Essays on the sources and mode of action of fever

I. Thackeray Prize Essay

Essay on the Sources and Mode of Propagation of the Continued Fevers of Great Britain and Ireland.

BY WILLIAM DAVIDSON, M. D.,

Senior Physician to the Glasgow Royal Infirmary, Lecturer on Materia Medica, Member of the Faculty of Physicians and Surgeons of Glasgow, &c.

CHAPTER I. On the Sources of Continued Fevers

Numerous kinds of continued fevers have been described by authors ; but many of these have been found, on investigation, only particular varieties, in place of being distinct species. This has been particularly the case with typhus, the most prevalent kind of continued fever in this country; and it may be accounted for, from its numerous and diversified complications giving rise to various and multiform symptoms. The pathology of typhus, however, of late years has been considerably advanced ; and it is now established, that this disease may be either simple or complicated, with organic affections of one or all of the different cavities of the body.

We shall not, at present, enter into any discussion respecting the various kinds of continued fever that are to be met with in the United Kingdom; but as perspicuity in arrangement requires some classification, we shall adopt the following, reserving the illustrations upon which this classification is founded for a future part of the essay : —

1. Typhus.

2. Febricula or Simple Fever.

3. Gastric or Intestinal Fever.

These affections seem to be distinct species of disease, differing

in their symptoms, causes, and laws ; and are generally treated in

private practice and in hospitals as continued fevers. To this list

l* may, perhaps, be added bronchitis, which, although an inflammatory affection, is more frequently confounded with them than any other disease.

Sect. I. — Sources of Typhus.

It appears to us quite unnecessary here to describe what is understood by typhus fever ; as we assent to the general correctness of our standard authors upon this subject, and as some of their descriptions will be quoted in another part of this essay. At the same time, it may be remarked that typhus possesses an advantage over the other forms of continued fever, in having a distinctive characteristic, viz. the eruption, which is present in none of the others, and which is now almost universally acknowledged as decisive of its existence. It must, however, be admitted that typhus can and does occur, without its characteristic eruption ; but it is equally certain that the large majority of patients who have decidedly the general typhoid symptoms, are more* or less spotted with this efflorescence. It is therefore the sources of typhus, as generally so characterised, which we mean to trace in this section.

There is considerable diversity of opinion amongst British physicians respecting the causes of continued fevers; but certainly the majority of authors have adopted the belief that typhus is propagated by contagion. The opinion of the majority appears to be supported by the facts connected with the progression of the disease ; it shall therefore be our object to establish this point. It is not intended, however, to enter into any speculations respecting the primordial source of the contagion of typhus; for the sources from which it, as well as that of other contagious fevers, originated, is involved in absolute obscurity ; and though we could trace them to the most remote era in antiquity, the same difficulty would be en-' countered. Some authors, apparently to get rid of this difficulty, and to account for the occurrences of typhus where no contagion could be traced, have adopted the opinion that it may be generated by common causes, such as impure air, filth, <fcc, and be afterwards capable of propagation by contagion. 1 The- argument of analogy is directly opposed to this belief; for if, in nature, there be no exception to the law, that two causes are never required to produce precisely the same effect, it will follow that whatever cause can be best reconciled with the phenomena of typhus, must be considered the true source of the disease. But, in order to apply this principle more immediately to the subject, it may be necessary to appeal to the various morbid poisons, the laws of which are known and generally admitted. The first we shall notice, are those which are admitted by all writers to be propagated by one cause only ;

1 The terms contagion and infection are used synonymously, as indicating the ponderable or imponderable matter, which is generated in a diseased living body, and which is capable of producing the same disease when applied to another.

viz. matter, whether ponderable, as the pus contained in a variolous pustule, or imponderable, as the effluvia issuing from a patient labouring under small-pox. Measles, scarlet fever, hooping-cough, are propagated only by the effluvia which are generated by the patient ; and though the material body by which it is effected cannot be collected into vessels, like the various gases, still the proofs, upon which their contagious qualities are based, are as unquestionable as those of small-pox. Almost all the contagious diseases of the skin, such as syphilis, scabies, the yaws, si wens, &c, furnish examples of propagation by only one cause, viz. contagion. There are no doubt authors who maintain that some cutaneous diseases are generated by filth, &c, such as some of the infectious species of porrigo; but of this there is no proof; and in all probability it is equally unfounded, as was a similar hypothesis respecting the origin of scabies. These diseases always retain the same characteristics ; the one is not convertible into the other ; and no known combination of them can generate a new contagion capable of perpetuating a new disease. A specious objection might be brought forward against the introduction of an analogy from chronic contagious diseases, which are only propagated by contact, according to the general belief; and besides are regulated in other respects by different laws, whereas typhus is propagated only by effluvia. It is quite evident that a class of diseases may be recognised by one leading and undeviating law, while they differ in many of their subordinate characters; and yet this peculiar law of similarity between them may be as certain and definite as if they had been united into one family by all their habits.

The effluvium which issues from a small-pox patient must be as essentially matter, as is the fluid of a variolous pustule ; for though the first cannot be collected in a separate form, it must possess one or other of the properties of small-pox matter, else it could not induce the disease: the only difference between them consisting in this, that the contagious matter is fluid in the one case and effluvial in the other. It is necessary that the foregoing observations respecting contagious diseases be kept in view; for upon the analogy between them and typhus we mean to establish an argument, that the latter disease can only be propagated by one cause. If it be true, then, that all the contagious fevers known can be propagated only by contagious matter, and by no other cause, however much their contagious qualities, their prevalence, and their fatality may be increased by other causes, it must follow from the law of analogy that if typhus can be proved to be contagious, it must also be propagated only by one cause, viz. contagion. We shall, therefore, endeavour to prove this point ; and, in the outset, it may be stated, that we do not mean to fatigue the reader by stories about fomites and persons who have carried the contagion about them for months or years, nor to hunt out a particular individual who has conveyed it from one town to another. In place of accumulating evidence of this kind, which although sometimes very conclusive, is in other cases somewhat questionable, we shall select a few facts from the history of our British and Irish hospitals, which, we trust, will be sufficient for our purpose; for if it can be established from these documents that the disease was contagious in all the large hospitals of Britain and Ireland, then it must be more or less so in every other place.

In selecting the facts, we shall adduce the most conclusive instances, such as where the whole, or almost the whole, of the attendants of the patients affected with typhus were infected; for were the whole body of evidence existing on this subject accumulated in this essay, the argument would be encumbered, and the proofs perhaps rendered less convincing. Those who deny the existence of typhous contagion, may assert that this is unfair, and that those hospitals also should be brought forward, where the medical and other attendants were rarely affected. As we shall, however, notice this and other objections elsewhere, it need not be farther alluded to here. Drs. Barker and Cheyne, in their admirable report of the fever which prevailed in Ireland during the years 1817-18-19, state that "in the hospitals of the House of Industry of Dublin, no clinical clerk or apothecary escaped an attack of the disease ; and on the 20th of January, 1819, it was reported to government that five of the medical attendants of the House of Industry were at that time lying ill of the disease. In the city of Cork, nine physicians, in attendance either on dispensaries or fever hospitals, were attacked ; every medical attendant at the South Fever Asylum, in that city, suffered. At the hospitals of the House of Industry, one hundred and seventy persons were employed in different offices of attendance on fever patients ; and from this part of the establishment were recorded one hundred and ninety eight cases of fever." In Dr. Crampton's medical report of the department of Steevens' Hospital, it is observed, "that, with the exception of Dr. Harvey and himself, all those concerned in attendance on the patients caught the disease; none of the nurses, none of the porters, barbers, or those occupied in handling, washing, or tending on the sick, escaped, and many of them had relapses and recurrences of fever.'" Dr. Bracken, in his report of the Fever Hospital of Waterford for 1818, states that "there were twenty-seven attacks and relapses of fever among the nurses, servants, and porters, whose number fluctuated according to the demand for them, but who, on an average, may have been about twenty-two during the year." He farther states that "the present year, 1819, bears a close resemblance to the last, in respect to the nurses and servants being attacked with fever, eighteen of the former having suffered under the disease; seven of them once, three twice, and one three times. The apothecary, who had not been long in the hospital, caught fever and relapsed twice. During his illness, a young man, who performed part of his duties, was attacked after a short attendance. A temporary apothecary was then engaged for a few weeks ; but he

1 Barker and Cheyne's Report of the Fever in Ireland, vol. i. p. 135.

had not been many days in his new employment when he also contracted a fever." 1

Drs. Barker and Cheyne remark that clergymen, who visited typhus patients in Ireland during the epidemic, were also observed to suffer in a very remarkable degree ; and they quote the following passage from Dr. Stokes's Essay on Contagion, which was published at a time when the fever had made little progress in Dublin : — " The deaths from fever recorded in Saunders's News- Letter, from August 1st to December 12th following, are sixty-four, and of these nineteen are of clergymen of some of the different persuasions, or of medical men of different descriptions, which appear greater than the proportion which these two classes bear to the whole of those whose deaths we may suppose were mentioned in that manner." 2 Dr. Tweedie, in his Clinical Illustrations of Fever for 1828-29, observes that " the London Fever Hospital is placed in an open space, situated in the vicinity of the metropolis, close to the Small-pox Hospital. Both these establishments stand in the centre of a large field, where the production of malaria is extremely improbable. I can state from the most authentic sources, that every physician who has been connected with it, with one exception (the late Dr. Bateman), has been attacked with fever during his attendance, and that three out of eight physicians have died. The resident medical officers, matrons, porters, laundresses, and domestic servants, not connected with the wards, and every female who has ever performed the duties of a nurse, have one and all invariably been the subjects of fever ; and to show that the disease may be engendered by fomites in clothing, the laundresses, whose duty it is to wash the patients' clothes, are so invariably and frequently attacked with fever, that few women will undertake this loathsome and frequently disgusting duty. Last summer, a most convincing illustration of contagion occurred. The present resident medical officer was attacked with fever, and it was necessary, in consequence, to appoint some one to perform his duties during his illness. The first person who officiated for him resided constantly in the house during the day, but took the precaution of sleeping at home. He was, of course, very much exposed in the wards in the performance of his duties. These, however, were soon interrupted by an attack of fever, which confined him for a considerable time. The duties were then undertaken by a medical pupil, who had completed his education, and entered the hospital in the most robust health. He had been taught, and did implicitly believe, in the non-contagious nature of fever, and ridiculed the idea of any personal danger from residing in the hospital. He performed the duty of house-surgeon for ten days only, when symptoms of a severe fever appeared." 3

1 Barker and Cheyne's Report of the Fever in Ireland, vol. i. p. 276.

2 Ibid. vol. i. p. 138.

3 Tweedie's Clinical Illustrations of Fever, p. 87.

Dr. Tweedie also adduces some important facts connected with the fever which prevailed in Edinburgh during the year 1817, which are the following: — Owing to the prevalence of fever at Edinburgh in 1817, it was necessary to apply to government to permit Q,ueensbury House to be employed as a fever hospital : " In the immediate neighbourhood of this extensive building fever was decidedly less prevalent than in any other quarter of the town. All those, however, who resided in the hospital, including the resident house-surgeon, clerks, apothecary, and nurses, were successively attacked." The following is Professor Alison's report on this subject. u When dueensbiiry House was formerly occupied by fever patients, every resident clerk and every nurse in the house were successively affected with the disease; and since it was reopened in December last (1826), the resident physician, two of the clerks (who have not been resident, but have been several hours in the day in the house), the apothecary, several servants, and all the nurses except two, in all above forty individuals, who had necessarily close intercourse with the sick there, have had fever. If this be the effect of a malaria, it must be a very virulent and effective one, and it is reasonable to expect that some record of similar visitations in the former history of the building would be found. But Q,ueensbury House has existed for about a century-; it was long occupied as a private dwelling-house by the noble family of that name ; afterwards it was occupied by a number of families, and afterwards as a soldiers' barrack ; and yet no record can be found of its having been, during these changes ; the seat of an epidemic fever.

If a malaria has existed, therefore, in that house, it must, on both occasions, have sprung up exclusively at the times when fever patients were removed thither and lasted only during their stay. During the present epidemic (1827-28, as well as that of 1817-19), many of the clerks and nurses employed in the Royal Infirmary have taken fever. Since November last, six of the clerks employed in the clinical wards only, four of those employed in the ordinary wards, and twenty-five nurses or servants have taken fever. All these persons had necessarily frequent and close intercourse with the fever patients in the house, having been employed more or less constantly in the fever wards, excepting only four of the servants. Of these four, two had been employed in the laundry, where the linen from the fever wards was washed. One was a porter employed at the gate, who would, of course, have communication with the fever patients at their entrance and dismissal, as well as with their relations coming to visit them; and one was a nurse employed in the servants' ward, but who was in the habit of visiting the fever wards." He adds further: " No one of the nurses, whose duty has confined them to the medical or surgical wards, where no fever patients were admitted, has taken fever, with the single exception of the woman in the servants' ward above mentioned ; and of the numerous patients in these ordinary wards, the only one who ims taken fever, within my knowledge, during the present year, was a patient in the men's general clinical ward, who lay in the bed next the door that communicates with the clinical ward."' Dr.

West, in his account of the cases of typhus exanthematicus that occurred in St. Bartholomew's Hospital in 1837-38, states that "since last summer, eleven gentlemen who were in the habit of frequenting the hospital have been attacked by the fever, to which three have fallen victims ; sixteen nurses and twenty-one patients admitted for other affections, have likewise suffered from the disease, which terminated fatally in ten instances, and I do not doubt but that many similar cases occurred which did not come under my notice." 2 Dr. Roupell, also, gives similar testimony in reference to St. Bartholomew's Hospital, and states that " amongst the nurses in attendance upon the sick, in that establishment, infection was almost universal." 3 In the Glasgow Fever Hospital, which is capable of containing 220 patients, during the last six or seven years almost every clerk and nurse of that establishment have caught fever while acting in the wards, unless they had previously laboured under the disease. On the other hand, the nurses connected with the medical and surgical wards, in the adjoining building, have almost uniformly escaped. Occasionally a case has appeared in the medical and surgical wards; but this fact ought to be coupled with the statement, that now and then typhus cases are sent, by mistake, into the medical wards, and cases of bed-sores, gangrene of the feet, &c. are transmitted from the fever hospital to the surgical wards. Dr. Cowan states that "All the gentlemen who have acted as clerks in the fever hospital for many years past have been attacked with fever, unless they had it previously to their election. During last year, twenty-seven of the nurses of the establishment were seized with fever, and five of them died: several of the students have been affected. One gentleman who acted as apothecary died in the house ; and if I have escaped, it must be attributed either to being past the period of life at which fever usually takes place, or to my being secured by having had two dangerous attacks at an earlier period of my career, when acting as physician's clerk in the infirmary, during the epidemic of 1816- 17-18." 4

Dr. Mateer gives a table of 9,588 cases, which were admitted into the Belfast Fever Hospital, from 1818 to 1835, showing the number of patients who had any communication with affected persons, either by residence in the same house, or by belonging to the same family. He draws the following conclusion from the table: "It thus appears that the number of families where contagion is traceable is 1,856, that the total number of persons belonging to them is 7.246, making an average of nearly four individuals to each family;

1 Tweedie's Clinical Illustrations of Fever. Edinb. Med. and Surg. Journal, vol. xxviii. p. 238. 2 Ibid., July, 1838, p. 143. 3 Roupell on Typhus. 4 Cowan's Vital Statistics, p. 26- and that the single cases, where the disease seemed to have arisen from other sources, amount only to 2342." 1

This assemblage of facts has been drawn from the large hospitals in England Scotland, and Ireland, and the observations have been made during various years and during different epidemics by gentlemen of the highest talents and respectability ; their authenticity cannot, therefore, for a moment be questioned. The simple relation of these facts would, we think, with the majority of men, produce conviction that fever was at least contagious in these hospitals, provided the mind was not preoccupied with an opposite theory; but a few observations will tend to produce a proper estimation of this testimony. It is quite obvious, that where a much larger proportion of persons is affected with any particular disease, in any particular place, than occurs amongst the general community, or in any particular grade of society, there must be some local cause for that increased ratio. This has, manifestly, been the result in the fever hospitals that have been enumerated ; for in all, a very large majority of the attendants, and in some the whole of them, were affected with fever. Now, no one will contend, that even amongst the lower classes (who generally suffer from fever to the greatest amount), such a proportion has ever been maintained, even in our most severe typhoid epidemics ; but if the number of hospital clerks be taken and compared with the unaffected number, in the particular grade of society to which they belong, such an attempt would be ridiculous ; for the united testimony of the hospital physicians of England, Scotland, and Ireland (whose statements we have already quoted) amounts to this, that almost every clerk of a fever hospital has laboured under fever during some period of his attendance upon it. It may be contended, in answer to this argument, that the atmosphere of the hospitals was contaminated by the exhalations arising from the number of patients an»d -th^-want of proper ventilation ; but the same process of -atmospheric deterioration ought to take place, in the medical and surgical wards, if they be equally filled, which is generally the case; and in the latter wards there are often, in addition to the ordinary exhalations, the effluvia arising from wounds, ulcers, &c, yet typhus rarely, and only in sporadic cases, springs up there.

The opponents of contagion, however, endeavour to explain the prevalence of fever among hospital attendants by the hypothesis, that the same cause that produced it in the filthy, ill-ventilated houses of the lower classes is in existence in these institutions; viz., a peculiar malaria, generated chiefly in large towns. If this hypothesis were true, it would follow, as a necessary consequence, that the other parts of the building, beingf similarly situated, would be subjected to the same malarious effluvia, and hence its inmates would be affected with the same kind of disease ; but this has never occurred in any of the large hospitals already alluded to, nor in any other, so far as we are aware, where patients affected with typhus are kept exclusively in one place. Again, it may be asserted by the noncontagionist, when driven to the last extremity, that though malarious effluvium be not generated in an hospital, it may be carried there by the clothes of the patients, and the attendants may be infected by coming into contact with them. The analogy of malarious diseases is in opposition to this belief; for it is not found that a patient labouring under ague infects any person who has not been in the malarious district; neither, according to the general belief, does a patient labouring under yellow fever, when removed from the quarter where he caught the disease, excite contagion in the vicinity of his new residence. But as this supposed typhoid malaria may be assumed to possess something sui generis, an argument stronger than analogy can be adduced, viz., the impossibility of carrying any principle of that kind into the wards. It is the practice, in many of the large fever hospitals, to remove the clothes of the patients, to bathe them, shave their heads, and give them clean linen, before they are sent into the wards. This plan is adopted in the Glasgow Fever Hospital, and the following is one of the regulations of the Waterford Hospital.

Dr. Bracken states, that " according to one of the regulations of the hospital, every patient has his hair closely cut at the time of his admission ; he is also well washed with warm water and soap, and supplied with linen before he enters the sick ward." 1

Sect. II. — On the Analogy of Typhus to Exanthematous Fevers.

Having discussed the most important and specious hypotheses which have been brought forward to explain the general and ultraproportionate prevalence of fever among the attendants of the sick in large hospitals, independent of the operation of contagion, we shall take notice of the general objections to the doctrine of contagion in typhus fever; and these maybe comprehended in the statement, that it is not characterised by the laws of other contagious fevers. Before entering upon this part of the subject it may be remarked, that more importance is generally attached to this argument than it merits; for though, in the absence of facts, analogy is the most conclusive process of reasoning that can be employed, yet, undoubtedly, when facts are opposed to the application of this principle in any individual case, the facts have the preponderance over the analogy. And, though we were unable to prove that typhus was analogous, in its leading characteristics, to the contagious exanthemata, yet if it be admitted that there is no theory which can explain satisfactorily the facts regarding the prevalence of the disease in hospital attendants, except that of contagion, the case would be conclusively determined, even in opposition to the analogy, and would be set down either as an exception, or as one of a new series of contagious diseases. It fortunately happens, however, that the law of analogy will be little violated by cornparing typhus with the contagious fevers, for in its leading characteristics it resembles them pretty closely; at the same time it ought to be observed, that typhus fever has only, of late years, been examined with sufficient care, as to many points, connected with its history, laws, and pathology, and that it labours under the disadvantage of being frequently confounded with other continued fevers, to which, in its early features, it bears an intimate resemblance ; so that the same certainty of analogical conclusion cannot be expected, as exists among the other exanthematous fevers. We shall endeavour, however, to show, by the facts which shall be quoted, that typhus comes distinctly within the range of their analogy, and that though it is not so regular in its progress, nor so certain in its eruption as smallpox or measles, yet that it differs as little from scarlet fever, in these respects, as the latter differs from smallpox.

The principal laws of the contagious exanthemata are the following :

1. The contagion can be traced in families, hospitals, schools, &c, and those exposed to it are very generally infected.

2. They only affect persons once during their lives.

3. They are characterised by an eruption, which has a rise, progress, and decline, and the disease cannot be checked in limine.

1. The contagion of typhus is traceable in hospitals, schools, families, fyc. In determining the contagious nature of any disease, it is not necessary that we should be able to trace every case, or even the majority of a particular amount of cases, to a communication with an infected person, or to exposure to a particular fomites; for this would imply that we could, like an American Indian, discover the trail of a patient and trace him through all the windings of a large city, and, besides, should investigate the history of every individual whom he has passed or rubbed shoulders with in every narrow and dirty alley. Even in smallpox, measles, and scarlet fever, any attempt of this kind to trace the contagion regularly would be fruitless, and for the very same reason. Smallpox was, at one period, believed by some authors to originate in filth, because it was found impossible, in numerous cases, to account for its existence in certain localities upon the principles of contagion. Dr. Adams remarks, that " many children born in London live for several years without receiving the smallpox. In the same neighbourhood a person arrives from the country, and without any apparent intercourse with an infected person is attacked by the disease." 1

Independent of the many exposures to infection, which are perfectly unknown and undiscoverable by the patient, it is very difficult to ascertain the facts connected with the ordinary movements of a patient, which, in many cases, can only be elicited by tedious

1 Adams on Morbid Poisons.

DAVIDSON ON THE CAUSES OF FEVER.

cross-examinations; so that this method of determining the point is liable to many objections, and greatly inferior in conclusiveness to the evidence derived from the spread of a disease in any large school or hospital ; but, certainly, it tends to prove the doctrine of contagion in typhus as much, if not more, than it does in smallpox, &c, as will appear from the following table. The whole of the eruptive cases of typhus, in which this point was investigated, and that were admitted into the Glasgow Fever Hospital from 1st May to 1st November, 1839, are included only in this table, the males and females being classed together.