Chapter I · (continued 5)

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 15¹⁶⁄33

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 50s. in 1821, and 40s. 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

Year Death-rate over all. One in Death-rate under five. One in Year Death-rate over all. One in Death-rate under five. 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.

Deaths from typhus fever Under ten years Over ten years Fever-deaths per cent. of deaths from 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 Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th 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 deaths in 1838 Typhus deaths 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.