Dispensary in Aldersgate Street having been started in 1770 with one physician, Lettsom was chosen additional physician in 1773, and threw himself into the work with great zeal[242]. In the first twelvemonth he saw many cases of fever, as in the following table:

Lettsom’s practice in Fevers at the Aldersgate Dispensary.

1773

Febris April May June July Aug. Sept. Oct. Nov. Dec.

hectica 2 2 4 13 4 2 3 4 9 inflammatoria -- -- -- -- -- -- -- 1 1 intermittens 3 1 7 1 1 1 1 -- 2 nervosa 4 3 4 14 7 11 4 5 1 putrida 14 19 14 25 14 21 34 22 11 remittens 6 10 5 4 3 6 7 3 12 simplex vel -- 2 1 6 2 5 4 5 -- diarium

1774 Total in Febris Jan. Feb. March 12 months Died

hectica 12 18 13 86 3 inflammatoria 1 -- 2 5 -- intermittens 1 2 2 22 -- nervosa 1 5 4 65 3 putrida 6 7 5 192 8 remittens 13 10 3 82 -- simplex vel -- -- 4 29 -- diarium

The nervous, putrid and remittent fevers, belonging, to the same group, make up the bulk of the fevers. The hectic fevers were almost all of children. The fatal cases of fever were fourteen, the fatal cases in all diseases for the year having been forty-four. What these putrid, nervous and remittent fevers were, will now appear from some of Lettsom’s descriptions. Fevers with symptoms of putrescency were marked by nausea, bitter taste, and frequent vomiting, by laboured breathing and deep sighing, offensive breath, sweats offensive and sometimes tinged with blood, almost constant delirium, the tongue dry, the tongue, teeth and lips covered with black or brown tenacious foulness, thrush and ulceration in the mouth and throat, the urine with a dark sediment, the stools excessively nauseous and foetid, and blackish or bloody, the eyes horny or glassy, with the whites often tinged of a deep blood colour, spots on the skin like fleabites, or larger haemorrhagic vibices, bleeding from the gums, nose or old ulcers, hiccup near death, often a cough through the fever. Lettsom’s treatment consisted in good liquors, Peruvian bark, and above all fresh, or “cold” air: “When it is considered that putrid fevers originate in close unventilated places, the introduction of fresh air seems so natural a remedy that I have often admired its aid should have been so long neglected[243].” Accordingly he persuaded the poor people to open their windows, and dragged the sick out of doors as soon as it was safe to do so; the effects, he says, were wonderful. His fifty-one cases are most valuable illustrations of the perennial fever in the crowded parts of London:

Case 1 is of a man aged forty who had occasion to visit a miserable crowded workhouse in Spitalfields. He was instantly seized with such a nausea and debility as induced him to keep his room as soon as he got home. At the end of a week Lettsom found him in “the true jail-fever, or, what is the same, a true workhouse-fever.” He had involuntary stools and leaping of the tendons, and took more wine in a week than he had done for many years.

Cases 2 to 12 were of several families in one house in a court in Long Lane, Aldersgate Street, who had been infected by a discharged prisoner from Newgate. Other cases follow, where the infection was caught from visiting the sick. In Case 17, Lettsom applied blisters “owing to the importunity of the friends,” but without advantage. Case 30, on 26th October, 1773, was of a family of six persons near Christ Church, Lambeth, father, mother, boy of seventeen, child of two (slight attack) and two maids. Other localities were courts off Whitecross Street, Jewin Street, Little Moorfields, Chiswell Street, and St Martin’s-le-Grand. Case 43 was of a woman, aged thirty, in Bunhill Row; she attended a relation who died of a putrid fever, and was herself attacked; her eyes were bloodshot, her skin marbled and interspersed with a general deep-coloured eruption, her cheeks and nose mortified. Cases 44-47 were of people in a “very helpless situation” in Gloucester Court, Whitecross Street.

The year 1773, to which these experiences in a small part of London relate, was one of high febrile mortality, according to the Bills. Two years after, Dr William Grant was moved to write an ‘Essay on the Pestilential Fever of Sydenham, commonly called Gaol, Hospital, Ship and Camp Fever[244],’ which, as he said in his preface, “I often see in this city: and though so common and fatal, appears not at present to be generally understood.” It was, he says, “an indigenous plant, frequent in this city, being produced by close confinement; but it often passes unnoticed, because unknown.” The deaths by “fever” in the London Bills were as follows until the end of the century:

Deaths from Fever and from all causes in London.

Fever All Year deaths deaths

1771 2273 21780 1772 3207 26053 1773 3608 21656 1774 2607 20884 1775 2244 20514 1776 1893 19048 1777 2760 23334 1778 2647 20399 1779 2336 20420 1780 2316 20517 1781 2249 20719 1782 2552 17918 1783 2313 19029 1784 1973 17828 1785 2310 18919 1786 2981 20454 1787 2887 19349 1788 2769 19697 1789 2380 20749 1790 2185 18038 1791 2013 18760 1792 2236 20213 1793 2426 21749 1794 1935 19241 1795 1947 21179 1796 1547 19288 1797 1526 17014 1798 1754 18155 1799 1784 18134 1800 2712 23068

There were higher figures in the years immediately before 1771, the years to which the generalities of Fordyce and Armstrong relate. There is a decline in the fever-mortality towards the end of the century; but it is just from the years 1799-1800 that we have an account by Willan of the prevalence and conditions of London typhus, than which nothing can well be imagined worse. The intermediate glimpses we get of typhus in London in the writings of Dr Hunter, physician, and of Dr James Sims, show that the disease was perennial.

“In the month of February, 1779,” says Hunter[245], “I met with two examples of fever in the lodgings of some poor people whom I visited that resembled in their symptoms the distemper which is called the jail or hospital fever. It appeared singular that this disease should show itself after three months of cold weather. Being therefore desirous of learning the circumstances upon which this depended I neglected no opportunity of attending to similar cases. I soon found a sufficient number of them for the purpose of further information. It appeared that the fever began in all in the same way and originated from the same causes. A poor family, consisting of the husband, the wife, and one or more children, were lodged in a small apartment not exceeding twelve or fourteen feet in length, and as much in breadth. The support of them depended on the industry and daily labour of the husband, who with difficulty could earn enough to purchase food necessary for their existence, without being able to provide sufficient clothing or fuel against the inclemencies of the season. In order therefore to defend themselves against the cold of the winter, their small apartment was closely shut up, and the air excluded by every possible means. They did not remain long in this situation before the air became so vitiated as to affect their health and produce a fever in some one of the miserable family. The fever was not violent at first, but generally crept on gradually ... soon after the first a second was seized with the fever, and in a few days more the whole family perhaps were attacked, one after another, with the same distemper. I have oftener than once seen four of a family ill at one time and sometimes all lying on the same bed. The fever appeared sooner or later as the winter was more or less inclement, as the family was greater or smaller, as they were worse or better provided with clothes for their persons and beds, and with fuel, and as their apartment was more or less confined. The slow approach of the fever, the great loss of strength, the quickness of the pulse with little hardness or fulness, the tremors of the hands, and the petechiae or brown spots upon the skin, to which may be added the infectious nature of the distemper, left no doubt of its being the same with what is usually called the jail or hospital-fever.”

Dr James Sims, who had seen much of Irish typhus in Tyrone in his earlier years, and had removed to London, wrote of typhus among the poor there in 1786, ten years before the more systematic and more circumstantial descriptions by Willan[246].

This fever was exceedingly mortal, several medical men, he had reason to believe, falling sacrifices to it. Sims never saw the cases till the 7th or 8th day, when they were desipient, insensible, with pulse scarcely to be felt and not to be counted, all having petechiae. None had scarlet rash or sore-throat. They sank and died quietly; the strongest cordials did not produce the smallest effect, and blisters in many did not even raise the skin[247].

It is in the year 1796 that we begin to have the full and accurate records by Willan of the prevailing diseases of London month by month as he saw them at the Carey Street Dispensary, situated in the crowded quarter between Holborn and the Strand[248]. His first reference to typhus is as follows:

“In September, also, fevers usually appear which from their commencement exhibit symptoms of malignancy; being attended with a brown dry tongue, violent pain of the head, delirium, or coma, deep-seated pains of the limbs, petechial spots and haemorrhagy. These fevers become highly contagious, especially when they occur in close, confined situations, and in houses where little attention is paid to ventilation or cleanliness. The disease is extended by infection during the months of October and November, but its progress is generally stopped by the frosts of December.”

Willan says little more of fever in London until September, 1798, when these contagious malignant fevers became more numerous, both in the city and adjacent villages, than had been known for many years before; also the fever was more fatal than usual, one in five or six dying, whereas one in seven was formerly a very unfavourable death-rate, and one in twenty not unknown. Haemorrhages, aphthae, diarrhoea, starting of the tendons, picking the bedclothes, violent delirium, ending in deafness, stupor, hiccough and involuntary evacuations, were the usual accompaniments of this fever. In the corresponding months of 1799 he recurs to the symptoms of this “malignant contagious fever,” and depicts typhus as clearly as may be. In September, 1799, it was “attended with a dull pain of the head, great debility or sense of lassitude and pains referred to the bones, tremblings, restlessness with slight delirium, a querulous tone of voice, a small and frequent pulse, heat of the skin, thirst and a fur upon the tongue, first of a dirty white colour, but turning in the latter stage of the disease to a yellowish brown. In this form the fever continued thirteen days without any dangerous symptoms, and then suddenly disappeared, leaving the patient, for some time after, languid and dispirited. All the individuals of a family were successively affected with the same train of symptoms; many of them so slightly as not to be much confined to their beds.” In October and November he describes the symptoms of the disease in a more dangerous form. By this fever, he was informed, some houses of the poor had been almost depopulated, the infection having extended to every inmate. “The rumour of a plague was totally devoid of foundation.”

He then describes the state of the dwellings where such fevers occurred--the unwashed bed-linen, the numbers in one bed, the rooms encumbered with furniture or utensils of trade, the want of light and air in the cellars and garrets and in the passages thereto, the excremental effluvia from the vault at the bottom of the staircase. It cannot be wondered at, he concludes, that contagious diseases should be thereby formed, and attain their highest degree of virulence; and he estimates that “hundreds, perhaps thousands” of labourers in and near London, heads of families and in the prime of life, perished annually from such fevers. He denies that his account is exaggerated, and appeals for the truth of it to medical practitioners whose “situation or humanity has led them to be acquainted with” the localities[249].

Typhus in Liverpool, Newcastle and Chester in the last quarter of the 18th century.

Liverpool, in the last quarter of the 18th century, came next in size to London, having a population (in 1790) of 56,000 to the capital’s estimated 800,000. According to a medical author, whose experiences lay among the middle classes, it was everything that could be wished in the way of healthfulness and prosperity; but it had a dark side as well. About 7,000 of the people lived in cellars underground, and nearly 9,000 in back houses, in small confined courts with a narrow passage to the street. “Among the inhabitants of the cellars,” says Currie[250], “and of these back houses, the typhus is constantly present; and the number of persons under this disease that apply for medical assistance to the charitable institutions, the public will be astonished to hear, exceeds three thousand annually.... In sixteen years’ practice I have found the contagious fever of Liverpool remarkably uniform among the poor. Seldom extending itself in any considerable degree among the other classes of the community, it has been supposed that Liverpool was little subject to fever; but this will be shewn from authentic documents to be a great and pernicious error.” At the Dispensary in the year 1780 the cases of typhus averaged 160 per month, the numbers being as remarkably steady from month to month as from year to year. In the ten years from 1 January, 1787, to 31 December, 1796, 31,243 cases of fever were entered on the books of the Dispensary, an average of 3124 per annum[251].

Of 213,305 cases of all diseases at the Dispensary in seventeen years, 1780 to 1796, 48,367, nearly one-fourth, were labouring under typhus. Supposing that these were all the cases of typhus in Liverpool, and that 1 in 15 died, we should have some 150 deaths from typhus in a year. Supposing also that typhus was relatively as common at that time in London, it will follow that nearly all the deaths under “fever” in the bills of mortality might well have been from typhus fever; for London in its several densely populated out-parishes was the fever-quarter of Liverpool a dozen times over[252].

The Newcastle Dispensary was opened in October, 1777, by the exertions of Dr John Clark, who was in correspondence with Lettsom in London[253]. Dr Clark had been in the East India Company’s service, and had seen much of ship-fever and of the fevers of the East. During a visit to his home in Roxburghshire in the summer of 1770, between his voyages, he attended several persons in continued fever. When he settled at Newcastle he saw the worst kinds of contagious fever, in workhouses and “in the sordid and crowded habitations of the indigent.” Putrid fever, or typhus, was by far the most common disease attended from the new dispensary, although less than at Liverpool, the operations of the charity being on a much smaller scale. It was seldom out of Newcastle a whole year; and in some years, as 1778, 1779, 1783, 1786 and 1787 it was unusually rife in particular districts, often attacking whole families. Scarlet fever was epidemic and very fatal in 1778 and 1779, while dysentery attacked great numbers of the poor in the autumns of 1783 and 1785. The following Table shows the principal diseases attended from the Dispensary during the first twenty-three months of its working, 1 Oct. 1777, to 1 Sept. 1779:

Newcastle Dispensary 1777-79.

Cases Too far visited Cured advanced Dead

Putrid fever 391 357 9 16 Ulcerated sore-throat 146 125 11 9 Dysentery 72 55 5 4 Smallpox 45 29 5 6

From 1 Oct. 1777, to 1 Sept. 1789, the cases of typhus visited were 1920, of which 121 were fatal. During the winter of 1790 and the spring and summer of 1791 it was prevalent amongst the poor, and was frequently introduced into genteel families and sometimes even into those of the first distinction. That outbreak was supposed to have been generated in the Gateshead poorhouse. For some time its ravages were confined chiefly to the low, ill-aired, narrow street called Pipewell Gate. In September it made its appearance in Newcastle; at first the contagion was easily traced from Pipewell Gate, and afterwards from one house to another. In that outbreak, 188 poor persons were visited from the Newcastle Dispensary, the Gateshead poor having been attended by the parochial surgeon. Clark’s ten cases recorded of the epidemic were all of people in good circumstances. The Dispensary Tables show cases of typhus every year down to 1850, the largest totals being in 1793 (374, 18 deaths), 1801 (435, 20 deaths), and 1819 (368, 14 deaths); and these, we may take it, were but a small fraction of all the cases in Newcastle.

Perhaps the most unexpected revelation of typhus is at Chester, from the time when Haygarth began to write upon its public health in 1772. Chester was then one of the most desirable places of residence in England. Boswell wrote to Johnson, “Chester pleases me more than any town I ever saw.” The old city within the walls was occupied by a superior class of residents, including the cathedral clergy, county families, retired officers and Anglo-Indians, professional men, merchants and tradesmen. It had the best theatre out of London. Squares, crescents and broad streets were replacing most of the old buildings. The six parishes that lay entirely within the walls had a population, in 1774, of 3502, and an annual average death-rate (in the ten years 1764 to 1773) of 1 in 58 or 17·2 per 1000, the central parish of St Peter having a rate of 1 in 62, and the cathedral parish 1 in 87. It passed as one of the healthiest cities in the kingdom, being far before Shrewsbury and Nottingham, to say nothing of the large towns where the burials exceeded the baptisms. But its moderate death-rate over all, 1 in 42 living, would have been much lower but for the four poor suburban parishes, with a population of 11,211, which had a death-rate of 1 in 35. Haygarth gives a deplorable account of them. The houses were small, close, crowded and dirty, ill supplied with water, undrained, and built on ground that received the sewage from within the walls. The people were ill-fed and they seldom changed or washed their clothes; when they went abroad they were noisome and offensive to the smell. Many of them worked on the large farms around Chester, others at shipbuilding and shipping (Chester had then a considerable foreign trade), others at the mills and markets, others at a nail-factory, while others were employed by the tradesmen within the walls. Fever seems to have been perennial among them, the deaths from typhus having been 23 in 1772, 33 in 1773 and 35 in 1774. “In these poor habitations,” says Haygarth, “when one person is seized with a fever, others of the family are generally affected with the same fever in a greater or less degree.” It became rifer than usual in August, 1773, and attacked 285, proving fatal to 28, or to one in ten. It had the common symptoms of malignant fevers produced by human effluvia, and particularly affected the head with pain, giddiness and delirium. It attacked in general the lowest, few of the middle rank, and none (or only one) of the highest rank[254].

Chester had no manufactures. Its population had grown rapidly of late, as that of Liverpool had grown, the poorer classes being the prolific part of the community; but it had no share in the industrial revolution, it did not employ its women and children in factories, and it was in some respects better than Leeds, Warrington, Manchester, or Carlisle. It is a good illustration of a town growing rapidly without manufactures, and of a community divided by the old walls into two quite distinct sections, a rich and a poor. Such had been the drift of things in England apart from the industrial revolution; but it is the latter which furnishes the best illustrations of a poor prolific populace, of a growing struggle, and of the attendant typhus fever.

Fever in the Northern Manufacturing Towns, 1770-1800.

The prosperity of the first two-thirds of the 18th century had been attended with a very small increase of population. From 1700 to 1750 the numbers in England are estimated to have grown no more than from about six millions to six millions and a half. The fecundity of many rural parishes was swallowed up by emigration to the American and West Indian colonies, by the army and navy, and by the great waste of life in London and some other towns. The increase was nearly all north of the Trent, while the old weaving towns of the south-west had actually declined. Gloucestershire, Somerset and Wilts were the most crowded counties in 1700. During the next fifty years, the greatest increase was as in the following rough estimate[255]:

Increase 1700 1750 per cent.

Lancashire 166,200 297,400 78 West Riding of Yorks. 236,700 361,500 52 Warwickshire 96,600 140,000 45 Durham 95,500 135,000 41 Staffordshire 117,200 160,000 36 Gloucestershire 155,200 207,800 34

In the counties where population had increased most, much of the increase was still rural or semi-rural. Defoe describes how the land near Halifax was divided into lots of from two to six or seven acres, hardly a house out of speaking distance from another, at every house a tenter, and on almost every tenter a piece of cloth, or kersey or shalloon. Every clothier kept one horse at least, to carry his manufactures to the market, and nearly every one kept a cow, or two or more, for his family. The houses were full of lusty fellows, some at the dye-vat, some at the looms, others dressing the cloths, the women and children carding or spinning, being all employed from the youngest to the oldest: not a beggar to be seen, nor an idle person[256]. We have no accounts of the health of this population, except Nettleton’s statistics of smallpox in and around Halifax in 1721 and 1722, given elsewhere, and the “epidemic constitutions” recorded by Wintringham at York during the same period, and by Hillary at Ripon.

Before the earliest of the inventions of spinning by machinery, the weavers were gathering to the towns of Yorkshire, Lancashire and other counties north of the Trent. The spinning-jenny of Hargreaves was wrecked by a Blackburn mob in 1768, and a mob wrecked the cotton-mill built by Arkwright at Chorley eleven years later. This was decidedly a time of movement from the country to the towns, a movement which preceded the spinning ingenuity of the sixties and may have been stimulated by the earlier use of the fly-shuttle in weaving.

Much of the country round Manchester, though it doubtless retained those farm-houses, hedgerows, and field paths which come into the idyllic opening of ‘Mary Barton’ more than half a century later, was “crowded with houses and inhabitants,” as Percival says: so populous were the environs of Manchester that every house in the township had been found by a late survey to contain an average of six persons. The proportion of deaths was less than in 1757; but that was chiefly due to the accession of new settlers from the country, which raised the ratios of marriages and births[257]. Manchester had increased from a population of about 8000 in 1717 to one of 19,839 (inclusive of Salford) in 1757. When the inhabitants were next counted in 1773, they were found to be 22,481 in Manchester (5317 families in 3402 houses) and 4765 in Salford (1099 families in 866 houses). According to Percival, who gives these figures, the death-rate in 1773 was 1 in 28·4, the births exceeding the deaths by forty in a year. The poor, he says, were now better lodged, and some of the most dangerous malignant distempers were less violent and less mortal. Manchester, however, was still an unhealthy place compared with the country, especially to young children. Thus, the thirty-one townships in the parish of Manchester contained, exclusive of the city, 13,786 inhabitants (2525 families in 2371 houses), and of these only 1 in 56 died annually (compared with 1 in 28 in the city)--the births being to the deaths as 401 to 246 in the year 1772.

Again, the bleak upland parish of Darwen with a population in the year 1774 of 1850 souls mostly occupied in the cotton manufacture, had, during the seven years before, more than twice as many baptisms as burials (508 to 233), the birth-rate (1 in 25·5) being high and the death-rate (1 in 56) low.

Leeds had a population of some six or seven thousand at the time of the Civil Wars, and lost 1325 in nine months of the year 1645 from plague, all of them the poorer class. A generation or two later, in the time of Thoresby’s ‘Diary,’ it was a centre of the cloth trade; and it appears to have grown steadily throughout the 18th century. In 1775 it had a population of 17,117. We hear from Lucas of an epidemic typhus in it previous to 1779[258]. Eighty persons had died of that fever in one year, and many who struggled through the disease died afterwards of lingering complaints. In two courts or yards (such as might have been the Lantern Yard which Silas Marner found pulled down when he revisited Leeds) forty persons were affected with the fever; some families had received ten shillings a week from the assessment for the poor. As early as 1779 Lucas proposed a house of reception for contagious fever, a proposal which was carried into effect in 1804, after a whole generation of typhus and at a time when there was little fever in Leeds or elsewhere. The infectious fevers, being chiefly confined to the poor, often prevailed, says this writer, for a length of time without exciting much alarm, or without their fatality being attended to; but, he adds about the year 1790, “should a few of the higher rank receive the infection, then the disease is described in most exaggerated terms.”

Carlisle was a good instance of the increase of urban population and the breeding of typhus. In seventeen years, from 1763 to 1780, the inhabitants had increased from 4158 to 6229, many of the immigrants being Scots and Irish with their families. The chief industry was the making of calico, in which the women and children were employed as well as the men. When Dr Heysham surveyed the town and suburbs for his census of 1779, he had “opportunity of seeing many scenes of poverty and filth and nastiness[259]”; and in the bill of mortality for that year he confesses himself astonished that there should be so little fever.

The great outburst of typhus at Carlisle began in the end of March, 1781, with no very obvious special provocation[260]. Upwards of 600 had typhus to February 7th, 1782, at which date 12 or 15 were still suffering from it. The deaths were less than 1 in 10 of all attacked: viz. 2 in May, 4 in June, 8 in July, 8 in August, 7 in September, 9 in October, 8 in November, 6 in December, and 3 in January, 1782, a total of 55. Of this total of fatal cases, 3 were boys, 4 bachelors, and 15 husbands: 3 girls, 2 maids, 22 wives, and 6 widows. Two-thirds of all the deaths were of married people; Heysham saw no case in a child under three years. It affected about a tenth part of the inhabitants of Carlisle (6299), and raged most among the lower class who lived in narrow, close, confined lanes and in small crowded apartments, of which there were a great many in Carlisle, generally going through all the inmates of a house where it had once begun. On seeking to trace the origin of the epidemic, he found that it began in the end of March, 1781, in a house in Richard-gate, which contained about half-a-dozen very poor families. Every window that could be spared was shut up, to save the window-tax. The surgeon who attended some of these poor wretches told Dr Heysham that the smell was so offensive that it was with difficulty he could stay in the house. One of the typhus patients in this house was a weaver, who, on his recovery, went to the large workshop where he worked, and there, it was supposed, gave the infection (in his clothes) to his fellow workmen, by whom new centres of infection were made in various other houses. In August, a young man just recovered from the fever went to his mother’s in the small village of Rockliffe, four or five miles from Carlisle, to get back his strength in the country air; his mother soon took the fever and died, and a neighbour woman who came to her in her sickness likewise caught it and died. These were all the cases known in the village, and they show the enormously greater fatality of typhus in those not inured to its atmosphere and conditions.

The state of population and health at Warrington was peculiar, and is given fully in another chapter. There could be no more striking instance of the growth of what the foreign writers call the proletariat; an old market-town, with a small sail-cloth industry from Elizabethan times, it became a busy weaving town owing to the demand for sail-cloth during the war with the American colonies. The whole population of some 9000 men, women and children, were wage-earners; the women were all the while unusually prolific, and the sacrifice of infant life was enormous, especially by smallpox. We have no particular accounts of fevers; but in the bill of mortality for 1773, the year of a disastrous smallpox epidemic, there were 25 deaths from fever, of which 10 were of “worm fever,” or the remittent of children[261].

By the year 1790, when Ferriar’s accounts of fever in Manchester begin, the industrial revolution had been accomplished, mills were everywhere, and the characteristic hardships and maladies of a prolific working class in a time of slack trade were already much the same as we find them pictured with fidelity and pathos in the pages of Mrs Gaskell half a century after.

But, so as not to exaggerate the ill health of the working class in Manchester at the end of the 18th century, let us compare the births with the deaths according to the doubtless imperfect registers[262]:

Manchester, Births and Deaths, 1770-91.

Year Births Deaths

1770 1050 988 1771 1169 993 1772 1127 904 1773 1168 923 1774 1245 958 1775 1359 835 1776 1241 1220 1777 1513 864 1778 1449 975 1779 1464 1288 1780 1566 993 1781 1591 1370 1782 1678 984 1783 1615 1496 1784 1958 1175 1785 1942 1734 1786 2319 1282 1787 2256 1761 1788 2391 1637 1789 2487 1788 1790 2756 1940 1791 2960 2286

The mean lodging-houses in the outskirts of the town, says Ferriar, in 1790[263], were the principal nurseries of febrile contagion: some of these were old houses with very small rooms, into each of which four or more people were crowded to eat, sleep, and frequently to work. They commonly bore marks of a long accumulation of filth, and some of them had been scarcely free from infection for many years past. As soon as one poor creature dies or is driven out of his cell he is replaced by another, generally from the country, who soon feels in his turn the consequences of breathing infected air. There was hardly any ventilation possible, many of these old houses being in dark narrow courts or blind alleys. In other parts of the town the lodging-houses were new, and not yet thoroughly dirty; but in these there was a long garret under the tiles, in which eight or ten people often lodged, the beds almost touching. Again, many lived in cellars, sleeping on the damp floor with few or no bedclothes; the cellars of Manchester, however, were better ventilated than those of Edinburgh, and freer from fever. These cellar-tenants were subject to the constant action of depressing passions of the mind. “I have seen patients,” says Ferriar, “in agonies of despair on finding themselves overwhelmed with filth and abandoned by everyone who could do them any service, and after such emotions I have seldom found them recover.” Addressing the Literary and Philosophical Society of Manchester previous to 1792, he pointed out in an argumentum ad hominem that “the situation of the poor at present is extremely dangerous, and often destructive to the middle and higher ranks of society[264].” And again, “the poor are indeed the first sufferers, but the mischief does not always rest with them. By secret avenues it reaches the most opulent, and severely revenges their neglect or insensibility to the wretchedness surrounding them[265].”

In an address to the Committee of Police in Manchester, he instances the following cases:

A family of the name of Turner in a dark cellar behind Jackson’s Row: they have been almost constantly patients of the Infirmary for three years past on account of disorders owing to their miserable dwelling. There are other instances of the same kind in Bootle Street.

In Blakely Street, under No. 4, is a range of cellars let out to lodgers, which threatens to become a nursery of disease. They consist of four rooms communicating with each other, of which the two centre rooms are completely dark; the fourth is very ill-lighted and chiefly ventilated through the others. They contain four or five beds in each, and are already extraordinarily dirty.

In a nest of lodging-houses in Brook’s entry near the bottom of Longmill-gate, a very dangerous fever constantly subsists, and has subsisted for a considerable number of years. He had known nine patients confined in fevers at the same time in one of those houses and crammed into three small dirty rooms without the regular attendance of any friend or of a nurse. Four of these poor creatures died, absolutely from want of the common offices of humanity and from neglect in the administration of their medicines. Another set of lodging-houses constantly infected is known by the name of the Five Houses, in Newton Street[266].

The fever in Manchester was not always malignant typhus: sometimes it had the symptoms and low rate of mortality that suggest relapsing fever. Thus, in the winter epidemic of 1789-90, very prevalent in Manchester and Salford, out of Ferriar’s first ninety patients only two died; in some the skin had a remarkable, pungent heat, in others there were profuse watery sweats; women were commonly affected with hysterical symptoms during convalescence, which was often tedious[267]. A certain number of these cases would run into “a formed typhus,” with petechiae and all the other signs of malignity; and in some seasons, as in the distressful year 1794, typhus was the usual form. Two fatal cases in children, examined after death, had peritonitis; “in the one no marks of the disease were discernible within the cavity of the [intestinal] tube;” in the other, the patient was covered with petechiae[268]. These cases of localized inflammation in typhus he compares with Pringle’s cases of spotted fever complicated with abscess of the brain.

The years 1792 and 1793 passed, says Ferriar, without any extraordinary increase of fever patients, although the noxious influences were always present. But in the summer and autumn of 1794 “the usual epidemic fever” became very prevalent among the poor in some quarters of the town, particularly after a bilious colic had raged among all ranks of people. This was a time when work was slack; many workmen enlisted and left their families. In November and December 1794, as many as 156 sent applications to the Infirmary in a week to be visited in fever at their homes.

This was a memorable time of scarcity and distress all over the country, the beginning of a twenty-years’ period of so-called “war-prices,” when farmers’ profits were so large that they could afford to double or treble their rents to the landlords. The history of epidemics comes at this point into close contact with the economic history, which I shall touch on in the sequel, after giving a few more particulars of typhus in England and Scotland generally, previous to the outbreak of the war with France in 1793.

Typhus in England and Scotland generally, in the end of the 18th century.

The introduction of machinery and the building of mills brought typhus fever to places much less crowded than Leeds, or Manchester, or Carlisle.

Dr David Campbell of Lancaster saw much of typhus in that town, and in mill villages near it, in the years 1782, 1783, and 1784. In Lancaster town he saw about 500 cases, of which 168 were in men, with 20 deaths, 236 in women, with 11 deaths, and 94 in children under fourteen, with 3 deaths. At Backbarrow cotton mill, twenty miles from Lancaster, there were 180 cases, of which 38 were in men, with 5 deaths, 11 in women, with 2 deaths, and 131 in children under fourteen, with no deaths[269]. At this mill there was an extremely offensive smell in the rooms, which came from the privy; the doors of the latter, “for indispensable reasons in the economy of these works, where so many children are employed, always communicate with the workrooms.” Every care had been taken to keep the air sweet, but without effect. The offensive smell was in all the cotton mills from the same cause; and in the Radcliffe mill belonging to Mr Peel, the typhus was ascribed to that source, the nuisance having been at length got rid of. Both at Backbarrow and Radcliffe the houses of the workpeople were new, airy and comfortable. In the same years typhus raged with uncommon severity at Ulverston and in various parts of Lancashire, where cotton-mills had been set up[270].

The typhus of Liverpool and Newcastle was reproduced in Whitehaven and Cockermouth on a scale proportionate to their size. Whitehaven, the port of the Cumberland coal-field, was the Newcastle of the west coast, and had a large trade with Ireland. Many of the labourers lived in cellars. Brownrigg’s experiences of typhus fever in it went back to near the middle of the 18th century. The Whitehaven Dispensary was opened in 1783, the occasion for it being thus explained:--

“Previous to the establishment of dispensaries Whitehaven and Cockermouth were infested by nervous and putrid fever. Many of their respectable inhabitants became its victims; and among the lower class of people it prevailed with deplorable malignancy. The present period happily exhibits a different picture. Notwithstanding our connection with the metropolis of Ireland, and other commercial places, contagion rarely appears; or, when accidentally introduced, is readily suppressed[271].”

The following is the abstract of “contagious fever cases” from the records of the Whitehaven Dispensary from 30 June, 1783, to 9 June, 1800[272]:

Year Cured Dead Total

1783 75 1 76 1784 401 9 410 1785 350 20 370 1786 91 6 97 1787 21 1 22 1788 53 7 60 1789 103 2 105 1790 288 21 309 1791 74 6 79 1792 17 2 19 1793 7 3 10 1794 13 1 14 1795 28 2 30 1796 48 1 49 1797 35 2 37 1798 12 1 13 1799 11 1 12 ---- --- ---- Total 1627 85 1712

The year 1790 is indicated as an unhealthy one, by the excess of burials over christenings, also at Macclesfield, where there were 316 christenings to 380 burials, the proportion being usually the other way[273].

Dr John Alderson of Hull wrote in 1788 an essay on the contagion of fever, in which there are no authentic details for Hull: “The calamity itself is the constant complaint of every neighbourhood, and almost every newspaper presents us with an example of the direful consequences of infection”--the reference being to gaols more particularly[274]. Whatever was the reason, there was undoubtedly a great deal of typhus in England in the eighties of the eighteenth century. Oxfordshire, Gloucestershire, Worcestershire, Wiltshire and Buckinghamshire experienced much typhus from 1782 to 1785, although we have few particulars. “The remembrance of its ravages at Gloucester, Worcester and Marlborough,” says Dr Wall of Oxford, “is still fresh in every mind, where its virulence proved so peculiarly fatal to the medical world.” At Aylesbury, Dr Kennedy survived an attack of the “contagious fever,” to write an account (1785) of the epidemic, which he traced to the gaol (the date, be it observed, is subsequent to Howard’s visitations)[275]. At Maidstone, also, in 1785, the gaol fever was the subject of a special account[276].

At Worcester in 1783 the younger Dr Johnstone caught typhus while visiting the gaol, which was thereafter rebuilt at great expense. A prisoner took it to Droitwich where 14 died[277].

Dr Wall gives clinical details of fifteen cases of typhus treated by him in private practice at Oxford in 1785; one of his patients was an apothecary whose business had exposed him very much to the influence of contagion, as he was much employed amongst the poor in the suburbs of the town and neighbouring villages and in the House of Industry[278]. In the year 1783-85, much of the epidemic fever was of the nature of ague, as described in another chapter. It is not always easy to separate it from typhus; but there is no doubt that both were prevalent together. Thus in the parish of Painswick, Gloucestershire, in the spring of 1785 there occurred both “a contagious fever” and an “epidemic ague,” the latter having left a good many persons dropsical and cachectic[279]. This had been part of an epidemical fever which had raged for some time in the county of Gloucestershire, and is said to have lately carried off a great number of poor. At Norton, within five miles of Gloucester, there lived in two adjoining tenements two families: in one a man and his wife and three children, in the other a man and his wife, of whom only one remained alive on the 1st of March, 1785[280].

The extraordinary failure of the harvest in Scotland in 1782 produced much distress, and with it fever, in the winter following. The Glasgow and Edinburgh municipalities imported grain for the public benefit. Various traces of the scarcity and fever appear in the Statistical Account written a few years after. Thus, in Holywood parish, Dumfriesshire, some fevers were wont to appear in February and March among people of low circumstances living in a narrow valley; and the unusual mortality in the dear year 1782 was owing to an infectious fever in the same cottages. In the regular bills of mortality of Torthorwald parish, Dumfriesshire, the deaths from “fever” fall in the dear years, 1782-3, 1785, &c. In Dunscore parish, in the same county, the burials of 1782 rose to the most unusual figure of 30 (the baptisms being 17), “owing to a malignant fever[281].”

But Scotland was now past the danger of actual famine from even a total failure of the harvest. Some farmers were ruined, and many more were unable to pay the year’s rent; but the very poorest were enabled to find food, one source being “the importation of white pease from America.” From Delting, in Shetland, one of the poorest parishes, the report is: “There is reason to believe that none died from mere want; but there is no doubt that many, from the unwholesome food, contracted diseases that brought them to their graves.”

The following relating to the parishes of Keithhall and Kinkell, Aberdeenshire, in the scarcity following the lost harvest of 1782, is a curiously detailed glimpse of the time:

“Several families who would not allow their poverty to be known lived on two diets of meal a day. One family wanted food from Friday night till Sunday at dinner. On the last Friday of December, 1782, the country people could get no meal in Aberdeen, as the citizens were afraid of a famine; and a poor man, in this district, could find none in the country the day after. But the distress of this family being discovered, they were supplied. Next day the [Kirk] session bought at a sale a considerable quantity of bere, which was made into meal. This served the poor people until the importation at Aberdeen became regular, and every man of humanity rejoiced that the danger of famine was removed[282].”

We hear most of fevers in the Highland parishes, with their subdivisions of holdings and an excess of population. Thus of Gairloch, Ross-shire, it is said: “Fevers are frequent, sometimes they are of a favourable kind, at other times they continue long and carry off great numbers”--the poor in this parish, upon the Kirk Session roll, numbering 84 in the year 1792, and the aggregate money paid to the whole number averaging £6. 7_s._ in a year, whereas the fertile parish of Ellon, Aberdeenshire, with 40 on the poor’s roll, paid them £43 per annum.

Again, of the fishing village of Eyemouth, it is said: “The only complaints that prove mortal in this place are different kinds of fevers and consumptions; and these are mostly confined to the poorest class of people, and ascribed to their scanty diet.” And of another fishing parish, in Banffshire, Fordyce, including Portsoy, it is said: “The most prevalent distemper is a fever, and that for the most part not universal, but confined to particular districts. It is sometimes thought to arise from infection and communication with other parts of the country; at other times from local situations and circumstances of the people’s houses and habits of living in particular districts[283].”

The beginning of the great French war was the occasion of a considerable increase of fever; although no records make it appear so fatal a time as the years 1783-86. The commercial distress and want of work which began in the autumn of 1792, were intensified by the bad harvests of 1794 and 1795, which followed two harvests also deficient. This was the period of distress and of epidemic fever to which Wordsworth referred in the passage in the first book of the ‘Excursion,’ where he is relating the story of Margaret’s ruined cottage[284].

There is little medical writing upon the epidemic fever of 1794-95; and, in the very district of Wordsworth’s story, the records of the Whitehaven Dispensary bear no traces of a great concourse of patients. There is reason to think that the fever, if slow and weakening, was seldom fatal, that it was typhus mitior, and that it was sometimes, perhaps often, relapsing. One glimpse we get of it in the family of the afterwards celebrated Dr Edward Jenner of Berkeley, in the winter of 1794-95. He thus writes to a friend about the visitation of “grim-visaged typhus:”

“You shall hear the history of our calamities. First fell Henry’s [his nephew and assistant] wife and sister. From the early use of bark, they both appeared to recover; but the former, after going about her ordinary business for some days, had a dreadful relapse which nearly destroyed her. It was during my attendance on this case that the venomed arrow wounded me.... Like Mrs Jenner’s fever, at an early period there was a clear intermission for four days.... On the eighth day after the first seizure it again set in, in good earnest, and continued one-and-twenty days.... Dr Parry was with me from Bath five times, Dr Hicks and Dr Ludlow as many, and my friend George was never absent from my bedside.... But, to return to that mansion of melancholy, Henry’s. His infant girl has now the fever; a servant maid in the house is dying with it; and to complete this tragical narrative, about five days ago fell poor Henry himself. His symptoms at present are such as one might expect: violent pain in the head, vertigo, debility, transient shiverings.... His pulse this evening is sunk from 125 to 100. The stench from the poor girl is so great as to fill the house with putrid vapour; and I shall remove him this morning by means of a sedan-chair to a cottage near my own house[285].”

This is a tolerably clear picture of a short-period fever with relapses, or of relapsing fever strictly so-called; the stench, also, of one patient is characteristic. Barker, of Coleshill or Birmingham, has much to say under the same year 1794, of a slow, tedious fever, marked by “sluggish action and comatose symptoms,” and much subject to relapses; but he does not give the duration of the first or subsequent paroxysms, as Jenner does, or the usual length of the clear intervals, his most definite case being of a young woman who died in twenty-four hours from a relapse which came on about three weeks after the fever had left her[286].

It was the access of fever in 1794-5, and the alarm that it caused among the richer classes, that led to the opening of the Manchester House of Recovery in 1796. In certain streets in the neighbourhood chosen for the hospital, Portland Street, Silver Street and others in the same block, the cases of contagious fever for nearly three years before the hospital was opened are given by Ferriar as follows:

Sept. 1793 to Sept. 1794, cases of fever, 400 Sept. 1794 to Sept. 1795, " " " 389 Sept. 1795 to May 1796, " " " 267

The cases began to be sent to the hospital on the 27th May, 1796, and an attempt was made to extinguish contagion in the houses, by white-washing, disinfecting and the like; so that in the same group of streets there were only 25 cases of fever from 13 July, 1794 to 13 March, 1797. Meanwhile the admissions to the hospital were few until the dearth of 1799-1802. One of the manufacturing towns which is known to have shared in the epidemic fever of 1794-96 was Ashton-under-Lyne, where upwards of three hundred cases (with few deaths) occurred in less than three months at the end of 1795. This epidemic must have been somewhat special to Ashton, for it produced much alarm in neighbouring places and caused Ashton to be avoided from fear of infection.

Shortly after 1796, Ferriar made an inquiry into an epidemic of fever at a village within a mile of Manchester; the houses were many of them new, built for the convenience of a large cotton mill; but even the new houses were offensive, with cellars occupied by lodgers, and almost every house overcrowded. This was the first fever in the village, and it was traced to a family who had come from Manchester with infected clothes. Stockport about the same time erected a House of Recovery, having “the same general causes of fever which render the disease so common in Manchester”; and Ferriar adds: “I believe there is not a town in the kingdom containing four thousand inhabitants which would not be greatly benefited by similar establishments.”

The bad harvest of 1794 raised the price of wheat to 55_s._ 7_d._ on 1 January, 1795, and the prospect of another short harvest to 77_s._ 2_d._ on 1 July. A famine being threatened, the Government caused neutral ships bound to French ports with corn to be seized, and brought into English ports, the owners receiving an ample profit. Agents were also sent to the Baltic to buy corn. By these means the price of wheat, which had risen in August to 108_s._ 4_d._, fell in October to 76_s._ 9_d._ Parliament met on the 29th October, and various measures were taken[287]. In the spring of 1796, the climax of distress was reached, wheat being at 100_s._ per quarter. The harvest of 1796 was abundant and wheat fell to 57_s._ 3_d._ The harvests of 1797 and 1798 were not equally good, but they were not altogether bad, and the price of wheat kept about 50_s._ for nearly three years, which were years of comparative comfort between the dearth of 1794-96 and the dearth of 1799-1802.

Fevers in the Dearth of 1799-1802.

Although Willan chooses the end of the year 1799 to enlarge upon the London fever, he does not connect it with the dearth that was already beginning to be felt (soup kitchens having been opened in various parts of London). The price of wheat, which had been steadily about 50_s._ in 1797 and 1798, rose in May, 1799 to 61_s._ 8_d._, after a hard winter which had probably injured the autumn-sown corn. The harvest turned out ill, and the price of wheat rose in December, 1799, to 94_s._ 2_d._ Bounties were offered on imported foreign grain, but in June, 1800, the price was 134_s._ 5_d._, falling in August to 96_s._ 2_d._ on the crops promising well. The latter end of harvest proved wet, much of the grain being lost, so that the price per quarter of wheat rose to 133_s._ in December. There was much suffering, and some rioting. Parliament met on the 11th November, 1800, on account of the dearth, the opinions of the members being much divided as to the causes of the high prices. In March, 1801, wheat was at 156_s._ 2_d._ per quarter, beef from 10_d._ to 10½_d._ per pound, mutton 11_d._ to 12_d._ per pound. It is to this year, when the quartern loaf was at one-and-eightpence, that a comparison by Arthur Young belongs, showing the great change in the purchasing power of wages[288]. By the end of summer, 1801, wheat rose to 180_s._, and the quartern loaf was for four weeks at 1_s._ 10½_d._

Whatever statistics were then kept of fever-cases, show a decided rise in the years 1800 and 1801:

Manchester Glasgow London House of Royal Newcastle Bills of Recovery Infirmary Dispensary Mortality Year (fever-cases) (fever-cases) (fever-cases) (fever-deaths)

1796 371 43 201 1547 1797 339 83 65 1526 1798 398 45 67 1754 1799 364 128 -- 1784 1800 747 104 -- 2712 1801 1070 63 425 2908 1802 601 104 -- 2201 1803 256 85 352 2326 1804 184 97 255 1702 1805 268 99 74 1307

The London Fever Hospital was not opened until February, 1802, a small house in Gray’s Inn Lane containing sixteen beds. It came at the end of the epidemic, and was in small request during the next fifteen years. The same epidemic at Leeds was the occasion of opening a House of Recovery there in 1804, twenty-five years after Lucas had first called for it. The state of affairs in Leeds, which at length moved the richer classes to that step, is thus described by Whitaker[289]:

“In the years 1801 and 1802 an alarming epidemic fever spread in Leeds and the neighbourhood. The contagion extended so rapidly and proved so fatal that some hundreds were affected at the same time, and two medical gentlemen, with several nurses, fell victims to the disease.... In 1802 whole streets were infected house by house; in one court, of crowded population, typhus raged for four months successively.”

One of the Leeds physicians, Dr Thorp, seized the occasion to urge the need of a fever hospital, in a pamphlet written in 1802, in which he said:

“In a visit made a few days ago to those abodes of misery, I saw in one particular district upwards of twenty-five families ill in contagious fever. In some houses two, in others six or seven [families] were confined, many of whom appeared to be in extreme danger.” The superintendent of the sick poor stated to Dr Thorp “that sixty families in epidemic fever are under his care at this time. New applications are making daily. In some families three, in others six or seven, are in the disease. Forty persons in fever have applied to him for medical aid within the present week[290].”

The wonder is that, with the enormous prices of food, things were not worse. At the time when provisions were dearest, work was slack in several industries. A commercial report of 1 April, 1801, speaks of the trade of Birmingham as very distressed, a large proportion of the men being out of work; the ribbon trade of Coventry was deplorable, and the woollen trade of Yorkshire still worse. Evidence of epidemic typhus in various parts of England came out in connexion with the reports on influenza in 1803. Holywell, in Flintshire, with a large cotton-making industry, had not been free from a bad kind of typhus for two years previous to the influenza of 1803[291]. In Bristol there was a good deal of fever in 1802-3, which found its way, through domestic servants, into good houses in Clifton, “and proved fatal in some instances[292].” It is probable that these are only samples, the writings on epidemics being singularly defective at this period. The following, dated 10th April, 1802, by a surgeon at Earlsoham, near Framlingham, Suffolk, gives us a glimpse of malignant contagious fever in a farm-house:

“The most prevailing epidemics for the last twelve months have been typhus maligna and mitior, scarlatina anginosa, measles, and mumps. Many of the former have proved alarmingly fatal in several of our villages, whilst those of the second class of typhoid fevers have put on the appearance of the low nervous kind attended with great prostration of strength, depression of spirits, loss of appetite, etc., which frequently continue many weeks before a compleat recovery ensues.” Five cases, of “the most malignant kind of typhus,” occurred in a farmer’s family: one of the sons, aged eighteen, died in a few days with delirium, and black sordes of the mouth, tongue and throat; then the father, two daughters, and another son, took the infection but all escaped with their lives. Of four persons who nursed them, one caught the fever, and died. Four persons in a neighbouring family, who visited them, took infection, of whom two died[293].

There was perhaps nothing very unusual in such instances of country fevers at the beginning of the century. The incident is exactly in the manner of one that figures prominently in a story of Scottish life and customs at the same period, which long passed current as a faithful picture and as enforcing a much-needed moral[294].

Comparative immunity from Fevers during the War and high prices of 1803-15.

From 1803 to 1816 there was comparatively little fever in this country. This was notably the case in London, but it was also true of all the larger towns where fever-hospitals had been established, and it was as true of Ireland as of England. This was, indeed, a time of great prosperity, which reached to all classes, the permanent rise of wages having more than balanced the increased cost of the necessaries of life. The following prices of wheat will show that a dear loaf did not necessarily mean distress while the war-expenditure lasted:

Prices of wheat (from Tooke).

s. d.

1802 57 1

1803 52 3

1804 Lady Day 49 6 Dec. 86 2

1805 Aug. 98 4 Dec. 74 5

1806 73 5

1807 Nov. 66

1808 May 73 6 Dec. 92

1809 March 95 July 86 6 Dec. 102 6

1810 June 113 5 Dec. 94 7

1811 June 86 11 Nov. 101 6

1812 Aug. 155 Nov. 113 6

1813 Aug. 112 Dec. 73 6

1814 July 66 5

1815 Dec. 53 7

1816 May 74 Dec. 103

1817 June 111 6

1817 Sept. 77 7

1818 Dec. 78 10

1819 Aug. 75

1820 72

1821 July 51 Dec. 50

1822 42

1823 Feb. 40 8 June 62 5 Oct. 46 5 Dec. 50 8

1824 65

The only years in the period from 1803 to 1816 in which there was some slight increase of fever were about 1811-12. There was undoubtedly some distress in the manufacturing districts at that time, owing to the much talked-of Orders in Council, which had the effect of closing American markets to British manufactures[295].

The small amount of fever in London between the year 1803 and the beginning of the epidemic of 1817-19 rests on the testimony of Bateman[296], who in 1804 took up Willan’s task of keeping a systematic record of the cases at the Carey Street Dispensary. He has only two special entries relating to typhus: one in the autumn of 1811, when some cases occurred in the uncleanly parts of Clerkenwell and St Luke’s (“but I have not learned that it has existed in any other districts of London”); the other in October and November 1813, when there was more typhus among the Irish in some of the filthy courts of Saffron Hill, near Hatton Garden, than for several years past, the infection having spread rapidly and fatally in several houses. The best evidence of this lull in typhus in London is the almost empty state of the new fever-hospital:

Year Admissions

1802 164 1803 176 1804 80 1805 66 1806 93 1807 63 1808 69 1809 29 1810 52 1811 43 1812 61 1813 85 1814 59 1815 80 1816 118 1817 760

Until it was removed to Pancras Road, in September, 1816, the London fever-hospital had only sixteen beds. But Bateman says that no one was refused admission, and that for several years the house was frequently empty three or four weeks together. Also at the Dispensary, in Carey Street, he had an opportunity during the period 1804-1816,

“Of observing the entire freedom from fevers enjoyed by the inhabitants of the numerous crowded courts and alleys within the extensive district comprehended in our visits from that charity.” And again, writing in the winter of 1814-15, Bateman says: “To those who recollect the numerous cases of typhoid fevers [this term did not then mean enteric] which called for the relief of dispensaries twelve or fourteen years ago, and the contagion of which was often with great difficulty eradicated from the apartments where it raged, and even seized the same individuals again and again when they escaped its fatal influences, the great freedom from these fevers which now exists, even in the most close and filthy alleys in London, is the ground of some surprise.” And once more, in the summer of 1816, just as the new epidemic period was about to begin, he says: “The extraordinary disappearance of contagious fever from every part of this crowded metropolis during the long period comprehended by these Reports [since 1804], cannot fail to have attracted the attention of the reader.”

Bateman concluded, not without reason, that this immunity of London from fever was due to the high degree of well-being among the poorer classes in times of plenty; and although he made out that the poor of Dublin, Cork and some Scotch towns did not profit by times of plenty so much as those in London, yet his reason for the abeyance of fever from 1804 to 1816 applied to England, Ireland and Scotland at large, and was doubtless the true reason.

The following figures from Manchester[297], Leeds[298] and Glasgow[299] hospitals, as well as the Irish statistics elsewhere given, are closely parallel with those of London:

Manchester House of Recovery.

Year Cases Deaths

1796-7 371 40 1797-8 339 16 1798-9 398 27 1799-1800 364 41 1800-1 747 63 1801-2 1070 84 1802-3 601 53 1803-4 256 33 1804-5 184 34 1805-6 268 29 1806-7 311 33 1807-8 208 15 1808-9 260 21 1809-10 278 30 1810-11 172 15 1811-12 140 18 1812-13 126 13 1813-14 226 17 1814-15 379 29 1815-16 185 14 1816-17 172 6

Leeds House of Recovery.

Year Cases Deaths

1804 (2 mo.) 10 0 1805 66 6 1806 75 2 1807 35 1 1808 80 3 1809 93 8 1810 75 14 1811 92 4 1812 80 12 1813 137 11 1814 79 4 1815 146 15 1816 121 13 1817 178 8 1818(10 mo.) 254 20

Glasgow Royal Infirmary (Fever Wards).

Year Cases

1795 18 1796 43 1797 83 1798 45 1799 128 1800 104 1801 63 1802 104 1803 85 1804 97 1805 99 1806 75 1807 25 1808 27 1809 76 1810 82 1811 45 1812 16 1813 35 1814 90 1815 230 1816 399 1817 714 1818 1371

Even such fever as there was in Britain from 1804 to 1817 was not all certainly typhus. The high death-rates at the Manchester fever-hospital in 1804 and 1805 (1 death in 7·5 cases and 1 death in 5·25 cases) may mean a certain proportion of enteric cases in those years. “From 1804 to 1805,” says Ferriar, “many cases were admitted of a most lingering and dangerous kind.... Many deaths took place from sudden changes in the state of the fever, contrary to the usual course of the disease, and only imputable to the peculiar character of the epidemic. Similar cases occurred at that time in private practice.” Next year, 1806, there was an epidemic among the troops at Deal, described under the name of “remittent fever,” which Murchison claims to have been enteric[300]. In September, 1808, says Bateman, several were admitted into the London House of Recovery, with malignant symptoms; “and some severe and even fatal instances occurred in individuals in respectable rank in life.” He still uses the name of typhus; but he is aware that the cases of continued fever, especially in the summer and autumn of 1810, had often symptoms pointing to a bowel-fever rather than to a head-fever[301].

The years 1807 and 1808 appear to have been the most generally unwholesome during this period of comparative immunity from fever; they were marked by the occurrence of dysenteries, agues, and infantile remittents, as well as of fevers of the “typhus” kind. The chief account comes from Nottingham[302]. The cases of “typhus” there were very tedious, but not violent, nor attended with any unfavourable symptoms, only one case having petechiae, and all having diarrhoea. The following table of admissions for various kinds of fever (as classified by Cullen) at the Nottingham General Hospital, 25 March, 1807, to 25 March, 1808, shows the preponderance of “synochus” and next to it, of infantile remittent:

Admitted to the Nottingham General Hospital, 1807.

Intermittent fever 7 Synocha 10 Typhus 27 Febris nervosa 26 Synochus 155 Febris infantum remittens 88 Dysentery 5

The state of war in the Peninsula was favourable to epidemic or spreading diseases, and there is a good deal to show that such diseases did exist among the British troops[303]. But there is only one good instance of England getting a taste of that experience of war-typhus which the Continent had to endure for many years. This was on the return of the remnant of the army after the defeat at Corunna on 16 January, 1809. The troops were crowded pell-mell on board transports, which had a very rough passage home. Dysentery broke out among them, and was the most urgent malady when they landed at Plymouth in a state of filth and rags. Typhus fever followed, but in the first three weeks at Plymouth, to the 18th of February, it was not of a malignant type, only 8 dying of it in the Old Cumberland Square Hospital; in the next three weeks, 28 died of it there. Up to the 27th of March, 1809, the sick at Plymouth from the Corunna army numbered 2432, of whom 241 died. Of 4 medical officers, 3 took the contagion, of 29 orderlies, 25 took it. The fever was in some cases followed by a relapse, which was more often fatal than the original attack[304]. This was a typical instance of typhus bred from dysentery or other incidents of campaigning, a contagion more dangerous to others than to those who had engendered it. “Within a few yards of the spot where I now write,” says Dr James Johnson, of Spring Gardens, London, “the greater part of a family fell sacrifices to the effects of fomites that lurked in a blanket purchased from one of these soldiers after their return from Corunna[305].” In August, 1813, an Irish regiment passing through Leyburn, a small market-town of the West Riding of Yorkshire, in an airy situation, was obliged to leave behind a soldier ill of typhus, who died of the fever after a few days. The infection appeared soon after in the cottages adjoining, and remained in that end of the town for several months, choosing the clean and respectable houses. In a farmer’s family, a son, aged twenty-nine, died of it, while another son and two daughters had a narrow escape. The disease appeared also in the village of Wensby, a mile distant, and in other villages. Few lives were lost[306].

These were, perhaps, not altogether solitary instances in Britain of typhus spread abroad by the movements of troops during the great French war. Let us multiply such instances by hundreds, and we shall vaguely realize the meaning of the statement that the period of the Napoleonic wars, and more particularly the period from the renewal of the war in 1803 until its close in 1815, was one of the worst times of epidemic typhus in the history of modern Europe. It was precisely in those years that England, Scotland and Ireland enjoyed a most remarkable degree of freedom from contagious fever.

The Distress and Epidemic Fever (Relapsing) following the Peace of 1815 and the fall of wages.

The long period of comparative immunity from typhus near the beginning of the 19th century was first broken, both in Great Britain and in Ireland, by the very severe winter of 1814-15; but it was not until the great depression of trade following the peace of 1815 (which made a difference of forty millions sterling a year in the public expenditure) and the bad harvest of 1816 that typhus fever and relapsing fever became truly epidemic, chiefly in Ireland but also in Scotland and England. The lesson of the history is unmistakable: with all the inducements to typhus from neglect of sanitation in the midst of rapidly increasing numbers, there was surprisingly little of the disease so long as trade was brisk and the means of subsistence abundant. The reckoning came in the thirty years following the Peace.

In London, says Bateman[307], the epidemic began in the autumn of 1816, before the influence of scarcity was acutely felt, in the courts about Saffron Hill, the same locality in which he mentioned fever in the winter of 1813-14 among the poor Irish. But this means little more than that the Irish, whether in Ireland or out of it, are the first to feel the effects of scarcity in producing fever. At the very same time that it began among them in Saffron Hill, it began among some young people at a silk factory in Spitalfields. In March, 1817, there was a good deal more of it in Saffron Hill, as well as among the silk-weavers in Essex Street, Whitechapel, in Old Street, in Clerkenwell, and in Shadwell workhouse. Many poor-houses, and especially those of Whitechapel, St Luke’s, St Sepulchre’s and St George’s, Southwark, were getting crowded in 1817 with half-starved persons, among whom fever was rife in the summer and autumn. There was also much of it in the homes of working people in the eastern, north-eastern and Southwark parishes, with more occasional infected households in Shoe Lane, Clare Market, Somers Town and St Giles’s in the Fields (“in the filthy streets between Dyot Street and the end of Oxford Street”)[307]. The hospitals and dispensaries were fully occupied with fever, and the new House of Recovery in Pancras Road, with accommodation for seventy patients, was soon full. At the Guardian Asylum for young women, more than half of the forty inmates were seized with the fever in one week. The cases were on the whole milder than in ordinary years; of 678 admitted to the House of Recovery in 1817, fifty died or 1 in 13·5. In two-thirds of these patients the fever lasted two weeks or to the beginning of the third week; of the remaining third, a few lost the fever on the 7th, 8th or 9th day, a larger number on the 12th to the 14th day, while a considerable number kept it to the end of the third week or beginning of the fourth. Of the whole 678, only 75 had a free perspiration, and in only 19 of these was the perspiration critical so as to end the fever abruptly. The fever relapsed in 54 of the 678, a proportion of relapsing cases which seemed to Bateman to be “remarkably great[308].” In most the symptoms continued without break throughout the illness. Besides other febrile symptoms, there were pains in the limbs and back, aching of the bones, and soreness of the flesh, as if the patients had been beaten. There was a certain proportion of severe complicated cases of typhus. Bateman held that the differences in type depended on the differences of constitution, giving the following reason for and illustration of his opinion:

“Thus, in the instance of a man and his wife who were brought to the House of Recovery together, the former was affected with the mildest symptoms of fever, which scarcely confined him to bed, and terminated in a speedy convalescence; while his wife was lying in a state of stupor, covered with petechiae and vibices; in a word, exhibiting the most formidable symptoms of the worst form of typhus. Yet these extreme degrees of the disease manifestly originated from the same cause; and it would be equally unphilosophical to account them different kinds of fever and give them distinct generic appellations as in the case of the benign and confluent smallpox, which are generated in like manner from one contagion.” Besides this woman, only eight others had petechiae.

The House of Commons Committee were unable to find out with numerical precision how much more prevalent the fever was in 1817-18 than in the years preceding[309]. To their surprise they found that in six of the general hospitals of London, which admitted cases of fever, “no register is kept in the hospital to distinguish the different varieties of disease.” The apothecary of St Luke’s Workhouse told them that he attended, on an average of common years, about 150 cases of fever; in the last year [1817] the number rose to 600; and they were assured by several besides Bateman, that the great decrease of the deaths from “fever” in the London bills of mortality during a space of fourteen years at the beginning of the century (1803-17), was not a mere apparent decrease, from the growing inadequacy of the bills, but was a real decrease.

The epidemic which began in 1817 continued in London throughout the years 1818 and 1819, chiefly in the densely populated poorer quarters of the town. Two instances of the London slums of the time came to light before the House of Commons Committee on Mendicity and Vagrancy in 1815-16: firstly, Calmel’s Buildings, a small court near Portman Square, consisting of twenty-four houses, in which lived seven hundred Irish in distress and profligacy, neglected by the parish and shunned by everyone from dread of contagion; and, secondly, George Yard, Whitechapel, consisting of forty houses, in which lived two thousand persons in a similar state of wretchedness. The dwellings of the poorer classes in London at this period, before the alleys and courts began to disappear, were described thus generally by Dr Clutterbuck[310]:

“The houses the poor occupy are often large, and every room has its family, from the cellar to the garret. Thirty or forty individuals are thus often collected under the same roof; the different apartments must be approached by a common stair, which is rarely washed or cleansed; there are often no windows or openings of any kind backwards; and the privies are not unfrequently within the walls, and emit a loathsome stench that is diffused over the whole house. The houses are generally situated in long and narrow alleys, with lofty buildings on each side; or in a small and confined court, which has but a single opening, and that perhaps a low gateway: such a court is in fact little other than a well. These places are at the same time the receptacles of all kinds of filth, which is only removed by the scavenger at distant and uncertain intervals, and always so imperfectly as to leave the place highly offensive and disgusting.”

In England, generally, this epidemic of 1817-19 is somewhat casually reported. One writes from Witney, Oxfordshire, “on the prevailing epidemic,” which began there in July, 1818, among poor persons, in crowded, filthy and ill-ventilated situations. At first it was like the ordinary contagious fever of this country, “a disease familiar to common observation”; but afterwards it showed choleraic and pneumonic complications. Sometimes the parotid and submaxillary glands were inflamed; petechiae were absent[311]. The type of fever at Ipswich in the spring of 1817 was contagious (e.g. six cases in one family) and sthenic, or of strong reaction, admitting of bloodletting, according to the teaching which Armstrong, Clutterbuck and others had been reviving for fevers[312]. Those instances, one from Oxfordshire the other from Suffolk, must stand for many. Hancock says that the fever of 1817-19 “visited almost every town and village of the United Kingdom[313].” Prichard says that it began in Ireland, “where the distress was most urgent, and afterwards prevailed through most parts of Britain,” some of the more opulent also being involved in the calamity. As to its prevalence in the manufacturing towns of Yorkshire we have ample testimony. The Leeds House of Recovery, which had not been fully occupied at any time since its opening in 1804, received 178 cases in 1817, and 254 in the first ten months of 1818. Of the latter, 66 came from low lodging-houses, of whom upwards of 50 were strangers. Of 50 admitted in January, 1818, 20 came from four or five lodging-houses in March Lane, and from another locality equally bad--Boot and Shoe Yard; while the rest of the 50 in that month came from houses and streets in the same vicinity. March Lane was one of the worst seats of the great Leeds plague in 1645. By the month of April, 1820, the epidemic had decreased a good deal in Leeds, the cases becoming at the same time more anomalous[314].

The following is one of the Rochdale cases:

June 2, 1818, Alice Eccles, a delicate young woman living in a crowded and filthy court from which fever had not been absent for nearly a year, was bled to ten ounces, purged, and recovered. On September 20th the same woman returned, desiring to be bled again. She was labouring under her former complaint; “since her last illness she had been repeatedly exposed to contagion, or rather, she had been living in an atmosphere thoroughly saturated with infectious effluvia, the house in which she resided, and generally the room in which she slept, having had one or more cases of fever in them,” and the windows kept closed[315].

At Halifax in the summer of 1818, typhus (or relapsing fever) had increased so much that fever-wards were added to the Dispensary. It had been alarmingly fatal in a high-lying village near Settle. It was prevalent in Ripon, Huddersfield and Wakefield; and had been brought from Leeds to Atley. A Bradford physician visited 27 cases of fever in one day at a neighbouring village. Throughout Yorkshire, it was confined to the lower orders, and was not very fatal[316]. At Carlisle it began about July, 1817, and became somewhat frequent in the winter and spring following; of 457 cases treated from the Dispensary 46 died, or 1 in 10[317]. At Newcastle, a mild typhus (typhus mitior) broke out in the autumn of 1816, not in the poorer quarters, but mostly among the domestics of good houses in elevated situations. There was much privation at Newcastle, as elsewhere, at this time, among the poor. Murchison takes this fever of the autumn of 1816 at Newcastle to have been enteric or typhoid; but it is described as a simple continued fever, with vertigo, headache, and bloodshot eyes, lasting from five or six days to four or five weeks, ending usually without a marked crisis, and causing few deaths[318]. The epidemic continued in Newcastle for three years, the admissions to the Fever Hospital from 4 Sept. 1818, to 4 March, 1819, having been 160, with 12 deaths. Dr McWhirter wrote, in April, 1819, that he saw on his rounds as dispensary physician “too many of the obvious causes of fever,” including the filth and wretchedness of the poor inhabitants: “one rather wonders that so many escape it than that some are its victims[319].”

Thus far there has been little besides Bateman’s essay to indicate the nature or type of the fever in England. In Ireland it was to a large extent relapsing fever, and, as we shall see, it was so also in Scotland. Bateman found less than a tenth part of the cases at the London Fever Hospital to have relapses, which was an unusually large proportion, in his experience. Elsewhere in England the tendency to relapse was either wanting or the relapses were described or accounted for in other ways; to understand this it has to be kept in mind that the epidemic was the occasion of a great revival of blood-letting, a practice which had fallen into disuse in fevers since the last half of the 18th century, and was something of a novelty in 1817. The fever of that year was undoubtedly abrupt in its onset, strong, “inflammatory,” with full bounding pulse, beating carotids, hot and dry skin, intense headache, suffused eyes, and the like symptoms, which seemed to call for depletion. The common practice was to bleed ad deliquium, which meant to ten, or fourteen, or twenty ounces, at the outset of the fever. There was hardly one of the writers upon the epidemic, unless it were Bateman, an advocate of the cordial and supporting regimen, who did not consider the stages or duration of the fever as artificially determined by the blood-letting, and not as belonging to the natural history.

In order to show how much the treatment by blood-letting dominated the view of the fever itself, of its type, its stages, or duration, I shall take the Bristol essay of Prichard, who adopted phlebotomy, as he says, at first tentatively and with some fear and trembling, but at length practised it vigorously, having found it to answer well[320]. The epidemic of fever in Bristol began about June, 1817, and lasted fully two years. The first cases brought to St Peter’s Hospital, which was the general workhouse of the city, were of wretched vagrants found ill by the wayside or abandoned in hovels. About the same time forty-two felons in the Bristol Newgate, “one of the most loathsome dungeons in Britain, perhaps I might say in Europe,” were infected, of whom only one died, and he of a relapse. From June, 1817, to the end of 1819, there were 591 cases in the poor’s house, 647 in the General Infirmary, and 975 treated from the Dispensary, making 2213 cases, of which a record was kept. But there were also many cases in private practice among the domestics, children, and others in good houses, such as those on Redcliff Hill. The cases in the poor’s house were classified by Prichard as follows:

1817 1818 1819

Simple Fever 22 45 40 with cephalic symptoms 24 27 25 " pneumonic symptoms 7 10 16 " gastric symptoms 3 11 5 " enteric symptoms 3 4 5 " hepatic symptoms 5 3 3 exhausted and moribund 1 6 4 not characterised 30 44 2 --- --- -- 95 150 105 --------------- Of these there died 20 16 11

The “genuine form,” or ground-type, according to Prichard, was “simple fever,” of which the cases with cephalic symptoms were merely the more protracted or more serious. “The pneumonic, hepatic, gastric, enteric and rheumatic forms may be regarded as varieties”--the gastric and hepatic being cases mostly in summer with jaundice, the enteric in autumn and winter with diarrhoea and dysentery. Nearly all these patients were bled within four or five days from the commencement of the disease: “in a very large proportion of the cases the fever was immediately cut short”; when it did not end thus abruptly, its symptoms declined gradually, and the attack was over within eight or ten days. After the blooding “sleep very frequently followed, and a partial or sometimes a complete remission of the symptoms.” Only one case of relapse is mentioned, No. 118, of the year 1818, and that was a relapse in a very prolonged case: the patient was admitted on 6 October, had a relapse on 18 November, and was discharged on 23 December. Prichard has not one word in his text to suggest relapsing fever; the bulk of his cases were simple continued fever, with or without cephalic or other local symptoms, ending in four, six, eight or ten days, while some were cases of typhus gravior. The fever was undoubtedly contagious: it spread through whole families, and in St Peter’s Hospital itself it attacked seventy of the ordinary pauper inmates, including a good many lunatics.

The Epidemic of 1817-19 in Scotland: Relapsing Fever.

Let us now turn to the epidemic in Scotland, where the relapsing type was as marked as in Ireland, if not more so. The destitution in the Scots towns in the autumn of 1816, and following years, was fully as great as anywhere in the kingdom, although the peasantry of Scotland were not famine-stricken, as those of Ireland were. The state of the poorer classes in Edinburgh was graphically set forth in an essay by Dr Yule, in 1818[321], and in an article in Blackwood’s Magazine the year after. Vigorous efforts to relieve the distress were made by the richer classes, and a special fever-hospital was opened at Queensbery House, the admissions to which, together with the fever-cases at the Royal Infirmary, were as follows:[322]

Year Admitted Died Ratio of deaths

1817 511 33 1 in 15-16/33 1818 1572 75 1 in 21 1819 1027 30 1 in 34 (to 1 Dec.)

Of this epidemic several accounts were published at the time, including one by Welsh, superintendent of the fever hospital, which is dominated, like the Bristol account of Prichard, by the idea that blood-letting cut short the fever[323]. Christison, who had experience of the relapsing form in his own person[324], describes also two other forms mixed with the cases of relapsing fever: a mild typhus, the typhus mitior (typhus gravior being exceedingly rare in that epidemic), and a form which began like the inflammatory relapsing synocha, and gradually after a week put on the characters of mild typhus.

The admissions for fever to the Glasgow Infirmary, which was then the only charity that received fever cases, had been at a somewhat low level since the last epidemic in 1799-1801. They began to rise again with the distress of 1816:--

Admissions for Fever, Glasgow Infirmary.

Year Cases

1814 90 1815 230 1816 399 1817 714 1818 1371 1819 630 1820 289 1821 234 1822 229 1823 269

At the height of the epidemic in 1818 an additional fever hospital was opened at Spring Gardens, to which 1929 cases were admitted in that and the following year. Great efforts were made in Glasgow to “stamp out” the contagion by disinfectants and removal to hospital[325]; but the course of the epidemic seemed to follow the economic conditions more than anything else.

The outbreak at Aberdeen was later than in the south of Scotland, having begun in August, 1818. The infection was said to have been brought to the city by a woman who found a lodging in Sinclair’s Close. A group of houses in the close, covering an area of seventy by fifty feet and containing one hundred and three inmates, became the first centre of the fever. The scenes described are like those of the Irish epidemics: in one room, a man, his wife, and five children were lying ill on the floor; in another, a man, his wife and six children; in a third, a young girl, whose mother had just died of fever, was left with three infant brothers or sisters. More than three-fourths of the denizens of the close were “confined to bed in fever, and all the others crawling about during the intervals of their relapses.” The value of all the furniture and clothing belonging to 103 persons could little exceed £5. There was a horrible stench both within and without the houses (relapsing fever being remarkable for its odour). Yet this close was usually as healthy as any other part of the town. A House of Recovery, with sixty beds, was opened in the Gallowgate, and thirty beds were given up to fever-cases in the Infirmary of the city. Besides those ninety hospital cases at the date of 17 December, 1818, it was estimated that were three hundred more. Begging had been put down, so that the contagion had not spread to the richer classes. Despite these removals to hospital, the epidemic became more general about the New Year, 1819, and of a worse type; two physicians died of it, and some others had a narrow escape. At the outset, the fever had been of the relapsing kind--“subject to relapses for a third and fourth time, more especially when they return too early to their usual labour[326].” At a later period the epidemic seems to have become ordinary typhus, as it did also in Ireland and elsewhere; and it was called typhus in the essay upon it by Dr George Kerr[327].

The extent of this epidemic of 1818-19 over Scotland generally is not known; but the following notice of it in a country parish of Forfarshire was probably a sample of more that might have been given.

Early in the summer of 1818 an epidemic of continued fever appeared in a manufacturing village seven miles from Lintrathen; it attacked at first young and plethoric subjects, and ran through whole families. In August it reached Lintrathen parish, in which one practitioner had forty cases, with no deaths. The fever was of an inflammatory nature; the bulk of the cases fell in October, and were nearly all of young women. They were bled to syncope, which then meant usually to 32 ounces. There was a prejudice against blooding among the old people, who said “they had had many fevers, and in their time no such thing was ever allowed.” But, according to the doctor, this withholding of the lancet had the effect of protracting their illnesses: “they toasted sick for six weeks, and were often confined to bed for months[328].”

The epidemic of 1817-19 brought into prominence two questions, the one theoretical, the other practical. The theoretical question (not debated at the time) was touching the place or affinities of relapsing fever in the nosology. Christison maintained that it was the inflammatory fever, or synocha of Cullen, showing a peculiar tendency to relapse. The fever of the same epidemic period in England was also undoubtedly a fever of strong or inflammatory reaction, corresponding to Cullen’s definition of synocha, but it relapsed much less frequently than in Ireland and Scotland in the same years. Even in Ireland and Scotland there were always many cases of “relapsing fever” which did not relapse. The law of its relapses was reduced to great simplicity by a physician learned in fevers, Dr John O’Brien, in the Dublin epidemic of 1827. The bulk of that epidemic was a fever of short periods--three, five, seven or nine days, most of the attacks ending on the fifth or seventh night of the fever. The attack being ended in a free perspiration, there might or might not happen, after an interval, a relapse, and again a relapse after that, or even a third. The five-days’ fever was more liable to relapse than the seven-days’ fever, the seven-days’ fever more liable than the nine-days’ fever, the fevers of the longest periods not liable at all. In other words, the sooner the patient “got the cool,” by a night’s sweating, the more liable he was to have one or more relapses[329].

The logical position of relapsing fever was completed by Dr Seaton Reid, of Belfast, when he proposed, in his account of the epidemic in 1846-7, to call it Relapsing Synocha[330]. Other fevers have shown a tendency to relapse in certain circumstances. Three fevers which have many points in common, the sweating sickness, dengue and influenza, are all subject to relapses. It was doubtless of the sweating sickness that Sir Thomas More was thinking when he wrote: “Considering there is, as physicians say, and as we also find, double the peril in the relapse that was in the first sickness.” Plague, also, might relapse, or recur in an individual once, twice, three times, or oftener in the same epidemic season. Enteric is an instance of a long-period fever which has at times a tendency to relapses[331]. None of these, however, can dispute the claim of relapsing synocha to be relapsing fever par excellence. For whatever reason, the short-period fever of times of distress and dearth or famine has shown a peculiar tendency to relapse, and has shown that tendency more in the 19th century than in the 18th, and more among the Irish and Scotch poor than among the English.

The practical question that came to the front in the epidemic fever of 1817-19 was that of isolation hospitals for the sick. It was thus stated by Dr Millar, of Glasgow, in a letter of advice to the authorities of Aberdeen:

“It is only by a universal, or nearly universal sweep of the sick into Fever Hospitals, joined to a universal or nearly universal purification of their dwellings, that anything is to be hoped for in the way of suppressing our epidemic. So far as this grand object is concerned, all the rest is folly: it is worse than folly[332].”

This was the well-meant but somewhat fanatical application of a trite and commonplace notion. It was well understood by reflective persons at that time, who were quite sound on the contagiousness of fever, that the whole question of segregating the poor in fever hospitals was beset with difficulties, not merely of expense but also of expediency. A Select Committee of the House of Commons sat upon it in 1818, and published their report, with the minutes of evidence, on the 20th May. So much had been said in Parliament by Peel and others, and said so truly, of the spreading of fever all over Ireland by whole families turned adrift in beggary, that the Select Committee were full of ideas of contagion, and of the great opportunity of suppressing fever by destroying its germs or seeds. But they had soon occasion to learn that a fever may be potentially contagious, yet not contagious in all circumstances, and that segregation in fever hospitals had a rival in dispersion through general hospitals. Half-a-dozen London physicians of position, answering respectively for Guy’s, St Thomas’s, the London, St Bartholomew’s, St George’s, the Westminster and the Middlesex Hospitals, declared that they mixed their cases of contagious fever in the ordinary wards among the other patients; and when asked by the astonished Committee whether the fever did not spread, they answered one after another with singular unanimity, “Never,” which under cross-examination, became in one or two instances, “hardly ever,” as, for example, in the evidence for St Thomas’s Hospital, where a sister and a nurse had caught fever and died. The point of this London evidence was that the great safeguard against febrile contagion was free dilution with air, and that the great provocation of a contagious principle was to “concentrate” the cases of fever[333]. The Bristol experience in the same epidemic, although it did not come before the Select Committee, was wholly in agreement with medical opinion in London. The fever-cases there were received either into St Peter’s Hospital, which was the city poor-house, or into the General Infirmary. The former was an old irregular building, badly ventilated, in which the contagion spread freely to the ordinary inmates and became very virulent. Contrasting with the apartments of the old poor’s house, the wards of the Bristol General Infirmary were spacious, lofty, well-ventilated:

“Here the patients labouring under fever were dispersed among invalids of almost every other description; so that, whatever effluvia emanated from infected bodies became immediately diluted in the mass of air free from such pollution. Here, accordingly, no instance occurred of the propagation of fever. None of the nurses were attacked, nor were patients lying in the adjacent beds in any instance infected, though cases of the worst description, some of them exhibiting all the symptoms of typhus gravior, were placed promiscuously among the other patients, scarcely two feet of space intervening between the beds[334].”

The same practice was kept up in the Edinburgh Infirmary until 1858 or longer; Christison, who gives a diagram of an ordinary ward with four fever-beds in it, declared in 1850 that there had been no spread of fever for fifteen years before, except on one occasion, when the rules of the house were neglected[335]. The bold policy of dispersing fever-patients among the healthy was begun by Pringle and Donald Monro during the campaigns of 1742-48 and 1761-63 in the Netherlands and North Germany. They found that concentration raised the contagion to high degrees of virulence and that dispersion weakened it to the point of non-existence, Monro’s success at Paderborn in 1761 having been of the most signal kind[336].

The Select Committee of 1818 were more influenced by what they were told of the good effects of the earliest Houses of Recovery, at Waterford, Manchester and other places in the end of the last century. For several years after their opening they were little needed, the epidemic which gave the immediate impulse to their establishment having subsided in due time both in the towns provided with Houses of Recovery and in the innumerable places where no such provision had been made. The recommendations of the Committee do not appear to have been carried out; for the London Fever Hospital, in Pancras Road, which had been enlarged to seventy beds when the epidemic began in 1817, remained the only special fever hospital in London until the establishment of the hospitals of the Metropolitan Asylums Board in 1870[337].

* * * * *

The confusion of commerce, depression of trade and lack of employment which followed the Peace of Paris, and gave occasion to the British and Irish epidemic fevers of 1817-19, gradually righted themselves. The price of wheat, which would have been still higher after the four-months drought of 1818, but for large imports, gradually fell, and was about 50_s._ in 1821, and 40_s._ in the winter of 1822-23. After that, it rose somewhat again, and the third decade of the century, in the middle of which occurred the great speculative crash of 1825, was on the whole a hard time for the working classes. The history of fever has few illustrations between the epidemic of 1817-19 and that of 1826-27, excepting the great famine-fever of Connemara and other parts of the West of Ireland in 1822, elsewhere described, which coincided with a somewhat prosperous time in England and called forth a princely charity[338].

The Relapsing Fever of 1827-28.

The epidemic of relapsing fever which was at a height in Dublin in 1826, did not culminate in Edinburgh, Glasgow, and other towns of Scotland until 1828. It was a somewhat close repetition of the epidemic of 1817-19, except that it was chiefly an affair of the towns, owing to depression of trade and want of work following the great crash of commercial credit in 1825-26. In Glasgow, the admissions for fever to the Royal Infirmary began to rise in 1825[339]:

Glasgow: Admissions for Fever.

Year

1824 523 1825 897 1826 926 1827 1084[340] 1828 1511[340] 1829 865 1830 729

At Edinburgh the cases of fever treated in hospital were fewer in ordinary years than at Glasgow, but they rose to a higher point in the epidemic years[341]:

Edinburgh: Admissions for Fever.

Year

1824 177 1825 341 1826 (nine months) 456 1827 1875 1828 2013 1829 771 1830 346

Christison gives the following account of the epidemic in Edinburgh in 1827-28:

“Like that of 1817-19, it arose in Edinburgh during a protracted period of want of work and low wages among the labouring classes and tradespeople; it prevailed only among the working classes and unemployed poor--in the Fountainbridge and West Port districts, the Grassmarket ‘closes,’ the Cowgate and the narrow ‘wynds’ descending on either side of the long sloping back of the High Street and Canongate.” The fever had the same three types as in 1817-19--many cases of inflammatory, or relapsing, or synocha, a few of low fever (typhus), and some between the two--militant or inflammatory for a week, then becoming low, and running the continuous course of typhus.... “The inflammatory fever presented the same extreme violence of reaction as in the former epidemic--the same tendency to abrupt cessation, with profuse sweating--the same liability to return abruptly a few days afterwards--and the same disposition to depart finally in a few days more, and again abruptly with free perspiration. The cases of typhus were more frequently severe than in 1818-19. Icteric synocha occurred also oftener, although far from frequently[342].”

The epidemic of relapsing fever in 1826-28, which made a great impression in the towns of Ireland and Scotland, has left few traces in specially English records. But it is clear that there was some increase of fever about the same time in London; and it becomes a matter of interest, as well as of no little difficulty, to ascertain the type or types of the same. It was just after this quasi-epidemic in London that Dr Burne published his essay on fevers, the preface bearing the date of 28th February, 1828[343]. The materials of this essay came from Guy’s Hospital, and they were both clinical and anatomical. The author seeks to find a common name for all varieties of continued fever, the name that he chooses being “Adynamic Fever.” “By far the greater number of cases,” he says, “are of the first or second degree only of severity, and not dangerous.” These were cases of “simple continued fever,” or fever of short duration, with flushed face, suffused eyes and other signs of the “inflammatory” type, or of synocha. Although Burne does not give the exact proportion of cases with relapse, as Bateman had done for the London epidemic of 1817-18, yet he makes it clear that relapses did occur, and he discusses the phenomenon in a manner which makes his testimony interesting: “Convalescents are more liable to a relapse after the adynamic fever than after any other disease; and this may be accounted for by the very enfeebled and exhausted state in which the powers of the system are left.” His relapses were obviously a return of the original fever, beginning again suddenly in the midst of convalescence with flushing of the face, headache, dry tongue, and scanty urine, and with a great access of febrile heat in the night, a disturbance of the system which generally continued for several days, while in some it went off sooner with a diarrhoea. He assigned three principal causes for the relapse--overloading the enfeebled but craving stomach, walking out in the open air too soon, and giving way to emotion[344].

The references to relapse apply almost certainly to fevers of the shorter periods (synocha or “inflammatory” fever), and not to those cases of enteric fever which did undoubtedly occur in the practice of Guy’s Hospital in the same seasons.

Typhoid or Enteric Fever in London, 1826.

The identification of enteric fever and relapsing fever respectively, or the separation of each from typhus, became actual in Britain at one and the same time. I have already said all that seems necessary as to the earlier appearances of relapsing fever on the stage of epidemiological history. This will be the fitting point in the chronology, the third decade of the 19th century, to bring in the question of enteric or typhoid fever. As to its identification, or recognition as a distinct species, that was not really completed, to the satisfaction of everyone, until the elaborate analysis of the symptoms respectively of typhus and enteric fevers by Sir William Jenner in 1849-51[345]. But, for ten years before that, the co-existence with maculated typhus of a different long-period fever, having abdominal symptoms and abdominal lesion, had been recognised, and the characteristic ulceration or sloughing of the lymph-follicles of the ileum, with sphacelation of the mesenteric lymph-glands, had been clearly described by several London physicians and depicted in coloured plates, in the years 1826 and 1827, during an unusual prevalence of such cases in London. The authentic history of enteric fever in Britain really begins with these writings by physicians of St George’s and Guy’s Hospitals. But, as it is improbable that the type of fever was absolutely new in the years 1825 and 1826, it may be asked whether the enteric type cannot be discovered in the old accounts of British fevers, and if so, whether we may assume in the past as much enteric fever relatively to spotted typhus, relapsing fever, or simple continued fever, as in the period after 1850.

Having adverted to this point from time to time in the preceding history as it arose, for example in connexion with Willis’s fever of 1661, Strother’s fever of 1727-29, the Rouen fever of 1750, and other instances both in children (remittent or convulsive or comatose fever of children) and in adults, I shall not recapitulate farther back than the beginning of the 19th century.

There was a certain amount of post-mortem observation in the 18th century, especially in camp sicknesses, by Pringle and others; but there is no trace of intestinal ulceration among their fatal fevers. It was found, however, in the epidemic of 1806 among the troops at Deal, and it is probable that Ferriar’s cases at Manchester about 1804, and Bateman’s cases of continued fever in London from 1804 to 1816, were in some part enteric, although the anatomical test is wanting. That was a period when there was singularly little of the old London fever in the houses of the poorer class. Then came the remarkable “constitution” of relapsing or simple continued fever, from about 1816 to 1828, the relapsing character of which was far more obvious in Ireland and Scotland, than in London, Bristol, or elsewhere in England, but was not altogether unobserved in London, whether in 1817-19 or in 1827-28. The relapsing type disappeared after that for fifteen or twenty years, and was replaced by typhus more maculated than had been seen for many years. But, before the relapsing or simple continued fever disappeared for a time, enteric fever was seen in London in company with it.

The chief season of enteric fever in London was the autumn of 1826, following a long period of great drought and heat. The remarkable weather of that season was the same in England, Ireland and Scotland, and is thus described for the last by Christison:

“The spring and summer seasons of that year were remarkable for the extraordinary drought and heat which prevailed for many continuous months. No such seasons could be recollected by anybody, and assuredly there has been nothing similar in this country since.... The fine weather set in with the beginning of March, and continued, with scarcely a check, well into the autumn.... The drought prevailed and the heat increased till the middle of June, when a thunderstorm with heavy rain cooled the air for a day or two. But the heat then became greater than ever, and there was continuous sunshine and no rain till after the middle of July, when again there was thunder and rain, after which sun, heat and drought ruled the season once more.” The shade temperature at Edinburgh was 84° Fahr., at 3 p.m. on three successive days of July[346]. The two summers preceding had also been exceptional, that of 1824 having been hot and moist, that of 1825 hot and dry, with dysentery in Dublin.

In August, 1826, Dr Cornwallis Hewett, of St George’s Hospital, published ten fatal cases of enteric fever, four of which had occurred in his own practice, six in the practice of his colleagues[347]. The first was admitted on 23 April, 1825, the latest on 3 July, 1826. While his paper was under hand, he had read in the Medico-chirurgical Review for July, 1826, some extracts from Bretonneau’s paper on “Dothiénentérite” (enteric fever), and he pronounced the London cases to be the same as those recently observed at Tours. Several other cases occurred at St George’s Hospital in the autumn of 1826, three of them reported by Dr Chambers[348]. At the very same time, there was a run of enteric cases at Guy’s Hospital. Dr Bright says: “Fever occurred with considerable frequency among the patients who presented themselves for admission into Guy’s Hospital, during the months of October, November and December, 1826. On the whole, the disease was not severe.” The more comprehensive account of these cases was given by Burne, early in 1828, from which it appears that the bulk of them were fevers of the shorter period, that there were relapsing cases among them, and that some were cases of enteric fever, verified by post-mortem examination[349]. It was the enteric cases that attracted the notice of Dr Bright, who says nothing of the relapsing cases, or of cases of simple continued fever. The fact that the intestinal mucous membrane may become diseased during fever was, he says, “long known in particular cases, but never suspected to be so general till brought into view by the French physicians, and which has lately been illustrated in this country with great beauty [this does not mean in plates] by the pens of my able and assiduous friends Dr Chambers and Dr Hewett.” He gives ten fatal cases, with coloured plates of the intestinal or mesenteric lesion in some of them, the earliest coloured plate having been made from a case admitted on 13 October, 1825, and the most typical plate of the sloughing Peyer’s follicles from a case admitted on 25 November, 1826. He gives also eleven cases of recovery, to show the benefit of treating the diarrhoea by calomel[350]. Nearly all the cases occurred in the end of the year, either of 1825 or 1826; and Burne confirms this when he says that the cases with enteric lesion were found at Guy’s Hospital only in autumn. Some two years after, in 1830, Drs Tweedie and Southwood Smith, physicians to the London Fever Hospital, described cases of fever with ulcerated intestine and sphacelated mesenteric glands. After that, the interest shifted to typhus, which reappeared in London of an unusually maculated type; so that the years 1826-30 make a somewhat distinct period in which the new fever, with enteric lesion, was an engrossing medical topic. It is tolerably certain that it was the unusual seasons of 1825 and 1826 which brought enteric fever into prominence; while, as soon as it became frequent, it could hardly have escaped the systematic apparatus of clinical case-taking and post-mortem examination, with preservation and drawing of specimens, for which Guy’s Hospital was already noted under the influence of Bright and his colleagues, and in which the staff of St George’s Hospital would appear to have been not less competent. Although Dr Hewett, in 1826, identified his cases with the dothiénentérite of Bretonneau, yet neither he nor Dr Bright took the abdominal ulcerations or sloughs as distinctive of a new kind of fever. They regarded them rather as a new complication of “idiopathic” typhus fever, a “complication” which appealed to them more on the side of treatment than of systematic nosology; hence the writings of both physicians are occupied mainly with the benefit of calomel in relieving the congestion of the bowels and in checking the diarrhoea.

It is undoubted that cases of enteric fever in 1826-27 were relatively more numerous in London than in Dublin and Edinburgh, where the epidemic fever was almost wholly of the relapsing type. In Edinburgh, at least, the comparative infrequency of enteric fever for years after it had been recognized in Paris, Tours and other French cities, and had been found in London as a common autumnal type, can be proved beyond cavil. Writing long after of the first epidemic of relapsing fever in Edinburgh, Christison said:

“Of enteric typhus (typhoid fever) we saw nothing then [1817-20], nor for many years afterwards. If it might have been overlooked during life, it could not have been missed after death. For our dissections were many, and, to meet the bias of the day for finding a local anatomical cause for all fevers [the doctrine of Broussais], every important organ in the body was habitually looked to. Nevertheless we were constantly met with the want of morbid appearances anywhere, unless slight signs of vascular congestion in various membranous textures be considered such[351].”

These vascular congestions were, indeed, scanned closely for traces of ulceration, after Bright’s plates of 1828, and any little irregularity on the surface of a congested Peyer’s patch was liberally construed in that sense, as in Craigie’s reports subsequently. But in the Edinburgh epidemic of 1827-29, the anatomical signs of enteric fever were wanting until the end of it. Writing in 1827, Alison said that he had dissected 26 cases dead of the epidemic fever, without finding intestinal ulceration in one of them. Christison, however, says that a very few cases of enteric fever were dissected in Edinburgh in 1829[352].

In Dublin, also, the anatomical mark of enteric fever was missed in 1826-27, in the few dissections that were made during the epidemic[353]. An opinion in a widely different sense was given on that point by Stokes twelve years after the event, to which I refer in a note[354].

Return of Spotted Typhus after 1831: “Change of Type.” Distress of the Working Class.

A fever with relapses, and a fever with sloughing of the follicles and lymph glands of the intestine, were not the only novelties in the first thirty or forty years of the 19th century. Relapsing fever and enteric or typhoid fever were each clearly separated, at a later date, from typhus fever. But what was the “typhus fever” from which they were at length separated? It was a fever which came prominently into notice after the “constitution” of 1826-29 was ended--a fever with a mottled, measly, or rubeoloid rash, and with various other spots, on account of which it was described by Dr Roupell in 1831, in a lecture before the College of Physicians of London, as a “new fever[355].” It was a new fever only in the sense in which each new febrile “constitution,” whether it were an influenza, an epidemic ague, or a malignant typhus, was apt to be called popularly “the new fever,” in the 16th and 17th centuries. There were, of course, erudite men at the College of Physicians in 1831 who knew that a fever with a mottled rash, with vibices and petechiae, and with all other symptoms of typhus gravior, had often occurred in England, Scotland and Ireland in former times. The “spotted fever” was perhaps the most familiar name of typhus in the 17th century. The mottled rash, like that of measles, was described for the fever of Cork by Rogers in the beginning of the 18th century, and for various other English and Irish epidemics by Huxham, O’Connell, Rutty and others. But undoubtedly the maculated typhus was somewhat new to the generation who saw it about 1830 and following years, the continued fevers which had prevailed in England, Scotland and Ireland since 1816 having been for the most part the simple continued, or synocha, with or without the relapsing character, and to some extent enteric fever[356].

It was from 1830 to 1834 that a change in the reigning type of fever began to be remarked in London, Dublin, Edinburgh and Glasgow, the new type becoming more and more evident as fevers became more prevalent in the ‘thirties’ and ‘forties.’ Typhus at length became so much a spotted fever that the question arose whether it should not be classed among the exanthemata. In 1840, Dr Charles West, having observed “the alteration in character which fever has undergone within the last few years,” went over the history (but more the foreign than the English) with a view “to illustrate the question whether typhus ought not to be classed among the exanthematous fevers[357]:” of course he found many old descriptions of a mottled rash or other spots, but saw no reason to make spotted typhus one of the exanthemata. Dr Kilgour, of Aberdeen, who treated more than a thousand cases in his fever-ward at the infirmary there from 1838 to 1840, wrote in 1841, “I am perfectly satisfied that this fever, call it by what name we will, is truly an exanthematous fever[358].” Previous to 1835, the spots of fever-cases in the Glasgow Infirmary had hardly been remarked; but after that date all cases were classed either as spotted or not, the spotted cases being three-fourths of the whole. Besides being spotted, the fever of the new constitution was insidious in its approach and low in its reaction, very unlike the sthenic, militant, inflammatory synocha of the generation before. The blood-letting which had been all but universally used in the fever from 1816 to 1828, and had seemed to answer well, was continued for a time in the fever of the ‘thirties.’ But it was soon found to be injurious: the patients in the new fever were apt to faint when only a few ounces of blood (four or six) had been drawn, whereas in the other fever (whether relapsing or simple continued) they had often lost thirty ounces before deliquium was reached. It was found, on the other hand, that fever-cases in the ‘thirties’ needed wine and other cordial regimen. There was nothing new in these revolutions, whether of the fevers themselves, or of the opinions as to their treatment. Sydenham’s method of taking his cue for treatment from the “constitution” of the season, which was the method of Hippocrates, appeared to be once more the best suited to the circumstances.

It is not easy to make out what were the circumstances of the time that led to the supersession of simple continued fever (or relapsing fever in Ireland and Scotland), by spotted fever or typhus gravior in all parts of the kingdom. Sydenham would have looked, among other things, to the weather and the character of seasons; but from 1830 onwards there was no season so notable as the dry and hot summer of 1826, although the end of the year 1836 was remarkably wet. The period of typhus gravior was a time of much sickness of other kinds--the Asiatic cholera of 1831-32, the influenza of 1831, 1833, and 1836-37, and the general unhealthiness of the year 1837. This was also the decade when the “condition-of-England question” was a common topic, a time of strikes and of much distress among the working classes, as shown in the reports of the Poor Law Commission.

In Glasgow there was a considerable prevalence of fevers year after year from the relapsing-fever epidemic of 1827-29, according to the following table of admissions for fever to the Royal Infirmary and the special fever-hospitals[359]:

Admissions for Fever, Glasgow.

Year Fever cases

1827 1084 1828 1511 1829 865 1830 729 1831 1657 1832 {1589 {1148[360] 1833 1288 1834 2003 1835 1359 1836 3125 1837 5387[361] 1838 2047 1839 1529

The worst year of the series for fever was 1837, and the worst month of that year was May, when the fever-deaths were 1 in 3·22 of the mortality from all causes. That great access of fever in Glasgow followed immediately upon the great strike of the cotton-spinners, on 8th April, 1837, by which eight thousand persons, mostly women, were thrown out of work[362]. The death-rate in Glasgow was in those years as high as anywhere in the kingdom, and was higher in the nine years from 1831 than in the nine years preceding. The population of Glasgow, says Cowan, had increased on the industrial side, out of proportion to its middle and wealthiest class[363]; and to that he would attribute the higher death-rates in the second period (right-hand side), of the following table:

Glasgow Death-rates.

1822-1830 | 1831-1839 | Death-rate Death-rate | Death-rate Death-rate over all. under five.| over all. under five. Year One in One in | Year One in One in 1822 44·4 101 | 1831 33·8 79 1823 36·4 78 | 1832 21·67 63 1824 37·0 81 | 1833 35·7 77 1825 36·3 81 | 1834 36·3 81 1826 40·6 105 | 1835 32·6 67 1827 37·0 84 | 1836 28·9 62 1828 33·0 79 | 1837 24·6 65 1829 37·9 100 | 1838 37·9 83 1830 41·5 97 | 1839 36·1 72

The high death-rates in some of the years in the second column were owing to special causes--Asiatic cholera in 1832, smallpox of children in 1835 and 1836, and to influenza, as well as to typhus, in 1831, 1833 and 1837. As to the fever which prevailed from 1831 to 1836, as it was not relapsing in type, so it was not associated with scarcity.

“The increase of fever in Glasgow,” says Cowan, “during the seven years prior to 1837, had taken place, not in years of famine or distress, but during a period of unexampled prosperity, when every individual able and willing to work was secure of steady and remunerating employment. From the close of 1836, one of those periodical depressions in trade, arising from the state of our monetary system, had visited this city, and deprived a large proportion of the population of the means of subsistence[364].”

It was then that the cases of typhus trebled in number.

The epidemic of fever reached its height in Dundee about the same time as in Glasgow, and in both towns sooner than anywhere else in Scotland or England. One reason of this was the labour-troubles culminating in strikes. In the twelvemonth from 15 June, 1836, to 12 June, 1837, more than three-fourths of all the admissions to the Dundee Infirmary on the medical side were for fever (700 cases). After the wet autumn of 1836 there were a good many cases of dysentery, of which 22 were treated in the infirmary, with two deaths[365].

At Edinburgh, as at Glasgow, there had been an unusual amount of fever in 1831 and 1832, and a steady prevalence of it thereafter. The epidemic of 1836-39 was for the most part typhus of the winter seasons, declining each spring and disappearing each summer, except in the summer of 1836, when many cases came in June, July and August from airy parts of the town[366]. The climax of the epidemic was in 1838, a year later than in Glasgow and Dundee, according to the admissions to the fever-wards of the infirmary[367]:

Admissions for Fever, Edinburgh Infirmary.

Year Cases

1831 758 1832 1394 1833 878 1834 690 1835 826 1836 652 1837 1224 1838 2244 1839 1235 1840 782

At Aberdeen the epidemic appears to have been later even than at Edinburgh, if the following admissions to one of the two fever-wards (Dr Kilgour’s) may be taken as a fair measure of it[368]:

Admissions for Fever, Aberdeen.

Year Cases Deaths

1838 (March to December) 189 26 1839 286 29 1840 534 53

In all these large towns of Scotland, the fever was purely typhus. The various observers all describe the fever as of the spotted kind, the proportion of cases with spots varying somewhat.

Thus, at Glasgow Infirmary, from 1835 to 1839, there were 4202 cases with eruption, 1270 without eruption, and 143 doubtful. And, that the cases without eruption were not cases of enteric or typhoid, is probable from the record kept of the fatalities in Dr Anderson’s fever-wards[369]:

In 1885 cases with eruption, 275 deaths, or 14·58 per cent. " 324 cases without eruption, 11 deaths, or 3·33 per cent. " 143 cases doubtful, 7 deaths, or 4·89 per cent.

At Aberdeen, Kilgour counted 59 cases spotted in a total of 189 in 1838, 96 in a total of 286 in 1839, and 278 in a total of 534 in 1840, all the cases, whether spotted or not, being of the same fever, which he considered an exanthematous malady as a whole. Of 169 cases tabulated by Craigie at Edinburgh, from 28 June, 1836, to 12 February, 1837, there were 79 with an eruption, which was usually the mottled or rubeoloid rash.

The fatalities were relatively more in Edinburgh than in Dundee, comparing two periods which were not the same. Of 700 cases at Dundee, from June, 1836, to June, 1837, only 50 died, or 1 in 14, notwithstanding a good many complications from chest complaints and bowel complaints[370]. At Edinburgh during fifteen months of 1838-39, there died 276 in 2037 cases, or 1 in 7·3; of those cases, 1075 were in females, with 116 deaths, or 1 in 9, and 962 males, with 160 deaths, or 1 in 6[371]. The most common age for the fever at Dundee was from twenty to forty years (416 out of 700 cases, with 26 deaths, or 1 in 16), while the most fatal age, as usual, was from forty to sixty years, at which one person died of three attacked. At Aberdeen, in the last year of the epidemic, the years of life from ten to twenty had more cases (233 in a total of 657) than any other decade of life. The average stay of a patient in the Aberdeen fever-wards was 18·67 days. The great preponderance of deaths in adolescents or adults was clearly shown in the Glasgow fever-statistics, 1835-39.

Fever-deaths per cent. Deaths from Under Over of deaths from typhus fever ten years ten years all causes

4788 752 4036 11·57

The corresponding epidemic of typhus in England had the fortune to be recorded in great part under the new system of Registration, which came into force on the 1st of July, 1837. At the beginning of registration of the causes of death, and until a good many years after, no distinction was made in the published tables between typhus fever and enteric fever. But we happen to know that the epidemic of 1837-38 was in London almost wholly typhus, just as it was in the large towns of Scotland. Of sixty cases in 1837-38, of which notes were kept by West, under Latham at St Bartholomew’s Hospital, none that died and were examined post-mortem had ulcerations, although some had congestion, of Peyer’s patches, the cases being all reckoned typhus exanthematicus[372]. Sir Thomas Watson, who was then physician to the Middlesex Hospital, says of the ulceration of Peyer’s patches in continued fever:

“Since attention has been drawn to the subject, the patches of glands, and the whole tract of mucous membrane, from the stomach to the rectum, have been diligently explored, and the result seems to be that, at certain times and places (in other words, in certain epidemics), the ulceration of the inner surface of the intestine is far less common than at others. It was comparatively rare in an epidemic of which I witnessed some part in Edinburgh [1827-29]. Then I came to London; and for several years I never saw a body opened after death by continued fever without finding ulcers of the bowels. More recently, however, and especially during the present epidemic (1838), I have looked for them carefully, in many cases that have proved fatal in the Middlesex Hospital, and have discovered neither ulceration nor any other apparent change in the follicles of the intestines.” And elsewhere he confirms the purely typhus character of the epidemic of 1838: “Our wards at the Middlesex are full of it, and scarcely a case presents itself without these spots. We speak of it familiarly as the spotted fever; or, from the resemblance which the rash bears to that of measles, as the rubeoloid fever[373].”

From which it would appear that not even the ordinary average number of endemic cases of enteric fever, such as might have been expected at a hospital in the west end of London, were forthcoming in the epidemic of 1837-38, so purely was the type of fever typhus.

The deaths from this epidemic in London, from the 1st of July, 1837, to the 31st of December, 1838, were as follows[374]:

1837 1838 3rd 4th 1st 2nd 3rd 4th Quarter Quarter Quarter Quarter Quarter Quarter

826 1107 1285 1176 829 788

--a total of 6011 deaths from fever, nearly all typhus, in eighteen months. The worst London parishes were Whitechapel and St Pancras, in which latter the fever-hospital was situated. The high mortality from fever, which had begun before the 1st of July, 1837, continued into the year 1839, when the deaths in London (probably including some enteric) were 1819.

Over all England and Wales, including London, the last six months of 1837 produced 9047 deaths from “typhus,” and the twelve months of 1838, 18,775 deaths, the winter of 1837-38 having been the most fatal period. After London, the large towns most affected by the epidemic in the latter half of 1837 were as follows:

Deaths from typhus in six months

Liverpool 524 Manchester } and Salford} 274 Birmingham 75 Bolton 75 Sunderland 72 Leeds 71 Sheffield 68 Bradford 65 Stockport 63 Dudley 54 Abergavenny 53 Wolverhampton 45 Newcastle 44 Wigan 43 Chorley 41 Swansea 36 Halifax 33 Macclesfield 33 Norwich 27

In each of the next two years the number of deaths from typhus in the four largest towns was as follows:

Typhus Typhus deaths deaths in 1838 in 1839

Manchester} and Salford} 627 416 Liverpool 573 358 Leeds 245 150 Birmingham 123 141

From nearly all the registration districts of England and Wales, deaths from fever were returned in 1837-39, so that the contagion must have been very widely spread in town and country[375]. In London the epidemic declined greatly in 1839, but in many parts of England the deaths registered as “typhus” were hardly less numerous than in 1838, and in some country divisions they were more, as if the contagion had taken longer to reach the villages[376]. One village epidemic in North Devon in the latter half of the year 1839 had been observed by Dr W. Budd, afterwards of Bristol:

The first case in the village (North Tawton, 1100 to 1200 inhabitants) was of a young woman in a poor and crowded cottage, who sickened on 11 July, 1839; her mother, brother, and sister sickened in succession, her father and a young infant escaping the infection. In another cottage, four out of six were ill of fever, in another, three persons had it, and so on, the whole number of cases treated by Dr Budd in the village until the beginning of November being about eighty. It was carried from North Tawton to neighbouring hamlets: thus, a sawyer who lodged next door to the first infected cottage sickened of the fever and, on 2 August, returned to his home in the hamlet of Morchard. As he lay there, he was visited by a friend, who assisted to raise him in bed: “While thus employed, the friend was quite overpowered by the smell from the sick man’s body,” and on the tenth day thereafter sickened of fever, which spread to two of his children and to a brother who came from a distance to see him. Another sawyer who lodged with the former left North Tawton ill a week after him (9 August) for his home, also at Morchard, where he died after a period not stated; ten days after his death his two children took the fever, his widow escaping it. In a third instance, a widow L---- left North Tawton on 21 August to visit her brother, a farmer in the hamlet of Chaffcombe, seven miles distant. Two days after her arrival she fell ill of fever and recovered slowly. In the same farmhouse the mistress caught it a month or two later and died on 4 November; the farmer himself took to bed with the fever on the day his wife died, and came safe through the attack. Three weeks after, an apprentice on the farm sickened, then a lad (the fifth in order) in the end of December, then the farmer’s sister, then another apprentice, then a serving-man, then a maidservant, and lastly the daughter of the widow L---- from North Tawton, who had been the first case in the house months before. This farmhouse at Chaffcombe sent off two distinct offshoots of contagion. The lad, who was fifth in the above series, was sent home ill to his mother’s cottage, between Bow and North Tawton, in the end of December. His mother sickened on 24 January, 1840, and died on 2 February. Next door to her lived a married daughter, whose whole household were attacked. Another married daughter, who came from a distance to visit the sick, took the infection on her return home, and so started a new focus. From the same farm at Chaffcombe, the maid, who was ninth in order in the above series, was sent home to her father’s cottage in the hamlet of Loosebeare, four miles away; her father caught the fever from her, and a farmer K----, who lived across the road, having visited this man several times in his illness, took the fever next, other cases following under farmer K’s. roof, and thereafter throughout the whole hamlet of Loosebeare[377].

This was doubtless the way the epidemic spread in all the country districts of England, the unwholesome state of labourers’ cottages, as revealed in the reports of the Poor Law Commission, favouring it. In the chapter on the fevers of Ireland we shall find that the contagion of typhus and relapsing fever was dispersed in the same way, but to a much greater extent, owing to the amount of vagrancy.

In the manufacturing towns of the North of England the fever continued at a somewhat steady epidemic level for several years. The pathetic scenes of typhus among the poor of Manchester in Mrs Gaskell’s famous tale of Mary Barton belong to the early part of the year 1839; but they might have been drawn from almost any months of the two or three years following, according to the passage cited below from the same work[378]. In 1839 the Lancashire deaths from typhus were 1343; in Wales, Monmouth and Herefordshire they were 1548. There is, indeed, little improvement in the statistical returns as late as 1842. The deaths from “typhus” were as follows in all England and Wales:

1838 1839 1840 1841 1842 18,775 15,666 17,177 14,846 16,201

The deaths from the epidemic maladies of infants and children during the same five years were also very high.

1838 1839 1840 1841 1842

Smallpox 16,268 9,131 10,434 6,368 2,715 Measles 6,514 10,937 9,326 6,894 8,742 Hooping cough 9,107 8,165 6,132 8,099 8,091 Scarlatina 5,802 10,325 19,816 14,161 12,807 Croup 4,463 4,192 4,336 4,177 4,457 Diarrhoea 2,482 2,562 3,469 3,240 5,241

The epidemic of smallpox corresponded closely to the epidemic of fever, the former being fatal chiefly to infants and young children, the latter fatal chiefly to adults. Before the smallpox epidemic had subsided scarlet fever became unusually mortal, especially in 1840, and kept its higher level of deaths for a generation after. The epidemic of fever, although it affected the mortality of the young comparatively little, was indirectly a reason why many of them died of other diseases; for the prostration of the parents, the impoverishment, and all the other troubles associated with an epidemic of typhus, led to inevitable sufferings among the young, which weakened their power of resistance.

The registration returns were not tabulated (except for London) from the end of 1842 to the beginning of 1847, but there is reason to think that the epidemic fever was not active in the interval. It is undoubted that the enormous construction of railroads in England during those years gave employment and wages to multitudes, and ended the distress the sooner. This effect of railroad-making in England was so obvious that Lord George Bentinck desired to relieve the distress in Ireland in 1846-47 by the same means.

Enteric Fever mixed with the prevailing Typhus, 1831-42.

While there is complete agreement among the hospital physicians of the great towns that the fever of 1837-39 was maculated typhus, to the total exclusion of cases with ulceration of the bowel, as in the experience of Watson at the Middlesex Hospital and of West (under Latham) at St Bartholomew’s, yet some allowance should be made, in interpreting the figures of fever mortality in those years throughout England and Wales, for admixture of enteric fever. Budd’s statement that the only case which was dissected in the epidemic at North Tawton, Devonshire, in 1839, had the bowel-lesion of enteric fever, if it is to count in the absence of the usual details (place, date, objective description), would mean that at least one case there was not of the prevailing type of contagious epidemic typhus. The coincidence of some such cases is made the more probable by the evidence from Anstruther, Fifeshire, reported by John Goodsir, afterwards Professor of Anatomy at Edinburgh, who was assisting his father in practice there from 1835 to 1839. During that period, which was the time of the typhus epidemic in the larger towns of Scotland, he attended about one hundred cases of fever annually in Anstruther and the neighbourhood; the fever was usually mild, only some sixteen of the cases having proved fatal; of those sixteen he examined ten after death, finding “ulceration” of the Peyer’s patches in all, and perforation of the intestine in four of them. These facts he gave orally to Dr John Reid, pathologist to the Edinburgh Infirmary, whose experience of the morbid anatomy of fever was altogether different. Goodsir, having kept the specimens, made them the subject of a paper some years after (1842), in which he described very minutely the stages and degrees of congestion, ulceration, sloughing and perforation in the lymph-follicles of the intestine in fever, placing congestions at one end of the scale and sloughing at the other, as the French pathologists then did[379]. Reid examined, at the Edinburgh Infirmary from October, 1838, to June, 1839, forty-one bodies dead of fever, to see whether the intestinal lesion, which Goodsir had told him of, occurred in them. The distinctness of the Peyer’s patches varied a good deal (differences which are known to be in part congenital and in part to depend on age), and in only two instances were they elevated and seemingly “ulcerated.”

One of these was the case of an Irishman, from Sligo, aged 25, who had been so constipated that he was purged with colocynth, etc.: “at the lower part of the ileum, the elliptical patches were irregular on the surface, and presented several superficial and ill-defined depressions (ulcerations).” The other was the case of a girl, aged 15, who had not suffered from diarrhoea, but had the intestinal patches elevated and superficially “ulcerated[380].” Neither of these cases would probably be reckoned typhoid or enteric fever at the present time on the anatomical evidence only. The early French observers, Chomel, Louis, Andral and others, included in a scale all the appearances of the Peyer’s patches in fever that they thought morbid, from mere prominence of the lymphatic tissue and distinctness of the follicular pits, up to extensive sloughing and ulceration of the same, as if they were all the signs of one and the same fever in its various stages of development. But simple prominence or congestion of Peyer’s patches may occur in typhus fever, or in relapsing fever; nor would a slight erosion, or “superficial ulceration” raise in all cases a suspicion of enteric fever.

The observations of Home, Reid’s predecessor as pathologist to the Edinburgh Infirmary, from 1833 to 1837, were however conclusive that true enteric fever had occurred now and again during the steady prevalence of typhus fever from year to year. In that space he made 101 post-mortem examinations in fever-cases; in 29 the Peyer’s patches were distinct, in 7 of those 29 there was “a greater or less degree of ulceration,” and in 2 of those 7 there was perforation[381]. Murchison examined the post-mortem register of the Edinburgh Infirmary for the years 1833 to 1838, and found only fifteen cases of fever with ulceration of the bowel. But in the eight months from 1 November, 1846, to June, 1847, there were nineteen dissections with the characteristic lesion of typhoid, the season having been remarkable everywhere for that disease.

In the following series of years the fatal cases of fever in the Edinburgh Infirmary with ulceration were few[382]:

Year Enteric deaths

1854 5 1855 2 1856 1 1857 8 1858 1 1859 2 1860 1 1861 6

It was thought remarkable that the form of continued fever which was most usually found in the great continental cities, in Paris, Berlin, Prague and Vienna, namely that with ulceration of the lymph-follicles of the intestine, should be but occasionally mixed with the old typhus in England, Ireland and Scotland in the very same years. But there was nothing to discredit the British observations, anatomical and clinical; and in 1836 Dr Lombard, of Geneva, having visited various cities in England, Scotland and Ireland bore witness to the matter of fact, strange as it was to him. Writing to Graves, of Dublin, on 16 June, 1836, he said: “Before I leave Ireland, allow me to express to you my great astonishment at what I have seen in this country respecting your continued fever;” and in a second letter, of 18 July, after his return to Geneva, he added, that in Liverpool, ulceration of the ileum in continued fever was “occasional,” that in Manchester he had been told it occurred “by no means always,” that in Birmingham the cases of fever were not many, but “always” with intestinal ulceration, and that in London “not a fourth part” of the cases of fever had the latter condition, and these mostly in autumn[383]. This was before the great epidemic of typhus had begun in the English towns. To the same non-epidemic period (1834) belongs the statement of Carrick, for Bristol, that fever was often observed to be infrequent or altogether absent in the most crowded and dirty parts of the city at times when there were a good many cases “in institutions and dwellings where cleanliness and free air are most carefully attended to,” and that ulceration of the bowel was the most common post-mortem appearance[384].

The comparative rarity of enteric fever in the chief towns of Scotland and Ireland continued for a good many years longer, indeed until after the differences between typhus and typhoid were perceived and admitted by all. Even at the London Fever Hospital, during twenty-four years (1848-71) after Sir William Jenner’s diagnostic points were strictly looked to in its wards, much the greater part of the admissions were of typhus; in only two periods, 1850-55 and 1858-61, during both of which there was comparatively little fever of any kind in London, did the admissions for enteric fever slightly exceed those for typhus; on an annual average of the twenty-four years ending 1871, the cases of the former were only about a fifth part of the whole. The cases of enteric fever increased decidedly after 1865. Murchison thought that the increase might be accounted for in part by the enlargement of the Fever Hospital, and by the unusually high temperature of certain years, the summers and autumns of 1865, 1866, 1868 and 1870 having been remarkable for their great heat and prolonged drought; but, he adds, “it is not a little remarkable that this increased prevalence of enteric fever in the metropolis has been contemporaneous with the completion of the main drainage scheme[385].”

Still more recently, the relative proportions of typhus and enteric fever have been reversed, so that there have been years with little or no typhus but with a good deal of enteric fever. There are some persons, unacquainted with the history, who cannot imagine that it was ever otherwise than now, who think of the former times of medicine, not as differing in social, economic, and various other respects from their own, but only as being less clever at diagnosis. There are others who realize clearly enough the historical matter of fact, but find it necessary to explain the almost contemporaneous decline of typhus and rise of typhoid by some hypothesis of the latter being “evolved” out of the former. This evolutional doctrine makes the mistake of ascribing to the species of disease the same comparative fixity of characters that belongs to the species of animals and plants. Beside the latter, the species of disease are the creatures of a day. In the nosological field, the origin of species is not analogous to the evolution of a new species of animal or plant out of an old, as in the hypothesis of Darwin, for the reason that every species of disease is evolved directly and, as it were, pro re nata, out of a few simple conditions of human life, variously mixed but always there to give occasion to one infective malady or another, which may have a shorter existence, like sweating sickness, or a longer, like plague. Edinburgh experiences offer a ready criticism of the evolutional doctrine. Typhus declined, and typhoid rose; but it was in the old tenement houses of the Canongate, Cowgate, Grassmarket, and High Street that typhus declined, and it was mostly in the new streets across the valley, or in the New Town of Edinburgh, that enteric fever arose, having sometimes no more mysterious an origin than the results of defective or cheap plumber-work, for example, the leakage of a soil-pipe fermenting, a foot deep, beneath the basement floor. But it was not until a good many years after that these new experiences became common; and meanwhile Edinburgh and other towns in Scotland saw much of typhus and relapsing fever.

Relapsing Fever in Scotland, 1842-44.

The epidemic of 1836-39 had been typhus of a specially maculated kind. The period or “constitution” of synocha, rising twice to epidemics of relapsing fever, had lasted from near the beginning of the century until 1828 or 1829. Then came the new constitution of low, depressed, spotted fever, which would not stand blood-letting. But in 1842-44 relapsing fever reappeared in Scotland. This reappearance was a blow to two doctrines of the time--first that Ireland was the original breeding-place of all such fevers, and secondly, that a return of the “constitution” of relapsing fever would warrant a return to the practice of blood-letting, which had fallen into disuse during the epidemic of typhus. The epidemic of 1842-44 was at first purely a Scots affair, with some extension to England, but none to Ireland. As to blood-letting, once it had been given over in fevers it was not readily taken up again, notwithstanding the theory that relapsing fever belonged to those sthenic or inflammatory types of sickness in which the lancet was still thought admissible. Moreover, Christison, who remembered the relapsing synocha of 1817-19 and of 1827-28, said of the third epidemic: “The synocha of 1843-44, though so prevalent, by no means presented the same strong phlogistic or sthenic character as in the earlier epidemics of 1817-20 and 1826-29. The pulse was neither so frequent nor so strong; the heat was not so pungent; the glow of the integuments was less lively and less general[386].”

I take conveniently from Murchison the following succinct account of the Scots relapsing fever of 1842-44[387]:

“The next epidemic of fever in 1843 differed from those that preceded it, inasmuch as it did not originate in or implicate Ireland, but was mainly confined to Scotland. There was no increase of fever in the Irish hospitals during this year, whereas the number of admissions into the Glasgow Infirmary rose from 1,194 to 3,467; in the Edinburgh Infirmary from 842 to 2,080; and in the Aberdeen Infirmary from 282 to 1,280. These numbers, too, are far from representing the true extent of the epidemic, for thousands of sick were sent from the hospital doors. The fever was almost exclusively relapsing fever; typhus was comparatively rare. The first cases were observed on the east coast of Fife, in 1841-2 (by H. Goodsir), and not in the crowded localities of large towns. In Dundee, where the proportion of typhus cases was comparatively great, the fever appeared early in the summer of 1842, and raged to a considerable extent during the whole of the autumn, before it showed itself elsewhere. In Glasgow the first cases occurred in September, 1842; but the fever was not generally prevalent until December, from which month the cases rapidly increased until October, 1843, when the epidemic began to decline. The number of cases in Glasgow was estimated at 33,000, or 11½ per cent. of the entire population. In Edinburgh relapsing fever was first observed in February, 1843. It rapidly spread until October, after which it gradually abated, until, by the following April, it had well nigh disappeared. In the month of October, 1843, the number of fever cases admitted into the Edinburgh Infirmary amounted to 638, and during several months, from thirty to fifty cases were daily refused admission. The total number of cases in Edinburgh was calculated by Alison at 9,000. In Aberdeen the epidemic commenced about the same time, and followed the same course as in Edinburgh. At Leith, curiously enough, it did not appear until September, 1843; it then spread rapidly for two months, after which it declined, and by the end of February, 1844, it had almost ceased; but during this brief period it attacked 1,800 persons, or one in every fourteen of the population. The disease was general over Scotland, and was not restricted to the large towns; it prevailed in Greenock, Paisley, Musselburgh, Tranent, Penicuick, Haddington, Dunbar, the Isle of Skye, etc. Although the epidemic was mostly confined to Scotland, the same fever was observed in some of the large towns of England. The number of admissions into the London Fever Hospital rose from 252 in the preceding year to 1,385 in 1843: and the annual report for 1843 makes it evident that a large proportion of these cases were relapsing fever. The rate of mortality of the epidemic was small, not exceeding from two-and-a-half to four per cent. Although this was the same fever as prevailed in 1817-19, even local bleeding was rarely resorted to, and many of the cases were thought to demand stimulants. All accounts agree in stating that the epidemic supervened upon a period of great distress among the Scottish poor, and that it was restricted throughout to the poorest and most wretched of the population.”

This epidemic, which was the subject of an altogether unusual amount of writing in Edinburgh[388], partly on the supposition that relapsing fever was a “new disease,” proved once for all that one had not to go to Ireland for the engendering or making of a famine-fever. The demonstration came just in time; for the epidemic was hardly over in Scotland, when the series of great potato-famines in Ireland began in 1845, soon to be followed by the disastrous epidemics of dysentery, relapsing fever and typhus from 1846 to 1848. Indeed, so near was the Scots epidemic to the Irish, that in the North of Ireland the first of the relapsing fever, in 1846, was called “the Scotch Fever,” on the supposition that it had reached them from its recent focus in the West of Scotland[389]. The Irish and original part of the great epidemic of 1846-48 has been fully described in another chapter; much of the mortality was due to dysentery, and the most prevalent fever was relapsing fever, with a very low rate of fatality among the poorer classes. But in Ireland itself there was also much typhus, very mortal to the richer classes who came in contact with the starving multitudes.

The “Irish Fever” of 1847 in England and Scotland.

The contagion that reached England and Scotland from the scene of famine in Ireland was more apt to produce typhus than relapsing fever. That the Irish contagion was the principal source of the great epidemics in England and Scotland in 1847-48, seems to be proved by every fact in their progress, direction and other circumstances. But it is not so clear that England and Scotland would not have had an unusual amount of typhus in the same years even if the Irish had been kept out by an ideally strict quarantine. What touched Ireland most, touched Scotland and England in a measure. The seasons were bad in all parts of the kingdom; many were out of work in the manufacturing towns; but as soon as the price of provisions fell in 1848, the epidemic in England came to a sudden end.

The epidemic of fever in England in 1847 was almost wholly typhus; in Scotland, it was to some extent relapsing fever, but there also it was mainly typhus. It was more severe, while it lasted, than the epidemic of 1837 and following years; but it was of shorter duration, ceasing almost abruptly in 1848. The rise of the epidemic of 1847 in London is shown by the following quarterly returns of the deaths from fever:

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

442 568 895 1279

In the last quarter of 1846, the deaths from fever in London had been 619. In all England, the last quarter of 1846 was also most unhealthy, its deaths from all causes being 53,055 (only 43,850 in the first quarter of the year). The summer of 1846 had been remarkable for heat and drought, and the end of the year was, according to precedent, an unwholesome time. It was just the season for enteric fever, as in the still more memorable circumstances of 1826. There is evidence from various parts of England and Scotland that much of the fever of the end of 1846 was enteric; and it was doubtless the unusual prevalence of that disease, and of other maladies that are favoured, like it, by extreme fluctuations of the ground-water, that explains the very high mortality of the last quarter of 1846[390]. But it is equally certain that it was typhus which raised the fever deaths in London in the last quarter of 1847 to 1,279, and the deaths from all causes in all England to the enormous total of 57,925. In the whole of the year 1847, typhus alone claimed 30,320 deaths in England and Wales, the total in 1848 falling to 21,406. Lancashire and Cheshire had the largest share of this epidemic, and Liverpool the largest share in Lancashire. In that Registration Division (the North-western) the deaths from typhus in 1847 were 9,076, and in 1848 they were 3,380. Next in order (excluding London and suburbs) came the West Midland Division, and next to that Yorkshire. At Liverpool, and in other places of the north-west of England, the fever was very clearly connected with the enormous Irish immigration, and was in great part among the Irish. There were floating lazarettos on the Mersey, filled with fever and dysentery, workhouses overflowing, and sheds hastily built to hold each 300 patients. The following returns from the several sub-divisions of Liverpool for the months of July, August and September, 1847, show the proportions of dysentery and fever, as well as the mortality from diarrhoea, which last was mostly an affair of the infants and young children[391]:

Liverpool deaths, July-Sept. 1847.

Fever Dysentery Diarrhoea St Martin’s 291 82 174 Dale Street 250 20 111 St Thomas (301 deaths on the floating lazarettos) Mount Pleasant 324 18 73 Islington 105 37 78 Great Howard Street (the fever extending to the upper classes)

In his report for the quarter before (April, May and June, 1847) the registrar of the Great Howard Street sub-district says: “Eight Roman Catholic priests, and one clergyman of the Church of England, have fallen victims to their indefatigable attentions to the poor of their church[392].”

In Manchester there were causes of fever independently of the Irish contagion. The registrar of the Deangate sub-district writes in the third quarter of 1847: “In the calamitous season just passed, manufactures have been almost at a stand-still; food has been unattainable by the poor, for employment they had none; Famine made her dwelling in their homes &c.” The hardships of the children caused an immense mortality from summer diarrhoea. The same registrar gives an account of the epidemic fever in his report for the second quarter of 1847, from which it appears that, although nearly all the hospital cases were distinctly maculated, and the fever was undoubtedly typhus in all other respects and in its conditions, yet tympanitis, with abdominal tenderness and diarrhoea, were specially noted[393].

Besides Liverpool and Manchester, many other towns in Lancashire had the “Irish fever” in them; also Birmingham, Dudley, Wolverhampton, Shrewsbury, Leeds, Hull, York and Sunderland. Except in London, the fever mortality was not unusual in the southern half of England[394].

In Scotland the epidemic was a mixture of relapsing fever and typhus. The following were the proportions of each admitted to the Glasgow Royal Infirmary:

Year Relapsing Fever Typhus

1846 777 500 1847 2,333 2,399 1848 513 980 1849 168 342

In the Barony Fever Hospital, Glasgow, open from 5 August 1847 to July 1848, the relapsing cases were double the typhus cases at the opening of the hospital, at the end of 1847 they were nearly equal, and from February 1848 the typhus cases were double the relapsing. In Edinburgh, where the epidemic was less severe, the same relations were observed--relapsing fever most at the beginning, typhus fever (much more fatal) most at the end[395]. Some relapsing fever occurred also in London, among destitute Irish, which was often attended by a miliary eruption (Ormerod).

Subsequent Epidemics of Typhus and Relapsing Fevers.

By midsummer, 1848, there was a most marked improvement in the public health, corresponding with the great fall in the prices of food, under the influence of free trade, and with a good harvest and the commencement of an era of steady employment for workers. The improvement is strikingly shown in the following comparison of the deaths from all causes in Lancashire and Cheshire in the third quarter of each of the years 1846, 1847 and 1848:

1846 1847 1848

Deaths in the 3rd Quarter 15,221 17,080 11,720

Since the epidemic of 1847, which was not unfairly called “the Irish fever,” there has been no such extensive and fatal outbreak of typhus or relapsing fever in England, Scotland or Ireland. The fever deaths rose somewhat in Ireland and in Glasgow in 1851-53, the type of disease being relapsing and typhus. In London there was a considerable increase of typhus in 1856, at the end of the Crimean War. From 1861 to 1867 there was a considerable epidemic of the same fever in England and Scotland (not much of it in Ireland until 1864), the chief centres in England having been the Lancashire towns, Preston, Manchester, Accrington, Chorley, Salford and Blackburn, and the occasion of it the “cotton famine” of the American Civil War[396]. Greenock was the chief seat of typhus in 1863-64 in Scotland; indeed, in the whole kingdom, its death-rate from that cause was approached by that of Liverpool only. Fevers had been very mortal there in the epidemic of 1847 (it is said 353 deaths); in the next fever-period they rose as follows[397]:

1860 1861 1862 1863 1864

19 57 63 98 274

This epidemic was more easily dealt with than those of the same kind before it. Very large sums were subscribed by the wealthy, of which, indeed, a considerable balance remained undistributed. Rawlinson, as engineer, and Villiers, as Minister, devised extensive relief works, in the form of main drainage for the distressed Lancashire towns, the whole cost being defrayed eventually by the municipalities themselves. The following table, from Murchison, shows the admissions for typhus to the fever hospitals of various towns, subsequently to the great epidemic of 1847-48. The first rise in London was in 1856; the next rise, which was somewhat prolonged, coincided with the epidemic in Lancashire.

Hospital Cases of Typhus, 1849-71.

London Edin. Glasgow Glasgow Dundee Aberdeen Cork Fever Royal Royal Fever Royal Royal Fever Year Hosp. Infirm. Infirm. Hosp. Infirm. Infirm. Hosp.

1849 155 -- 342 -- -- -- -- 1850 130 -- 382 -- -- -- -- 1851 68 -- 919 -- -- -- -- 1852 204 -- 1293 -- -- -- -- 1853 408 -- 1551 -- -- -- -- 1854 337 -- 760 -- -- -- -- 1855 342 -- 385 -- -- -- -- 1856 1062 -- 385 -- -- -- -- 1857 274 -- 314 -- -- -- -- 1858 15 -- 175 -- 17 -- -- 1859 48 -- 175 -- 128 -- -- 1860 25 -- 229 -- 67 -- -- 1861 86 -- 509 -- 129 -- 116 1862 1827 14 780 -- 54 -- 272 1863 1309 74 1286 -- 236 379 (4 mos.) 692 1864 2493 212 2150 -- 264 811 1021 1865 1950 447 2334 1154 891 422 791 1866 1760 847 1055 384 706 167 247 1867 1396 303 761 795 225 68 124 1868 1964 280 620 1023 502 78 245 1869 1259 259 1430 2023 402 170 136 1870 631 287 947 702 232 61 165 1871 411 101 418 511 257 3 397

During the unusual prevalence of fever in Scotland, 1863-65, it was made clear by the diagnosis in hospitals, that the excess was caused by typhus, and not by enteric.

Of 440 cases of fever treated in the Royal Infirmary of Edinburgh, in 1864, 212 were cases of pure typhus, 140 were enteric fevers, while 88 were simple continued fever and febricula. In the Royal Infirmary of Glasgow in 1864, of 2,190 cases of fever, 2,150 were reported to be cases of typhus fever, while only 40 were cases of enteric fever. In the Aberdeen Royal Infirmary not a case of enteric fever was observed: of 396 cases in the year 1863, 387 were pure typhus, and 9 febricula; and in 1864, of 926 cases, 897 were pure typhus and 29 febricula. In the Royal Infirmary of Dundee, of 355 cases of fever treated in 1864, 318 were typhus, 16 enteric fever, and 21 febricula. It was only at Perth, and there not exclusively in hospital practice, that an excess of typhoid fever was observed; from 1st August, 1863, to 30th April, 1864 (months which included the special typhoid season), there were 101 cases of gastro-enteric or typhoid fever, 46 cases of typhus, 19 of relapsing fever, and 59 of simple continued fever[398].

The last considerable prevalence of contagious fever in England and Scotland was in 1869 and 1870. It was relapsing fever, mixed with some typhus, and it was restricted almost to a few large towns, including London, Liverpool, Manchester, Leeds, Bradford, Glasgow, and Edinburgh[399]. It was first seen in London in 1868 among Polish Jews. It was heard of as late as 1872 at Newcastle. It was observed during this epidemic in Liverpool, Bradford and Edinburgh that the subjects of the relapsing fever were not suffering from want[400]. The same observation has been made in some foreign countries. Still, on the great scale and in a broad view, relapsing fever has been typhus famelicus or famine-fever, occurring in association with other maladies due to want, and especially in the circumstances which have been discussed fully in the chapter on fevers in Ireland.

Relative prevalence of Typhus and Enteric Fevers since 1869.

It was not until the year 1869, or about the time when typhus fever ceased to be epidemic or common, that the deaths from typhus fever, simple continued fever and enteric fever began to be tabulated separately in the Registrar-General’s reports. The following tables show for England and Wales and for London a steady decline of the deaths from typhus and simple continued fever since the end of the epidemic period 1869-71, which was the last epidemic of typhus and relapsing fever in this country hitherto. The deaths from enteric fever, it will be seen, remained somewhat steady (in a growing population) for about ten years after the separation, and then began to decline.

Continued-fever Deaths in England and Wales, 1869-91.

Simple or Year Typhus Ill-defined Enteric

1869 4281 5310 8659 1870 3297 5254 8731 1871 2754 4248 8461 1872 1864 3352 8741 1873 1638 3081 8793 1874 1762 3089 8861 1875 1499 2599 8913 1876 1192 1974 7550 1877 1104 1923 6879 1878 906 1776 7652 1879 533 1472 5860 1880 530 1490 6710 1881 552 1159 5529 1882 940 1016 6036 1883 877 963 6068 1884 328 768 6380 1885 318 662 4765 1886 245 505 5061 1887 211 502 5165 1888 168 436 4848 1889 140 413 4971 1890 160 361 6146 1891 148 325 5075

Continued-fever Deaths in London, 1869-91.

Simple or Year Typhus Ill-defined Enteric

1869 716 615 1069 1870 472 570 976 1871 384 436 871 1872 174 322 867 1873 277 325 968 1874 312 337 879 1875 128 272 817 1876 159 202 769 1877 157 194 901 1878 151 197 1033 1879 71 160 849 1880 74 134 702 1881 92 134 971 1882 53 95 975 1883 55 102 963 1884 32 75 925 1885 28 78 597 1886 13 73 618 1887 19 44 612 1888 9 35 694 1889 16 42 538 1890 10 35 604 1891 11 44 557

Such being the proportions of typhus and enteric fever since 1869, when the separation was made, it remains to ask what share each of them may have had in the total of “typhus,” or of continued fever generally, in the years before the two forms were distinguished in the annual registration reports. Of course, they were distinguished by many of the profession long before that; so that there are means of forming a judgment. At the London Fever Hospital, enteric fever and typhus were distinguished after 1849. If the admissions of each kind of fever to that hospital be assumed to have been proportionate to the prevalence of each in London from year to year, we should get in the following table a means of estimating which of the two forms of continued fever furnished most of the deaths in all London, as given in the first column:

Admissions to London Deaths in Fever Hospital London from Year both fevers Typhus Typhoid

1838 4078 -- -- 1839 1819 -- -- 1840 1262 -- -- 1841 1151 -- -- 1842 1184 -- -- 1843 2094 -- -- 1844 1721 -- -- 1845 1324 -- -- 1846 1838 -- -- 1847 3297 -- -- 1848 3685 -- -- 1849 2564 155 138 1850 2032 130 137 1851 2374 68 234 1852 2183 204 140 1853 2617 408 212 1854 2816 337 228 1855 2410 342 217 1856 2717 1062 149 1857 2195 274 214 1858 1919 15 180 1859 1840 48 176 1860 1476 25 95 1861 1848 86 161 1862 3673 1827 220 1863 2871 1309 174 1864 3782 2493 253 1865 3217 1950 523 1866 2688 1760 582 1867 2184 1396 380 1868 2468 1964 459

From this it will appear that every great annual rise in the London deaths from “fever,” since the last great typhus epidemic of 1847-48, has corresponded to a greatly increased admission, not of enteric cases, but of typhus cases into the London Fever Hospital. On the other hand, enteric fever has been at a somewhat steady or endemic level for a good many years. Even at that level it would have had a small share of the whole fever-mortality in the old London; in modern London, especially in its residential quarters, its rate has probably been higher than in former times; while in recent years, owing to the absolute decline of typhus, it has been by far the most common continued fever. If the conditions were the same in London as in Edinburgh, it was the very creation of residential streets and new quarters of the town that called forth typhoid fever; while the more the town was remodelled, the more were the fomites of typhus destroyed. Thus it seems probable that the same progress in well-being among all classes, which has gradually brought typhus down almost to extinction (or apparently so for the present), has been attended with an increase of typhoid, an increase which has happily fallen within the last few years from its highest point.

The disappearance, during the last twenty years, of typhus and relapsing fevers from the observation of all but a few medical practitioners in England, Scotland and Ireland, is one of the most certain and most striking facts in our epidemiology. Most of the recent English cases have occurred in Lancashire, especially in Liverpool, and in Sunderland, Gateshead, Newcastle and other shipping places of the north. In the decennial period 1871-80 the death-rate from typhus, per 1000 living, was 0·58 in Liverpool and 0·33 in Sunderland, rates which were about the same as those from enteric fevers. The rates in 1881-83 were also high in the same group of towns. As to other industrial centres, including the coal-districts of Cumberland, Wales and Scotland, it is probable that a good deal of typhus passes under the name of “typhoid,” the change in medical fashion having outrun somewhat the real change in the relative prevalence of each fever[401]. In Scotland the disease is still heard of from time to time in Glasgow, Edinburgh, Leith, Dundee, Aberdeen, Inverness and Thurso. In London the recent immunity from it is remarkable, but intelligible. First, the populace is better housed: we have got rid of the window-tax, rebuilt the houses in regular streets opening upon wide thoroughfares, pulled down most of the back-to-back houses, dispersed the working population over square miles of suburbs easily accessible from the heart of the town by tramways and railways, perfected the sewerage and the water-supply. These great structural changes are so far an earnest that typhus cannot come back in the old way. Secondly, food has been for a long time cheap and wages good. During the remarkable lull in typhus from 1803 to 1816, Bateman pointed out that the unwholesome state of the dwellings of the working class remained the same as before, but that money was flowing freely among all classes (thanks to the special war-expenditure). Under free trade, the same abundance of the necessaries of life has been secured in another way. Typhus, it need hardly be said, is an indigenous or autochthonous infection; the conditions of its engendering are never very far off. In a small and remote island off the coast of Skye, which I happened to know in its pleasing aspects from having landed upon it during a summer vacation, typhus fever was reported by the newspapers a few months after to have broken out in the hamlet of twenty or thirty families, the winter storms having prevented the fishers from leaving their cottages or any stranger from approaching the island. In a sparsely populated parish of the east coast of Scotland, two cases of genuine typhus (one of them fatal), and two only, have occurred, to medical knowledge, within the last ten years, each in a very poor cottage in a different part of the parish and in a different season. So long as our cheap supplies of food, fuel and clothing are uninterrupted, there is small chance of typhus or relapsing fever. But the population of England being now twice as great as the home-grown corn can feed, a return of those fevers on the great scale is not out of the question in the event of the foreign food-supply being interfered with, or the necessaries of life becoming permanently dearer from any other cause.

The following Table of the fever-deaths in Scotland since the beginning of Registration does not distinguish enteric from typhus, relapsing and simple continued during the first ten years of the period; but it is probable, from all that is known non-statistically or by hospital figures only, as to the history of enteric fever in Scotland, that it made the smaller part of the generic total of fever-deaths so long as typhus and relapsing fevers were common.

Scotland--Deaths from the Continued Fevers since the beginning of Registration.

Year

1855 2419 } 1856 2363 } 1857 3087 } 1858 2790 } 1859 2436 } Inclusive of typhus, relapsing, enteric 1860 2344 } and other continued fevers. 1861 2579 } 1862 3021 } 1863 3441 } 1864 4804[402]}

Simple Infantile Cerebro-Spinal Typhus Enteric Relapsing continued Remittent

1865 3272 1048 62 839 164 -- 1866 2172 1404 34 249 159 -- 1867 1745 1378 40 105 119 -- 1868 1561 1404 45 100 132 -- 1869 2059 1335 29 121 157 -- 1870 1460 1207 205 151 141 -- 1871 1129 1234 411 108 124 -- 1872 795 1223 115 103 118 -- 1873 628 1495 31 192 117 -- 1874 726 1455 27 104 80 -- 1875 615 1625 17 98 85 -- 1876 471 1448 18 65 88 -- 1877 265 1427 5 164 -- -- 1878 263 1477 2 147 -- -- 1879 210 1013 5 133 -- -- 1880 170 1338 4 155 -- -- 1881 229 1004 0 115 -- -- 1882 180 1204 2 90 -- -- 1883 152 998 1 71 -- 7 1884 138 1050 2 63 -- 9 1885 111 889 1 58 -- 8 1886 80 755 2 62 -- 10 1887 126 835 7 65 -- 4 1888 102 665 6 58 -- 6 1889 69 795 1 45 -- 2 1890 77 777 -- 30 -- 3 1891 107 799 4 23 -- 6

Circumstances of Enteric Fever.

The circumstances of typhus and relapsing fevers need no general stating after what has been said of particular epidemics in England and Scotland, or remains to be said, for the most distinctive instances of all, in the chapter on fevers in Ireland. There has been so little typhus in the country at large since the disease began to be registered apart in the mortality returns, in 1869, that hardly anything can be inferred except the fact of its disappearance. It is significant, however, that Sunderland, one of the two great towns which have kept typhus longest and in largest measure (Liverpool being the other) is distinguished for the overcrowding of its dwelling-houses (7·24 persons to a house in the Census of 1881, 7·00 in the Census of 1891).

But the circumstances of enteric fever are not only not so obvious as those of typhus in the historical way; they are also more complex and disputable. One fact in the natural history of enteric fever has been made clear in the chronology, namely, its greater frequency after a severe drought. It was in the autumn of 1826, after the driest and hottest summer of the century, that cases of fever with ulceration of the bowel were first described and figured in London. It was in the autumn of 1846, after the next very dry and hot summer, that cases of the same fever again became unusually common in many parts of England and Scotland. The same sequence has been remarked on more recent occasions and in various countries. It is explained by taking into account some other facts in the natural history of enteric fever. In nearly all countries in our latitudes, autumn is its principal season, and autumn is the season when the level of the water in the soil, or in the wells, is lowest. Virchow states the law of enteric fever in the following simple and concrete way: “We [in Berlin] have a certain number of cases of typhoid at all times. The number increases when the sub-soil water falls, and decreases when it rises. Every year, at the time of the lowest level of the sub-soil water, we have a small epidemic.” A sharp rise above the mean level of the year, from the first week of September to the end of October, has been well shown for London from the admissions to the hospitals of the Metropolitan Asylums Board, 1875-1884. The curve has an equally sharp descent, passing below the mean line of the year in the second week of December[403]. There are indications that it is the partial filling of the pores of the sub-soil with water, after they have long been occupied with air only, that makes the virus of typhoid active, or, in other words, that the rains of late summer and autumn are the occasion of the seasonal increase of the infection.

Yet it is not the changes in the ground-water by themselves, just as it is not rainfall and temperature by themselves, that make enteric fever to prevail. The soil in which those vicissitudes of drought and saturation are potent for evil must be one that is befouled with animal organic matters, more especially with excremental matters. For that and other reasons (such as the geological formation), enteric fever shows, in its more steady or endemic prevalence from year to year or from decade to decade, certain marked preferences of locality. Since 1869, when the deaths from it began to be registered apart, it has been much more common, per head of the population, in the quick-growing manufacturing and mining towns than in any other parts of England and Wales, the districts with highest enteric death-rates being the mining region of the East Coast from the mouth of the Tees to somewhat north of the Tyne, the mining region of Glamorgan, certain manufacturing towns of Lancashire and the West Riding of Yorkshire, and some districts in the valley of the Trent in Staffordshire and Nottinghamshire. The following Table shows, by comparison with all England and Wales and with London, the excessive death-rates from enteric fever in the registration divisions which head the list:

Highest mortalities from Enteric Fever in Registration Divisions of England and Wales[404].

------------------------------------------------------------------ Decennium | Decennium 1871-80 | 1881-90 -------------------------------------------------------|---------- | Annual | Annual | | |death-rate,|death-rate,|Enteric| Deaths, |all causes,| Enteric, |Deaths | Enteric, | per 1000 | per 1000 | in 10 | in 10 | living | living | years | years -----------------------|-----------|-----------|-------|---------- England and Wales | 21·27 | 0·32 | 78421 | 53509 London | 22·37 | 0·24 | 8536 | 7497 -----------------------|-----------|-----------|-------|---------- Durham co. | 23·77 | 0·56 | 4525 | 2590 South Wales | 21·09 | 0·45 | 3715 | 2550 W. Riding, Yorks. | 23·24 | 0·45 | 9166 | 5170 N. Riding, Yorks. | 19·68 | 0·44 | 1259 | 896 Nottinghamshire | 21·23 | 0·43 | 1707 | 1263 Lancashire | 25·17 | 0·39 | 12388 | 9874

Durham Mining Districts.

Stockton incl. part of | | | | Middlesborough | | | | (4¾ years) | 26·64 | 1·09 | 561 | -- | | | | Stockton (5¼ years) | 22·49 | 0·62 | 208 | 258 | | | (5¼ | | | | years)| Guisborough, incl. part| | | | of Middlesborough | | | | (4¾ years) | 24·80 | 1·17 | 251 | -- | | | | Guisborough | | | | (5¼ years) | 20·45 | 0·38 | 71 | 106 | | | | Middlesborough[405] | | | | (5¼ years) | 19·93 | 0·63 | 272 | 460 | | | (5¼ | | | | years)| | | | | Auckland | 24·52 | 0·71 | 541 | 318

South Wales Mining Districts.

Pontypridd[406] | 23·16 | 0·71 | 515 | 541 Merthyr Tydvil | 24·23 | 0·62 | 639 | 249 Swansea | 22·38 | 0·63 | 505 | 387 Llanelly | 20·93 | 0·8 | 330 | 165

In the second decennium of the Table, 1881-90, the total deaths from enteric fever (the death-rates are still unpublished) are much below those of 1871-80. All the counties of England and Wales have shared in that notable decline, including Durham and Glamorgan. But these two great districts of the coal and iron mining are, by the latest returns, still keeping the lead; and it is probable that we shall find in them, or in particular towns within them, the conditions that have been most favourable to enteric fever in the earlier decennia of this century and are still favourable to it. First it is to be observed that one of the most noted of the old typhoid centres in Glamorgan, namely Merthyr Tydvil, has ceased to be in that class; its enormous rate of growth has been checked (to 18·9 per cent. from 1881 to 1891) and it has at the same time become a more uniform and better-ordered municipality.

On the other hand, on the same river Taff, and in the tributary valley of the Rhondda, there is an immense population of miners, among whom the enteric fever death-rate will probably be found to have been higher in 1881-90 than in any other registration district. The most populous part of the district is the town of Ystradyfodwg, which had 44,046 inhabitants in 1881 and 68,720 in 1891, an increase of over fifty per cent., the highest urban rate of increase in the country. On the mean of the last three years, 1891-93, its enteric fever death-rate has been ·62 per 1000. There are several populous towns or townships in the mining districts of the north-east which have in like manner kept their high rate of typhoid mortality--Auckland, Easington, Bellington (Morpeth) and Middlesborough. It is held by many that enteric fever has been most characteristically a product of the modern system of closet-pipes and sewers. It is, of course, the defects of the system that are, in this hypothesis, to blame, including its partial adoption, the transition-state from the older system, the tardy extension to new streets, as well as cheap and faulty construction. All those things, together with the inherent difficulty of connecting with a main sewerage the irregular squattings of a mining community, are probably to be found in highest degree in those districts of Durham and South Wales that are most subject to enteric fever. While enteric fever is in some places steady or endemic from year to year, in others its force is felt mostly in great and sudden explosions.

One such happened in the city and district of Bangor in the summer of 1882. The registration district had only 95 deaths from enteric fever in the ten years 1871-80, but in the single year 1882 it had 87 deaths registered under that name. Of 548 attacks (with 42 deaths) which were known from 22 May to 12 September, 407 fell in August and the first twelve days of September[407]. In the following year and throughout the rest of the decennium the district had its usual low average of enteric-fever deaths. One thing relevant to the explosion was probably the excessive rainfall of June and July (9·5 inches, as compared with 4·8 inches about London).

Another explosion, probably unique in the history of enteric fever, took place at Worthing, on the Sussex coast, in the summer of 1893. The enteric death-rate of the town had been much below the average of England and Wales from 1871 to 1880, the rate being 0·15 per 1000 and the whole deaths in ten years 36. During the next ten years, 1881-90, the whole enteric deaths were 43 in the entire registration district (population in 1891, 32,394). In 1891 the typhoid deaths were two, in 1892 they were six. In 1893 a severe outbreak of typhoid took place within the municipal borough (population 16,606): In the first quarter of the year Worthing was one of the places mentioned for typhoid, having had 5 deaths; in April there were no deaths, in May 25, in June 19, in July 61, in August 64, in September 11, and in the last quarter of the year 8, making 193 deaths in the year. The highest weekly number of cases notified was 253 in the second week of July. The enormously wide dispersion of the poison, in a town little subject to enteric fever, caused suspicion to fall on the water-supply, the more reasonably that the district of West Worthing, which had a separate water-supply, was said not to have suffered from the outbreak. A new water-supply was at once undertaken. A relief fund of £7000 was raised for the sufferers.

The towns of Middlesborough, Stockton and Darlington, in the lower valley of the Tees, were together the scene of two remarkable explosions of enteric fever, the first from 7 September to 18 October, 1890, the second from 28 December, 1890, to 7 February, 1891. The phenomenal nature of these outbreaks in the autumn and winter of 1890-91 will appear from the following table of deaths by enteric fever:

Darlington Stockton Middlesborough Ten years 1881-90 104 258 460 ----------------------------------- 1890 21 66 130 1891 17 59 93

In the first of the two explosions the three towns were almost equally attacked per head of their populations; in the second explosion, in mid-winter, Darlington had relatively only half as many cases as each of the other two, which had about the same number of cases as in the former six-weeks’ period. In both periods, of six weeks each, the three towns had together 1334 cases of typhoid, while the country districts near them had a mere sprinkling. A flooded state of the Tees appeared to be a relevant antecedent to each of the explosions. The Tees is a broad shallow river flowing rapidly, subject to frequent inundations, tortuous in its lower course, forming at its mouth, where Middlesborough stands, a wide estuary bordered by low flat grounds. The rainfall at Middlesborough was 6·3 inches in August, of which 2·2 inches fell on the 12th of the month, the river being high in flood thereafter. There were again high floods in November, chiefly caused by the melting of snow in the upper basin (5 inches fell at Barnard Castle in November, 3·1 inches at Middlesborough, while the December fall was 1·2 inches at the former and 1·4 inches at the latter). To apply correctly the ground-water doctrine of enteric fever to these explosions, other particulars would have to be known, more especially the extent of the previous dryness of the subsoil (the rainfall at Middlesborough was 9·3 inches in the first half of 1890, 15·6 in the second half, and below average for the whole year). But the flooded state of the Tees valley in August and November must have changed abruptly the state of the ground-ferments within the areas of the respective towns and so afforded, according to the general law, the conditions for an abrupt increase of enteric fever in these its endemic or perennial soils[408].

While the more or less steady or endemic prevalence of typhoid fever is due to the formation and reproduction in the soil of an infective principle (probably of faecal origin) which affects more or less sporadically the individuals living thereon, after the manner of a miasma rising from the ground, there have been some hardly disputable instances of the infection being conveyed to many at once from a single source in the drinking water and by the medium of milk[409]. But such instances, suggestive though they be and easy of apprehension by the laity, must not be understood as giving the rule for the bulk of enteric fever. In like manner, the escape or reflux of excremental gases from pipes or sewers, or the leakage into basements or foundations from faulty plumber-work, are causes, real no doubt, but of limited application, which do not conflict with, as they do not supersede, the more comprehensive and cognate explanation of enteric fever as an infection having its habitat in the soil and an incidence upon individuals after the manner of other miasmatic infections. Sex has little or nothing to do with the incidence of the infective virus. As to age, enteric fever rarely befalls infants, and, in the general belief of practitioners, is a less frequent cause of death among children than among adolescents and adults.

In the following Table from the Registrar-General’s Decennial Review, 1871-80, enteric fever is not separated from other continued fevers. It is probable that a considerable ratio of the deaths from 0 to 5 years are due to febrile disorders other than enteric.

Annual Mortality per million living at all ages and at eleven groups of ages, males and females, from fever (including Typhus, Enteric Fever and Different Forms of Continued Fever) 1871-80.

All ages 0- 5- 10- 15- 20- 25- 35- 45- 55- 65- 75+

Both sexes 484 651 518 439 543 509 411 379 402 458 553 498 Males 494 644 483 390 513 579 436 395 437 503 629 593 Females 477 658 550 487 573 445 387 362 369 418 488 425

The cases notified under the Act in 1891 and 1892 have been found to average five or six for every death registered in the corresponding districts, the rate of fatality ranging widely. It is matter of familiar knowledge that many of the attacks and fatalities occur among the richer classes. New comers to an endemic seat of the disease are most apt to take it (this has been elaborately shown for Munich, and holds good for the British troops in India). There are undoubtedly constitutional proclivities to it among individuals, which may run strongly in families. As in other miasmatic infective diseases, such as yellow fever, Asiatic cholera, and (formerly) plague, there seem to be occasions in the varying states of body and mind, as well as in the external circumstances, when the infection of enteric fever is specially apt to find a lodgement and to become effective. The old plague-books gave lists of the things that were apt to invite venom or to stir venom (see former volume pp. 212, 674); and it is probable that some of these hold good also for the incidence of enteric fever.