“It is only by a universal, or nearly universal sweep of the sick into

Fever Hospitals, joined to a universal or nearly universal

purification of their dwellings, that anything is to be hoped for in

the way of suppressing our epidemic. So far as this grand object is

concerned, all the rest is folly: it is worse than folly[332].”

This was the well-meant but somewhat fanatical application of a trite and

commonplace notion. It was well understood by reflective persons at that

time, who were quite sound on the contagiousness of fever, that the whole

question of segregating the poor in fever hospitals was beset with

difficulties, not merely of expense but also of expediency. A Select

Committee of the House of Commons sat upon it in 1818, and published their

report, with the minutes of evidence, on the 20th May. So much had been

said in Parliament by Peel and others, and said so truly, of the spreading

of fever all over Ireland by whole families turned adrift in beggary, that

the Select Committee were full of ideas of contagion, and of the great

opportunity of suppressing fever by destroying its germs or seeds. But

they had soon occasion to learn that a fever may be potentially

contagious, yet not contagious in all circumstances, and that segregation

in fever hospitals had a rival in dispersion through general hospitals.

Half-a-dozen London physicians of position, answering respectively for

Guy’s, St Thomas’s, the London, St Bartholomew’s, St George’s, the

Westminster and the Middlesex Hospitals, declared that they mixed their

cases of contagious fever in the ordinary wards among the other patients;

and when asked by the astonished Committee whether the fever did not

spread, they answered one after another with singular unanimity, “Never,”

which under cross-examination, became in one or two instances, “hardly

ever,” as, for example, in the evidence for St Thomas’s Hospital, where a

sister and a nurse had caught fever and died. The point of this London

evidence was that the great safeguard against febrile contagion was free

dilution with air, and that the great provocation of a contagious

principle was to “concentrate” the cases of fever[333]. The Bristol

experience in the same epidemic, although it did not come before the

Select Committee, was wholly in agreement with medical opinion in London.

The fever-cases there were received either into St Peter’s Hospital, which

was the city poor-house, or into the General Infirmary. The former was an

old irregular building, badly ventilated, in which the contagion spread

freely to the ordinary inmates and became very virulent. Contrasting with

the apartments of the old poor’s house, the wards of the Bristol General

Infirmary were spacious, lofty, well-ventilated:

“Here the patients labouring under fever were dispersed among invalids

of almost every other description; so that, whatever effluvia emanated

from infected bodies became immediately diluted in the mass of air

free from such pollution. Here, accordingly, no instance occurred of

the propagation of fever. None of the nurses were attacked, nor were

patients lying in the adjacent beds in any instance infected, though

cases of the worst description, some of them exhibiting all the

symptoms of typhus gravior, were placed promiscuously among the other

patients, scarcely two feet of space intervening between the

beds[334].”

The same practice was kept up in the Edinburgh Infirmary until 1858 or

longer; Christison, who gives a diagram of an ordinary ward with four

fever-beds in it, declared in 1850 that there had been no spread of fever

for fifteen years before, except on one occasion, when the rules of the

house were neglected[335]. The bold policy of dispersing fever-patients

among the healthy was begun by Pringle and Donald Monro during the

campaigns of 1742-48 and 1761-63 in the Netherlands and North Germany.

They found that concentration raised the contagion to high degrees of

virulence and that dispersion weakened it to the point of non-existence,

Monro’s success at Paderborn in 1761 having been of the most signal

kind[336].

The Select Committee of 1818 were more influenced by what they were told

of the good effects of the earliest Houses of Recovery, at Waterford,

Manchester and other places in the end of the last century. For several

years after their opening they were little needed, the epidemic which gave

the immediate impulse to their establishment having subsided in due time

both in the towns provided with Houses of Recovery and in the innumerable

places where no such provision had been made. The recommendations of the

Committee do not appear to have been carried out; for the London Fever

Hospital, in Pancras Road, which had been enlarged to seventy beds when

the epidemic began in 1817, remained the only special fever hospital in

London until the establishment of the hospitals of the Metropolitan

Asylums Board in 1870[337].

* * * * *

The confusion of commerce, depression of trade and lack of employment

which followed the Peace of Paris, and gave occasion to the British and

Irish epidemic fevers of 1817-19, gradually righted themselves. The price

of wheat, which would have been still higher after the four-months drought

of 1818, but for large imports, gradually fell, and was about 50_s._ in

1821, and 40_s._ in the winter of 1822-23. After that, it rose somewhat

again, and the third decade of the century, in the middle of which

occurred the great speculative crash of 1825, was on the whole a hard time

for the working classes. The history of fever has few illustrations

between the epidemic of 1817-19 and that of 1826-27, excepting the great

famine-fever of Connemara and other parts of the West of Ireland in 1822,

elsewhere described, which coincided with a somewhat prosperous time in

England and called forth a princely charity[338].

The Relapsing Fever of 1827-28.

The epidemic of relapsing fever which was at a height in Dublin in 1826,

did not culminate in Edinburgh, Glasgow, and other towns of Scotland until

1828. It was a somewhat close repetition of the epidemic of 1817-19,

except that it was chiefly an affair of the towns, owing to depression of

trade and want of work following the great crash of commercial credit in

1825-26. In Glasgow, the admissions for fever to the Royal Infirmary began

to rise in 1825[339]:

_Glasgow: Admissions for Fever._

Year

1824 523

1825 897

1826 926

1827 1084[340]

1828 1511[340]

1829 865

1830 729

At Edinburgh the cases of fever treated in hospital were fewer in ordinary

years than at Glasgow, but they rose to a higher point in the epidemic

years[341]:

_Edinburgh: Admissions for Fever._

Year

1824 177

1825 341

1826 (nine months) 456

1827 1875

1828 2013

1829 771

1830 346

Christison gives the following account of the epidemic in Edinburgh in

1827-28:

“Like that of 1817-19, it arose in Edinburgh during a protracted

period of want of work and low wages among the labouring classes and

tradespeople; it prevailed only among the working classes and

unemployed poor--in the Fountainbridge and West Port districts, the

Grassmarket ‘closes,’ the Cowgate and the narrow ‘wynds’ descending on

either side of the long sloping back of the High Street and

Canongate.” The fever had the same three types as in 1817-19--many

cases of inflammatory, or relapsing, or synocha, a few of low fever

(typhus), and some between the two--militant or inflammatory for a

week, then becoming low, and running the continuous course of

typhus.... “The inflammatory fever presented the same extreme violence

of reaction as in the former epidemic--the same tendency to abrupt

cessation, with profuse sweating--the same liability to return

abruptly a few days afterwards--and the same disposition to depart

finally in a few days more, and again abruptly with free perspiration.

The cases of typhus were more frequently severe than in 1818-19.

Icteric synocha occurred also oftener, although far from

frequently[342].”

The epidemic of relapsing fever in 1826-28, which made a great impression

in the towns of Ireland and Scotland, has left few traces in specially

English records. But it is clear that there was some increase of fever

about the same time in London; and it becomes a matter of interest, as

well as of no little difficulty, to ascertain the type or types of the

same. It was just after this quasi-epidemic in London that Dr Burne

published his essay on fevers, the preface bearing the date of 28th

February, 1828[343]. The materials of this essay came from Guy’s Hospital,

and they were both clinical and anatomical. The author seeks to find a

common name for all varieties of continued fever, the name that he chooses

being “Adynamic Fever.” “By far the greater number of cases,” he says,

“are of the first or second degree only of severity, and not dangerous.”

These were cases of “simple continued fever,” or fever of short duration,

with flushed face, suffused eyes and other signs of the “inflammatory”

type, or of synocha. Although Burne does not give the exact proportion of

cases with relapse, as Bateman had done for the London epidemic of

1817-18, yet he makes it clear that relapses did occur, and he discusses

the phenomenon in a manner which makes his testimony interesting:

“Convalescents are more liable to a relapse after the adynamic fever than

after any other disease; and this may be accounted for by the very

enfeebled and exhausted state in which the powers of the system are

left.” His relapses were obviously a return of the original fever,

beginning again suddenly in the midst of convalescence with flushing of

the face, headache, dry tongue, and scanty urine, and with a great access

of febrile heat in the night, a disturbance of the system which generally

continued for several days, while in some it went off sooner with a

diarrhoea. He assigned three principal causes for the relapse--overloading

the enfeebled but craving stomach, walking out in the open air too soon,

and giving way to emotion[344].

The references to relapse apply almost certainly to fevers of the shorter

periods (synocha or “inflammatory” fever), and not to those cases of

enteric fever which did undoubtedly occur in the practice of Guy’s

Hospital in the same seasons.

Typhoid or Enteric Fever in London, 1826.

The identification of enteric fever and relapsing fever respectively, or

the separation of each from typhus, became actual in Britain at one and

the same time. I have already said all that seems necessary as to the

earlier appearances of relapsing fever on the stage of epidemiological

history. This will be the fitting point in the chronology, the third

decade of the 19th century, to bring in the question of enteric or typhoid

fever. As to its identification, or recognition as a distinct species,

that was not really completed, to the satisfaction of everyone, until the

elaborate analysis of the symptoms respectively of typhus and enteric

fevers by Sir William Jenner in 1849-51[345]. But, for ten years before

that, the co-existence with maculated typhus of a different long-period

fever, having abdominal symptoms and abdominal lesion, had been

recognised, and the characteristic ulceration or sloughing of the

lymph-follicles of the ileum, with sphacelation of the mesenteric

lymph-glands, had been clearly described by several London physicians and

depicted in coloured plates, in the years 1826 and 1827, during an unusual

prevalence of such cases in London. The authentic history of enteric fever

in Britain really begins with these writings by physicians of St George’s

and Guy’s Hospitals. But, as it is improbable that the type of fever was

absolutely new in the years 1825 and 1826, it may be asked whether the

enteric type cannot be discovered in the old accounts of British fevers,

and if so, whether we may assume in the past as much enteric fever

relatively to spotted typhus, relapsing fever, or simple continued fever,

as in the period after 1850.

Having adverted to this point from time to time in the preceding history

as it arose, for example in connexion with Willis’s fever of 1661,

Strother’s fever of 1727-29, the Rouen fever of 1750, and other instances

both in children (remittent or convulsive or comatose fever of children)

and in adults, I shall not recapitulate farther back than the beginning of

the 19th century.

There was a certain amount of post-mortem observation in the 18th century,

especially in camp sicknesses, by Pringle and others; but there is no

trace of intestinal ulceration among their fatal fevers. It was found,

however, in the epidemic of 1806 among the troops at Deal, and it is

probable that Ferriar’s cases at Manchester about 1804, and Bateman’s

cases of continued fever in London from 1804 to 1816, were in some part

enteric, although the anatomical test is wanting. That was a period when

there was singularly little of the old London fever in the houses of the

poorer class. Then came the remarkable “constitution” of relapsing or

simple continued fever, from about 1816 to 1828, the relapsing character

of which was far more obvious in Ireland and Scotland, than in London,

Bristol, or elsewhere in England, but was not altogether unobserved in

London, whether in 1817-19 or in 1827-28. The relapsing type disappeared

after that for fifteen or twenty years, and was replaced by typhus more

maculated than had been seen for many years. But, before the relapsing or

simple continued fever disappeared for a time, enteric fever was seen in

London in company with it.

The chief season of enteric fever in London was the autumn of 1826,

following a long period of great drought and heat. The remarkable weather

of that season was the same in England, Ireland and Scotland, and is thus

described for the last by Christison:

“The spring and summer seasons of that year were remarkable for the

extraordinary drought and heat which prevailed for many continuous

months. No such seasons could be recollected by anybody, and assuredly

there has been nothing similar in this country since.... The fine

weather set in with the beginning of March, and continued, with

scarcely a check, well into the autumn.... The drought prevailed and

the heat increased till the middle of June, when a thunderstorm with

heavy rain cooled the air for a day or two. But the heat then became

greater than ever, and there was continuous sunshine and no rain till

after the middle of July, when again there was thunder and rain, after

which sun, heat and drought ruled the season once more.” The shade

temperature at Edinburgh was 84° Fahr., at 3 p.m. on three successive

days of July[346]. The two summers preceding had also been

exceptional, that of 1824 having been hot and moist, that of 1825 hot

and dry, with dysentery in Dublin.

In August, 1826, Dr Cornwallis Hewett, of St George’s Hospital, published

ten fatal cases of enteric fever, four of which had occurred in his own

practice, six in the practice of his colleagues[347]. The first was

admitted on 23 April, 1825, the latest on 3 July, 1826. While his paper

was under hand, he had read in the _Medico-chirurgical Review_ for July,

1826, some extracts from Bretonneau’s paper on “Dothiénentérite” (enteric

fever), and he pronounced the London cases to be the same as those

recently observed at Tours. Several other cases occurred at St George’s

Hospital in the autumn of 1826, three of them reported by Dr

Chambers[348]. At the very same time, there was a run of enteric cases at

Guy’s Hospital. Dr Bright says: “Fever occurred with considerable

frequency among the patients who presented themselves for admission into

Guy’s Hospital, during the months of October, November and December, 1826.

On the whole, the disease was not severe.” The more comprehensive account

of these cases was given by Burne, early in 1828, from which it appears

that the bulk of them were fevers of the shorter period, that there were

relapsing cases among them, and that some were cases of enteric fever,

verified by post-mortem examination[349]. It was the enteric cases that

attracted the notice of Dr Bright, who says nothing of the relapsing

cases, or of cases of simple continued fever. The fact that the intestinal

mucous membrane may become diseased during fever was, he says, “long known

in particular cases, but never suspected to be so general till brought

into view by the French physicians, and which has lately been illustrated

in this country with great beauty [this does not mean in plates] by the

pens of my able and assiduous friends Dr Chambers and Dr Hewett.” He gives

ten fatal cases, with coloured plates of the intestinal or mesenteric

lesion in some of them, the earliest coloured plate having been made from

a case admitted on 13 October, 1825, and the most typical plate of the

sloughing Peyer’s follicles from a case admitted on 25 November, 1826. He

gives also eleven cases of recovery, to show the benefit of treating the

diarrhoea by calomel[350]. Nearly all the cases occurred in the end of the

year, either of 1825 or 1826; and Burne confirms this when he says that

the cases with enteric lesion were found at Guy’s Hospital only in autumn.

Some two years after, in 1830, Drs Tweedie and Southwood Smith, physicians

to the London Fever Hospital, described cases of fever with ulcerated

intestine and sphacelated mesenteric glands. After that, the interest

shifted to typhus, which reappeared in London of an unusually maculated

type; so that the years 1826-30 make a somewhat distinct period in which

the new fever, with enteric lesion, was an engrossing medical topic. It is

tolerably certain that it was the unusual seasons of 1825 and 1826 which

brought enteric fever into prominence; while, as soon as it became

frequent, it could hardly have escaped the systematic apparatus of

clinical case-taking and post-mortem examination, with preservation and

drawing of specimens, for which Guy’s Hospital was already noted under the

influence of Bright and his colleagues, and in which the staff of St

George’s Hospital would appear to have been not less competent. Although

Dr Hewett, in 1826, identified his cases with the _dothiénentérite_ of

Bretonneau, yet neither he nor Dr Bright took the abdominal ulcerations or

sloughs as distinctive of a new kind of fever. They regarded them rather

as a new complication of “idiopathic” typhus fever, a “complication” which

appealed to them more on the side of treatment than of systematic

nosology; hence the writings of both physicians are occupied mainly with

the benefit of calomel in relieving the congestion of the bowels and in

checking the diarrhoea.

It is undoubted that cases of enteric fever in 1826-27 were relatively

more numerous in London than in Dublin and Edinburgh, where the epidemic

fever was almost wholly of the relapsing type. In Edinburgh, at least, the

comparative infrequency of enteric fever for years after it had been

recognized in Paris, Tours and other French cities, and had been found in

London as a common autumnal type, can be proved beyond cavil. Writing long

after of the first epidemic of relapsing fever in Edinburgh, Christison

said:

“Of enteric typhus (typhoid fever) we saw nothing then [1817-20], nor

for many years afterwards. If it might have been overlooked during

life, it could not have been missed after death. For our dissections

were many, and, to meet the bias of the day for finding a local

anatomical cause for all fevers [the doctrine of Broussais], every

important organ in the body was habitually looked to. Nevertheless we

were constantly met with the want of morbid appearances anywhere,

unless slight signs of vascular congestion in various membranous

textures be considered such[351].”

These vascular congestions were, indeed, scanned closely for traces of

ulceration, after Bright’s plates of 1828, and any little irregularity on

the surface of a congested Peyer’s patch was liberally construed in that

sense, as in Craigie’s reports subsequently. But in the Edinburgh epidemic

of 1827-29, the anatomical signs of enteric fever were wanting until the

end of it. Writing in 1827, Alison said that he had dissected 26 cases

dead of the epidemic fever, without finding intestinal ulceration in one

of them. Christison, however, says that a very few cases of enteric fever

were dissected in Edinburgh in 1829[352].

In Dublin, also, the anatomical mark of enteric fever was missed in

1826-27, in the few dissections that were made during the epidemic[353].

An opinion in a widely different sense was given on that point by Stokes

twelve years after the event, to which I refer in a note[354].

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

Working Class.

A fever with relapses, and a fever with sloughing of the follicles and

lymph glands of the intestine, were not the only novelties in the first

thirty or forty years of the 19th century. Relapsing fever and enteric or

typhoid fever were each clearly separated, at a later date, from typhus

fever. But what was the “typhus fever” from which they were at length

separated? It was a fever which came prominently into notice after the

“constitution” of 1826-29 was ended--a fever with a mottled, measly, or

rubeoloid rash, and with various other spots, on account of which it was

described by Dr Roupell in 1831, in a lecture before the College of

Physicians of London, as a “new fever[355].” It was a new fever only in

the sense in which each new febrile “constitution,” whether it were an

influenza, an epidemic ague, or a malignant typhus, was apt to be called

popularly “the new fever,” in the 16th and 17th centuries. There were, of

course, erudite men at the College of Physicians in 1831 who knew that a

fever with a mottled rash, with vibices and petechiae, and with all other

symptoms of typhus gravior, had often occurred in England, Scotland and

Ireland in former times. The “spotted fever” was perhaps the most familiar

name of typhus in the 17th century. The mottled rash, like that of

measles, was described for the fever of Cork by Rogers in the beginning of

the 18th century, and for various other English and Irish epidemics by

Huxham, O’Connell, Rutty and others. But undoubtedly the maculated typhus

was somewhat new to the generation who saw it about 1830 and following

years, the continued fevers which had prevailed in England, Scotland and

Ireland since 1816 having been for the most part the simple continued, or

synocha, with or without the relapsing character, and to some extent

enteric fever[356].

It was from 1830 to 1834 that a change in the reigning type of fever began

to be remarked in London, Dublin, Edinburgh and Glasgow, the new type

becoming more and more evident as fevers became more prevalent in the

‘thirties’ and ‘forties.’ Typhus at length became so much a spotted fever

that the question arose whether it should not be classed among the

exanthemata. In 1840, Dr Charles West, having observed “the alteration in

character which fever has undergone within the last few years,” went over

the history (but more the foreign than the English) with a view “to

illustrate the question whether typhus ought not to be classed among the

exanthematous fevers[357]:” of course he found many old descriptions of a

mottled rash or other spots, but saw no reason to make spotted typhus one

of the exanthemata. Dr Kilgour, of Aberdeen, who treated more than a

thousand cases in his fever-ward at the infirmary there from 1838 to 1840,

wrote in 1841, “I am perfectly satisfied that this fever, call it by what

name we will, is truly an exanthematous fever[358].” Previous to 1835, the

spots of fever-cases in the Glasgow Infirmary had hardly been remarked;

but after that date all cases were classed either as spotted or not, the

spotted cases being three-fourths of the whole. Besides being spotted, the

fever of the new constitution was insidious in its approach and low in its

reaction, very unlike the sthenic, militant, inflammatory synocha of the

generation before. The blood-letting which had been all but universally

used in the fever from 1816 to 1828, and had seemed to answer well, was

continued for a time in the fever of the ‘thirties.’ But it was soon found

to be injurious: the patients in the new fever were apt to faint when only

a few ounces of blood (four or six) had been drawn, whereas in the other

fever (whether relapsing or simple continued) they had often lost thirty

ounces before deliquium was reached. It was found, on the other hand, that

fever-cases in the ‘thirties’ needed wine and other cordial regimen. There

was nothing new in these revolutions, whether of the fevers themselves, or

of the opinions as to their treatment. Sydenham’s method of taking his cue

for treatment from the “constitution” of the season, which was the method

of Hippocrates, appeared to be once more the best suited to the

circumstances.

It is not easy to make out what were the circumstances of the time that

led to the supersession of simple continued fever (or relapsing fever in

Ireland and Scotland), by spotted fever or typhus gravior in all parts of

the kingdom. Sydenham would have looked, among other things, to the

weather and the character of seasons; but from 1830 onwards there was no

season so notable as the dry and hot summer of 1826, although the end of

the year 1836 was remarkably wet. The period of typhus gravior was a time

of much sickness of other kinds--the Asiatic cholera of 1831-32, the

influenza of 1831, 1833, and 1836-37, and the general unhealthiness of the

year 1837. This was also the decade when the “condition-of-England

question” was a common topic, a time of strikes and of much distress among

the working classes, as shown in the reports of the Poor Law Commission.

In Glasgow there was a considerable prevalence of fevers year after year

from the relapsing-fever epidemic of 1827-29, according to the following

table of admissions for fever to the Royal Infirmary and the special

fever-hospitals[359]:

_Admissions for Fever, Glasgow._

Year Fever cases

1827 1084

1828 1511

1829 865

1830 729

1831 1657

1832 {1589

{1148[360]

1833 1288

1834 2003

1835 1359

1836 3125

1837 5387[361]

1838 2047

1839 1529

The worst year of the series for fever was 1837, and the worst month of

that year was May, when the fever-deaths were 1 in 3·22 of the mortality

from all causes. That great access of fever in Glasgow followed

immediately upon the great strike of the cotton-spinners, on 8th April,

1837, by which eight thousand persons, mostly women, were thrown out of

work[362]. The death-rate in Glasgow was in those years as high as

anywhere in the kingdom, and was higher in the nine years from 1831 than

in the nine years preceding. The population of Glasgow, says Cowan, had

increased on the industrial side, out of proportion to its middle and

wealthiest class[363]; and to that he would attribute the higher

death-rates in the second period (right-hand side), of the following

table:

_Glasgow Death-rates._

1822-1830 | 1831-1839

|

Death-rate Death-rate | Death-rate Death-rate

over all. under five.| over all. under five.

Year One in One in | Year One in One in

1822 44·4 101 | 1831 33·8 79

1823 36·4 78 | 1832 21·67 63

1824 37·0 81 | 1833 35·7 77

1825 36·3 81 | 1834 36·3 81

1826 40·6 105 | 1835 32·6 67

1827 37·0 84 | 1836 28·9 62

1828 33·0 79 | 1837 24·6 65

1829 37·9 100 | 1838 37·9 83

1830 41·5 97 | 1839 36·1 72

The high death-rates in some of the years in the second column were owing

to special causes--Asiatic cholera in 1832, smallpox of children in 1835

and 1836, and to influenza, as well as to typhus, in 1831, 1833 and 1837.

As to the fever which prevailed from 1831 to 1836, as it was not relapsing

in type, so it was not associated with scarcity.

“The increase of fever in Glasgow,” says Cowan, “during the seven

years prior to 1837, had taken place, not in years of famine or

distress, but during a period of unexampled prosperity, when every

individual able and willing to work was secure of steady and

remunerating employment. From the close of 1836, one of those

periodical depressions in trade, arising from the state of our

monetary system, had visited this city, and deprived a large

proportion of the population of the means of subsistence[364].”

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

The epidemic of fever reached its height in Dundee about the same time as

in Glasgow, and in both towns sooner than anywhere else in Scotland or

England. One reason of this was the labour-troubles culminating in

strikes. In the twelvemonth from 15 June, 1836, to 12 June, 1837, more

than three-fourths of all the admissions to the Dundee Infirmary on the

medical side were for fever (700 cases). After the wet autumn of 1836

there were a good many cases of dysentery, of which 22 were treated in the

infirmary, with two deaths[365].

At Edinburgh, as at Glasgow, there had been an unusual amount of fever in

1831 and 1832, and a steady prevalence of it thereafter. The epidemic of

1836-39 was for the most part typhus of the winter seasons, declining each

spring and disappearing each summer, except in the summer of 1836, when

many cases came in June, July and August from airy parts of the town[366].

The climax of the epidemic was in 1838, a year later than in Glasgow and

Dundee, according to the admissions to the fever-wards of the

infirmary[367]:

_Admissions for Fever, Edinburgh Infirmary._

Year Cases

1831 758

1832 1394

1833 878

1834 690

1835 826

1836 652

1837 1224

1838 2244

1839 1235

1840 782

At Aberdeen the epidemic appears to have been later even than at

Edinburgh, if the following admissions to one of the two fever-wards (Dr

Kilgour’s) may be taken as a fair measure of it[368]:

_Admissions for Fever, Aberdeen._

Year Cases Deaths

1838 (March to December) 189 26

1839 286 29

1840 534 53

In all these large towns of Scotland, the fever was purely typhus. The

various observers all describe the fever as of the spotted kind, the

proportion of cases with spots varying somewhat.

Thus, at Glasgow Infirmary, from 1835 to 1839, there were 4202 cases

with eruption, 1270 without eruption, and 143 doubtful. And, that the

cases without eruption were not cases of enteric or typhoid, is

probable from the record kept of the fatalities in Dr Anderson’s

fever-wards[369]:

In 1885 cases with eruption, 275 deaths, or 14·58 per cent.

" 324 cases without eruption, 11 deaths, or 3·33 per cent.

" 143 cases doubtful, 7 deaths, or 4·89 per cent.

At Aberdeen, Kilgour counted 59 cases spotted in a total of 189 in

1838, 96 in a total of 286 in 1839, and 278 in a total of 534 in 1840,

all the cases, whether spotted or not, being of the same fever, which

he considered an exanthematous malady as a whole. Of 169 cases

tabulated by Craigie at Edinburgh, from 28 June, 1836, to 12 February,

1837, there were 79 with an eruption, which was usually the mottled or

rubeoloid rash.

The fatalities were relatively more in Edinburgh than in Dundee, comparing

two periods which were not the same. Of 700 cases at Dundee, from June,

1836, to June, 1837, only 50 died, or 1 in 14, notwithstanding a good many

complications from chest complaints and bowel complaints[370]. At

Edinburgh during fifteen months of 1838-39, there died 276 in 2037 cases,

or 1 in 7·3; of those cases, 1075 were in females, with 116 deaths, or 1

in 9, and 962 males, with 160 deaths, or 1 in 6[371]. The most common age

for the fever at Dundee was from twenty to forty years (416 out of 700

cases, with 26 deaths, or 1 in 16), while the most fatal age, as usual,

was from forty to sixty years, at which one person died of three attacked.

At Aberdeen, in the last year of the epidemic, the years of life from ten

to twenty had more cases (233 in a total of 657) than any other decade of

life. The average stay of a patient in the Aberdeen fever-wards was 18·67

days. The great preponderance of deaths in adolescents or adults was

clearly shown in the Glasgow fever-statistics, 1835-39.

Fever-deaths per cent.

Deaths from Under Over of deaths from

typhus fever ten years ten years all causes

4788 752 4036 11·57

The corresponding epidemic of typhus in England had the fortune to be

recorded in great part under the new system of Registration, which came

into force on the 1st of July, 1837. At the beginning of registration of

the causes of death, and until a good many years after, no distinction was

made in the published tables between typhus fever and enteric fever. But

we happen to know that the epidemic of 1837-38 was in London almost

wholly typhus, just as it was in the large towns of Scotland. Of sixty

cases in 1837-38, of which notes were kept by West, under Latham at St

Bartholomew’s Hospital, none that died and were examined post-mortem had

ulcerations, although some had congestion, of Peyer’s patches, the cases

being all reckoned typhus exanthematicus[372]. Sir Thomas Watson, who was

then physician to the Middlesex Hospital, says of the ulceration of

Peyer’s patches in continued fever:

“Since attention has been drawn to the subject, the patches of glands,

and the whole tract of mucous membrane, from the stomach to the

rectum, have been diligently explored, and the result seems to be

that, at certain times and places (in other words, in certain

epidemics), the ulceration of the inner surface of the intestine is

far less common than at others. It was comparatively rare in an

epidemic of which I witnessed some part in Edinburgh [1827-29]. Then I

came to London; and for several years I never saw a body opened after

death by continued fever without finding ulcers of the bowels. More

recently, however, and especially during the present epidemic (1838),

I have looked for them carefully, in many cases that have proved fatal

in the Middlesex Hospital, and have discovered neither ulceration nor

any other apparent change in the follicles of the intestines.” And

elsewhere he confirms the purely typhus character of the epidemic of

1838: “Our wards at the Middlesex are full of it, and scarcely a case

presents itself without these spots. We speak of it familiarly as the

_spotted_ fever; or, from the resemblance which the rash bears to that

of measles, as the _rubeoloid_ fever[373].”

From which it would appear that not even the ordinary average number of

endemic cases of enteric fever, such as might have been expected at a

hospital in the west end of London, were forthcoming in the epidemic of

1837-38, so purely was the type of fever typhus.

The deaths from this epidemic in London, from the 1st of July, 1837, to

the 31st of December, 1838, were as follows[374]:

1837 1838

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

Quarter Quarter Quarter Quarter Quarter Quarter

826 1107 1285 1176 829 788

--a total of 6011 deaths from fever, nearly all typhus, in eighteen

months. The worst London parishes were Whitechapel and St Pancras, in

which latter the fever-hospital was situated. The high mortality from

fever, which had begun before the 1st of July, 1837, continued into the

year 1839, when the deaths in London (probably including some enteric)

were 1819.

Over all England and Wales, including London, the last six months of 1837

produced 9047 deaths from “typhus,” and the twelve months of 1838, 18,775

deaths, the winter of 1837-38 having been the most fatal period. After

London, the large towns most affected by the epidemic in the latter half

of 1837 were as follows:

Deaths from

typhus in

six months

Liverpool 524

Manchester }

and Salford} 274

Birmingham 75

Bolton 75

Sunderland 72

Leeds 71

Sheffield 68

Bradford 65

Stockport 63

Dudley 54

Abergavenny 53

Wolverhampton 45

Newcastle 44

Wigan 43

Chorley 41

Swansea 36

Halifax 33

Macclesfield 33

Norwich 27

In each of the next two years the number of deaths from typhus in the four

largest towns was as follows:

Typhus Typhus

deaths deaths

in 1838 in 1839

Manchester}

and Salford} 627 416

Liverpool 573 358

Leeds 245 150

Birmingham 123 141

From nearly all the registration districts of England and Wales, deaths

from fever were returned in 1837-39, so that the contagion must have been

very widely spread in town and country[375]. In London the epidemic

declined greatly in 1839, but in many parts of England the deaths

registered as “typhus” were hardly less numerous than in 1838, and in some

country divisions they were more, as if the contagion had taken longer to

reach the villages[376]. One village epidemic in North Devon in the latter

half of the year 1839 had been observed by Dr W. Budd, afterwards of

Bristol:

The first case in the village (North Tawton, 1100 to 1200 inhabitants)

was of a young woman in a poor and crowded cottage, who sickened on 11

July, 1839; her mother, brother, and sister sickened in succession,

her father and a young infant escaping the infection. In another

cottage, four out of six were ill of fever, in another, three persons

had it, and so on, the whole number of cases treated by Dr Budd in the

village until the beginning of November being about eighty. It was

carried from North Tawton to neighbouring hamlets: thus, a sawyer who

lodged next door to the first infected cottage sickened of the fever

and, on 2 August, returned to his home in the hamlet of Morchard. As

he lay there, he was visited by a friend, who assisted to raise him in

bed: “While thus employed, the friend was quite overpowered by the

smell from the sick man’s body,” and on the tenth day thereafter

sickened of fever, which spread to two of his children and to a

brother who came from a distance to see him. Another sawyer who lodged

with the former left North Tawton ill a week after him (9 August) for

his home, also at Morchard, where he died after a period not stated;

ten days after his death his two children took the fever, his widow

escaping it. In a third instance, a widow L---- left North Tawton on

21 August to visit her brother, a farmer in the hamlet of Chaffcombe,

seven miles distant. Two days after her arrival she fell ill of fever

and recovered slowly. In the same farmhouse the mistress caught it a

month or two later and died on 4 November; the farmer himself took to

bed with the fever on the day his wife died, and came safe through the

attack. Three weeks after, an apprentice on the farm sickened, then a

lad (the fifth in order) in the end of December, then the farmer’s

sister, then another apprentice, then a serving-man, then a

maidservant, and lastly the daughter of the widow L---- from North

Tawton, who had been the first case in the house months before. This

farmhouse at Chaffcombe sent off two distinct offshoots of contagion.

The lad, who was fifth in the above series, was sent home ill to his

mother’s cottage, between Bow and North Tawton, in the end of

December. His mother sickened on 24 January, 1840, and died on 2

February. Next door to her lived a married daughter, whose whole

household were attacked. Another married daughter, who came from a

distance to visit the sick, took the infection on her return home, and

so started a new focus. From the same farm at Chaffcombe, the maid,

who was ninth in order in the above series, was sent home to her

father’s cottage in the hamlet of Loosebeare, four miles away; her

father caught the fever from her, and a farmer K----, who lived across

the road, having visited this man several times in his illness, took

the fever next, other cases following under farmer K’s. roof, and

thereafter throughout the whole hamlet of Loosebeare[377].

This was doubtless the way the epidemic spread in all the country

districts of England, the unwholesome state of labourers’ cottages, as

revealed in the reports of the Poor Law Commission, favouring it. In the

chapter on the fevers of Ireland we shall find that the contagion of

typhus and relapsing fever was dispersed in the same way, but to a much

greater extent, owing to the amount of vagrancy.

In the manufacturing towns of the North of England the fever continued at

a somewhat steady epidemic level for several years. The pathetic scenes of

typhus among the poor of Manchester in Mrs Gaskell’s famous tale of _Mary

Barton_ belong to the early part of the year 1839; but they might have

been drawn from almost any months of the two or three years following,

according to the passage cited below from the same work[378]. In 1839 the

Lancashire deaths from typhus were 1343; in Wales, Monmouth and

Herefordshire they were 1548. There is, indeed, little improvement in the

statistical returns as late as 1842. The deaths from “typhus” were as

follows in all England and Wales:

1838 1839 1840 1841 1842

18,775 15,666 17,177 14,846 16,201

The deaths from the epidemic maladies of infants and children during

the same five years were also very high.

1838 1839 1840 1841 1842

Smallpox 16,268 9,131 10,434 6,368 2,715

Measles 6,514 10,937 9,326 6,894 8,742

Hooping cough 9,107 8,165 6,132 8,099 8,091

Scarlatina 5,802 10,325 19,816 14,161 12,807

Croup 4,463 4,192 4,336 4,177 4,457

Diarrhoea 2,482 2,562 3,469 3,240 5,241

The epidemic of smallpox corresponded closely to the epidemic of

fever, the former being fatal chiefly to infants and young children,

the latter fatal chiefly to adults. Before the smallpox epidemic had

subsided scarlet fever became unusually mortal, especially in 1840,

and kept its higher level of deaths for a generation after. The

epidemic of fever, although it affected the mortality of the young

comparatively little, was indirectly a reason why many of them died of

other diseases; for the prostration of the parents, the

impoverishment, and all the other troubles associated with an epidemic

of typhus, led to inevitable sufferings among the young, which

weakened their power of resistance.

The registration returns were not tabulated (except for London) from the

end of 1842 to the beginning of 1847, but there is reason to think that

the epidemic fever was not active in the interval. It is undoubted that

the enormous construction of railroads in England during those years gave

employment and wages to multitudes, and ended the distress the sooner.

This effect of railroad-making in England was so obvious that Lord George

Bentinck desired to relieve the distress in Ireland in 1846-47 by the same

means.

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

While there is complete agreement among the hospital physicians of the

great towns that the fever of 1837-39 was maculated typhus, to the total

exclusion of cases with ulceration of the bowel, as in the experience of

Watson at the Middlesex Hospital and of West (under Latham) at St

Bartholomew’s, yet some allowance should be made, in interpreting the

figures of fever mortality in those years throughout England and Wales,

for admixture of enteric fever. Budd’s statement that the only case which

was dissected in the epidemic at North Tawton, Devonshire, in 1839, had

the bowel-lesion of enteric fever, if it is to count in the absence of the

usual details (place, date, objective description), would mean that at

least one case there was not of the prevailing type of contagious epidemic

typhus. The coincidence of some such cases is made the more probable by

the evidence from Anstruther, Fifeshire, reported by John Goodsir,

afterwards Professor of Anatomy at Edinburgh, who was assisting his father

in practice there from 1835 to 1839. During that period, which was the

time of the typhus epidemic in the larger towns of Scotland, he attended

about one hundred cases of fever annually in Anstruther and the

neighbourhood; the fever was usually mild, only some sixteen of the cases

having proved fatal; of those sixteen he examined ten after death, finding

“ulceration” of the Peyer’s patches in all, and perforation of the

intestine in four of them. These facts he gave orally to Dr John Reid,

pathologist to the Edinburgh Infirmary, whose experience of the morbid

anatomy of fever was altogether different. Goodsir, having kept the

specimens, made them the subject of a paper some years after (1842), in

which he described very minutely the stages and degrees of congestion,

ulceration, sloughing and perforation in the lymph-follicles of the

intestine in fever, placing congestions at one end of the scale and

sloughing at the other, as the French pathologists then did[379]. Reid

examined, at the Edinburgh Infirmary from October, 1838, to June, 1839,

forty-one bodies dead of fever, to see whether the intestinal lesion,

which Goodsir had told him of, occurred in them. The distinctness of the

Peyer’s patches varied a good deal (differences which are known to be in

part congenital and in part to depend on age), and in only two instances

were they elevated and seemingly “ulcerated.”

One of these was the case of an Irishman, from Sligo, aged 25, who had

been so constipated that he was purged with colocynth, etc.: “at the

lower part of the ileum, the elliptical patches were irregular on the

surface, and presented several superficial and ill-defined depressions

(ulcerations).” The other was the case of a girl, aged 15, who had not

suffered from diarrhoea, but had the intestinal patches elevated and

superficially “ulcerated[380].” Neither of these cases would probably

be reckoned typhoid or enteric fever at the present time on the

anatomical evidence only. The early French observers, Chomel, Louis,

Andral and others, included in a scale all the appearances of the

Peyer’s patches in fever that they thought morbid, from mere

prominence of the lymphatic tissue and distinctness of the follicular

pits, up to extensive sloughing and ulceration of the same, as if they

were all the signs of one and the same fever in its various stages of

development. But simple prominence or congestion of Peyer’s patches

may occur in typhus fever, or in relapsing fever; nor would a slight

erosion, or “superficial ulceration” raise in all cases a suspicion of

enteric fever.

The observations of Home, Reid’s predecessor as pathologist to the

Edinburgh Infirmary, from 1833 to 1837, were however conclusive that true

enteric fever had occurred now and again during the steady prevalence of

typhus fever from year to year. In that space he made 101 post-mortem

examinations in fever-cases; in 29 the Peyer’s patches were distinct, in 7

of those 29 there was “a greater or less degree of ulceration,” and in 2

of those 7 there was perforation[381]. Murchison examined the post-mortem

register of the Edinburgh Infirmary for the years 1833 to 1838, and found

only fifteen cases of fever with ulceration of the bowel. But in the eight

months from 1 November, 1846, to June, 1847, there were nineteen

dissections with the characteristic lesion of typhoid, the season having

been remarkable everywhere for that disease.

In the following series of years the fatal cases of fever in the Edinburgh

Infirmary with ulceration were few[382]:

Year Enteric deaths

1854 5

1855 2

1856 1

1857 8

1858 1

1859 2

1860 1

1861 6

It was thought remarkable that the form of continued fever which was most

usually found in the great continental cities, in Paris, Berlin, Prague

and Vienna, namely that with ulceration of the lymph-follicles of the

intestine, should be but occasionally mixed with the old typhus in

England, Ireland and Scotland in the very same years. But there was

nothing to discredit the British observations, anatomical and clinical;

and in 1836 Dr Lombard, of Geneva, having visited various cities in

England, Scotland and Ireland bore witness to the matter of fact, strange

as it was to him. Writing to Graves, of Dublin, on 16 June, 1836, he said:

“Before I leave Ireland, allow me to express to you my great astonishment

at what I have seen in this country respecting your continued fever;” and

in a second letter, of 18 July, after his return to Geneva, he added, that

in Liverpool, ulceration of the ileum in continued fever was “occasional,”

that in Manchester he had been told it occurred “by no means always,” that

in Birmingham the cases of fever were not many, but “always” with

intestinal ulceration, and that in London “not a fourth part” of the cases

of fever had the latter condition, and these mostly in autumn[383]. This

was before the great epidemic of typhus had begun in the English towns. To

the same non-epidemic period (1834) belongs the statement of Carrick, for

Bristol, that fever was often observed to be infrequent or altogether

absent in the most crowded and dirty parts of the city at times when there

were a good many cases “in institutions and dwellings where cleanliness

and free air are most carefully attended to,” and that ulceration of the

bowel was the most common post-mortem appearance[384].

The comparative rarity of enteric fever in the chief towns of Scotland and

Ireland continued for a good many years longer, indeed until after the

differences between typhus and typhoid were perceived and admitted by all.

Even at the London Fever Hospital, during twenty-four years (1848-71)

after Sir William Jenner’s diagnostic points were strictly looked to in

its wards, much the greater part of the admissions were of typhus; in only

two periods, 1850-55 and 1858-61, during both of which there was

comparatively little fever of any kind in London, did the admissions for

enteric fever slightly exceed those for typhus; on an annual average of

the twenty-four years ending 1871, the cases of the former were only about

a fifth part of the whole. The cases of enteric fever increased decidedly

after 1865. Murchison thought that the increase might be accounted for in

part by the enlargement of the Fever Hospital, and by the unusually high

temperature of certain years, the summers and autumns of 1865, 1866, 1868

and 1870 having been remarkable for their great heat and prolonged

drought; but, he adds, “it is not a little remarkable that this increased

prevalence of enteric fever in the metropolis has been contemporaneous

with the completion of the main drainage scheme[385].”

Still more recently, the relative proportions of typhus and enteric fever

have been reversed, so that there have been years with little or no typhus

but with a good deal of enteric fever. There are some persons,

unacquainted with the history, who cannot imagine that it was ever

otherwise than now, who think of the former times of medicine, not as

differing in social, economic, and various other respects from their own,

but only as being less clever at diagnosis. There are others who realize

clearly enough the historical matter of fact, but find it necessary to

explain the almost contemporaneous decline of typhus and rise of typhoid

by some hypothesis of the latter being “evolved” out of the former. This

evolutional doctrine makes the mistake of ascribing to the species of

disease the same comparative fixity of characters that belongs to the

species of animals and plants. Beside the latter, the species of disease

are the creatures of a day. In the nosological field, the origin of

species is not analogous to the evolution of a new species of animal or

plant out of an old, as in the hypothesis of Darwin, for the reason that

every species of disease is evolved directly and, as it were, _pro re

nata_, out of a few simple conditions of human life, variously mixed but

always there to give occasion to one infective malady or another, which

may have a shorter existence, like sweating sickness, or a longer, like

plague. Edinburgh experiences offer a ready criticism of the evolutional

doctrine. Typhus declined, and typhoid rose; but it was in the old

tenement houses of the Canongate, Cowgate, Grassmarket, and High Street

that typhus declined, and it was mostly in the new streets across the

valley, or in the New Town of Edinburgh, that enteric fever arose, having

sometimes no more mysterious an origin than the results of defective or

cheap plumber-work, for example, the leakage of a soil-pipe fermenting, a

foot deep, beneath the basement floor. But it was not until a good many

years after that these new experiences became common; and meanwhile

Edinburgh and other towns in Scotland saw much of typhus and relapsing

fever.

Relapsing Fever in Scotland, 1842-44.

The epidemic of 1836-39 had been typhus of a specially maculated kind. The

period or “constitution” of synocha, rising twice to epidemics of

relapsing fever, had lasted from near the beginning of the century until

1828 or 1829. Then came the new constitution of low, depressed, spotted

fever, which would not stand blood-letting. But in 1842-44 relapsing fever

reappeared in Scotland. This reappearance was a blow to two doctrines of

the time--first that Ireland was the original breeding-place of all such

fevers, and secondly, that a return of the “constitution” of relapsing

fever would warrant a return to the practice of blood-letting, which had

fallen into disuse during the epidemic of typhus. The epidemic of 1842-44

was at first purely a Scots affair, with some extension to England, but

none to Ireland. As to blood-letting, once it had been given over in

fevers it was not readily taken up again, notwithstanding the theory that

relapsing fever belonged to those sthenic or inflammatory types of

sickness in which the lancet was still thought admissible. Moreover,

Christison, who remembered the relapsing synocha of 1817-19 and of

1827-28, said of the third epidemic: “The synocha of 1843-44, though so

prevalent, by no means presented the same strong phlogistic or sthenic

character as in the earlier epidemics of 1817-20 and 1826-29. The pulse

was neither so frequent nor so strong; the heat was not so pungent; the

glow of the integuments was less lively and less general[386].”

I take conveniently from Murchison the following succinct account of the

Scots relapsing fever of 1842-44[387]:

“The next epidemic of fever in 1843 differed from those that preceded

it, inasmuch as it did not originate in or implicate Ireland, but was

mainly confined to Scotland. There was no increase of fever in the

Irish hospitals during this year, whereas the number of admissions

into the Glasgow Infirmary rose from 1,194 to 3,467; in the Edinburgh

Infirmary from 842 to 2,080; and in the Aberdeen Infirmary from 282 to

1,280. These numbers, too, are far from representing the true extent

of the epidemic, for thousands of sick were sent from the hospital

doors. The fever was almost exclusively relapsing fever; typhus was

comparatively rare. The first cases were observed on the east coast of

Fife, in 1841-2 (by H. Goodsir), and not in the crowded localities of

large towns. In Dundee, where the proportion of typhus cases was

comparatively great, the fever appeared early in the summer of 1842,

and raged to a considerable extent during the whole of the autumn,

before it showed itself elsewhere. In Glasgow the first cases occurred

in September, 1842; but the fever was not generally prevalent until

December, from which month the cases rapidly increased until October,

1843, when the epidemic began to decline. The number of cases in

Glasgow was estimated at 33,000, or 11½ per cent. of the entire

population. In Edinburgh relapsing fever was first observed in

February, 1843. It rapidly spread until October, after which it

gradually abated, until, by the following April, it had well nigh

disappeared. In the month of October, 1843, the number of fever cases

admitted into the Edinburgh Infirmary amounted to 638, and during

several months, from thirty to fifty cases were daily refused

admission. The total number of cases in Edinburgh was calculated by

Alison at 9,000. In Aberdeen the epidemic commenced about the same

time, and followed the same course as in Edinburgh. At Leith,

curiously enough, it did not appear until September, 1843; it then

spread rapidly for two months, after which it declined, and by the end

of February, 1844, it had almost ceased; but during this brief period

it attacked 1,800 persons, or one in every fourteen of the population.

The disease was general over Scotland, and was not restricted to the

large towns; it prevailed in Greenock, Paisley, Musselburgh, Tranent,

Penicuick, Haddington, Dunbar, the Isle of Skye, etc. Although the

epidemic was mostly confined to Scotland, the same fever was observed

in some of the large towns of England. The number of admissions into

the London Fever Hospital rose from 252 in the preceding year to 1,385

in 1843: and the annual report for 1843 makes it evident that a large

proportion of these cases were relapsing fever. The rate of mortality

of the epidemic was small, not exceeding from two-and-a-half to four

per cent. Although this was the same fever as prevailed in 1817-19,

even local bleeding was rarely resorted to, and many of the cases were

thought to demand stimulants. All accounts agree in stating that the

epidemic supervened upon a period of great distress among the Scottish

poor, and that it was restricted throughout to the poorest and most

wretched of the population.”

This epidemic, which was the subject of an altogether unusual amount of

writing in Edinburgh[388], partly on the supposition that relapsing fever

was a “new disease,” proved once for all that one had not to go to Ireland

for the engendering or making of a famine-fever. The demonstration came

just in time; for the epidemic was hardly over in Scotland, when the

series of great potato-famines in Ireland began in 1845, soon to be

followed by the disastrous epidemics of dysentery, relapsing fever and

typhus from 1846 to 1848. Indeed, so near was the Scots epidemic to the

Irish, that in the North of Ireland the first of the relapsing fever, in

1846, was called “the Scotch Fever,” on the supposition that it had

reached them from its recent focus in the West of Scotland[389]. The Irish

and original part of the great epidemic of 1846-48 has been fully

described in another chapter; much of the mortality was due to dysentery,

and the most prevalent fever was relapsing fever, with a very low rate of

fatality among the poorer classes. But in Ireland itself there was also

much typhus, very mortal to the richer classes who came in contact with

the starving multitudes.

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

The contagion that reached England and Scotland from the scene of famine

in Ireland was more apt to produce typhus than relapsing fever. That the

Irish contagion was the principal source of the great epidemics in England

and Scotland in 1847-48, seems to be proved by every fact in their

progress, direction and other circumstances. But it is not so clear that

England and Scotland would not have had an unusual amount of typhus in the

same years even if the Irish had been kept out by an ideally strict

quarantine. What touched Ireland most, touched Scotland and England in a

measure. The seasons were bad in all parts of the kingdom; many were out

of work in the manufacturing towns; but as soon as the price of provisions

fell in 1848, the epidemic in England came to a sudden end.

The epidemic of fever in England in 1847 was almost wholly typhus; in

Scotland, it was to some extent relapsing fever, but there also it was

mainly typhus. It was more severe, while it lasted, than the epidemic of

1837 and following years; but it was of shorter duration, ceasing almost

abruptly in 1848. The rise of the epidemic of 1847 in London is shown by

the following quarterly returns of the deaths from fever:

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

442 568 895 1279

In the last quarter of 1846, the deaths from fever in London had been

619. In all England, the last quarter of 1846 was also most unhealthy, its

deaths from all causes being 53,055 (only 43,850 in the first quarter of

the year). The summer of 1846 had been remarkable for heat and drought,

and the end of the year was, according to precedent, an unwholesome time.

It was just the season for enteric fever, as in the still more memorable

circumstances of 1826. There is evidence from various parts of England and

Scotland that much of the fever of the end of 1846 was enteric; and it was

doubtless the unusual prevalence of that disease, and of other maladies

that are favoured, like it, by extreme fluctuations of the ground-water,

that explains the very high mortality of the last quarter of 1846[390].

But it is equally certain that it was typhus which raised the fever deaths

in London in the last quarter of 1847 to 1,279, and the deaths from all

causes in all England to the enormous total of 57,925. In the whole of the

year 1847, typhus alone claimed 30,320 deaths in England and Wales, the

total in 1848 falling to 21,406. Lancashire and Cheshire had the largest

share of this epidemic, and Liverpool the largest share in Lancashire. In

that Registration Division (the North-western) the deaths from typhus in

1847 were 9,076, and in 1848 they were 3,380. Next in order (excluding

London and suburbs) came the West Midland Division, and next to that

Yorkshire. At Liverpool, and in other places of the north-west of England,

the fever was very clearly connected with the enormous Irish immigration,

and was in great part among the Irish. There were floating lazarettos on

the Mersey, filled with fever and dysentery, workhouses overflowing, and

sheds hastily built to hold each 300 patients. The following returns from

the several sub-divisions of Liverpool for the months of July, August and

September, 1847, show the proportions of dysentery and fever, as well as

the mortality from diarrhoea, which last was mostly an affair of the

infants and young children[391]:

_Liverpool deaths, July-Sept. 1847._

Fever Dysentery Diarrhoea

St Martin’s 291 82 174

Dale Street 250 20 111

St Thomas (301 deaths on the floating lazarettos)

Mount Pleasant 324 18 73

Islington 105 37 78

Great Howard Street (the fever extending to the upper classes)

In his report for the quarter before (April, May and June, 1847) the

registrar of the Great Howard Street sub-district says: “Eight Roman

Catholic priests, and one clergyman of the Church of England, have fallen

victims to their indefatigable attentions to the poor of their

church[392].”

In Manchester there were causes of fever independently of the Irish

contagion. The registrar of the Deangate sub-district writes in the third

quarter of 1847: “In the calamitous season just passed, manufactures have

been almost at a stand-still; food has been unattainable by the poor, for

employment they had none; Famine made her dwelling in their homes &c.” The

hardships of the children caused an immense mortality from summer

diarrhoea. The same registrar gives an account of the epidemic fever in

his report for the second quarter of 1847, from which it appears that,

although nearly all the hospital cases were distinctly maculated, and the

fever was undoubtedly typhus in all other respects and in its conditions,

yet tympanitis, with abdominal tenderness and diarrhoea, were specially

noted[393].

Besides Liverpool and Manchester, many other towns in Lancashire had the

“Irish fever” in them; also Birmingham, Dudley, Wolverhampton, Shrewsbury,

Leeds, Hull, York and Sunderland. Except in London, the fever mortality

was not unusual in the southern half of England[394].

In Scotland the epidemic was a mixture of relapsing fever and typhus. The

following were the proportions of each admitted to the Glasgow Royal

Infirmary:

Year Relapsing Fever Typhus

1846 777 500

1847 2,333 2,399

1848 513 980

1849 168 342

In the Barony Fever Hospital, Glasgow, open from 5 August 1847 to July

1848, the relapsing cases were double the typhus cases at the opening of

the hospital, at the end of 1847 they were nearly equal, and from February

1848 the typhus cases were double the relapsing. In Edinburgh, where the

epidemic was less severe, the same relations were observed--relapsing

fever most at the beginning, typhus fever (much more fatal) most at the

end[395]. Some relapsing fever occurred also in London, among destitute

Irish, which was often attended by a miliary eruption (Ormerod).

Subsequent Epidemics of Typhus and Relapsing Fevers.

By midsummer, 1848, there was a most marked improvement in the public

health, corresponding with the great fall in the prices of food, under the

influence of free trade, and with a good harvest and the commencement of

an era of steady employment for workers. The improvement is strikingly

shown in the following comparison of the deaths from all causes in

Lancashire and Cheshire in the third quarter of each of the years 1846,

1847 and 1848:

1846 1847 1848

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

Since the epidemic of 1847, which was not unfairly called “the Irish

fever,” there has been no such extensive and fatal outbreak of typhus or

relapsing fever in England, Scotland or Ireland. The fever deaths rose

somewhat in Ireland and in Glasgow in 1851-53, the type of disease being

relapsing and typhus. In London there was a considerable increase of

typhus in 1856, at the end of the Crimean War. From 1861 to 1867 there was

a considerable epidemic of the same fever in England and Scotland (not

much of it in Ireland until 1864), the chief centres in England having

been the Lancashire towns, Preston, Manchester, Accrington, Chorley,

Salford and Blackburn, and the occasion of it the “cotton famine” of the

American Civil War[396]. Greenock was the chief seat of typhus in 1863-64

in Scotland; indeed, in the whole kingdom, its death-rate from that cause

was approached by that of Liverpool only. Fevers had been very mortal

there in the epidemic of 1847 (it is said 353 deaths); in the next

fever-period they rose as follows[397]:

1860 1861 1862 1863 1864

19 57 63 98 274

This epidemic was more easily dealt with than those of the same kind

before it. Very large sums were subscribed by the wealthy, of which,

indeed, a considerable balance remained undistributed. Rawlinson, as

engineer, and Villiers, as Minister, devised extensive relief works, in

the form of main drainage for the distressed Lancashire towns, the whole

cost being defrayed eventually by the municipalities themselves. The

following table, from Murchison, shows the admissions for typhus to the

fever hospitals of various towns, subsequently to the great epidemic of

1847-48. The first rise in London was in 1856; the next rise, which was

somewhat prolonged, coincided with the epidemic in Lancashire.

_Hospital Cases of Typhus, 1849-71._

London Edin. Glasgow Glasgow Dundee Aberdeen Cork

Fever Royal Royal Fever Royal Royal Fever

Year Hosp. Infirm. Infirm. Hosp. Infirm. Infirm. Hosp.

1849 155 -- 342 -- -- -- --

1850 130 -- 382 -- -- -- --

1851 68 -- 919 -- -- -- --

1852 204 -- 1293 -- -- -- --

1853 408 -- 1551 -- -- -- --

1854 337 -- 760 -- -- -- --

1855 342 -- 385 -- -- -- --

1856 1062 -- 385 -- -- -- --

1857 274 -- 314 -- -- -- --

1858 15 -- 175 -- 17 -- --

1859 48 -- 175 -- 128 -- --

1860 25 -- 229 -- 67 -- --

1861 86 -- 509 -- 129 -- 116

1862 1827 14 780 -- 54 -- 272

1863 1309 74 1286 -- 236 379 (4 mos.) 692

1864 2493 212 2150 -- 264 811 1021

1865 1950 447 2334 1154 891 422 791

1866 1760 847 1055 384 706 167 247

1867 1396 303 761 795 225 68 124

1868 1964 280 620 1023 502 78 245

1869 1259 259 1430 2023 402 170 136

1870 631 287 947 702 232 61 165

1871 411 101 418 511 257 3 397

During the unusual prevalence of fever in Scotland, 1863-65, it was made

clear by the diagnosis in hospitals, that the excess was caused by typhus,

and not by enteric.

Of 440 cases of fever treated in the Royal Infirmary of Edinburgh, in

1864, 212 were cases of pure typhus, 140 were enteric fevers, while 88

were simple continued fever and febricula. In the Royal Infirmary of

Glasgow in 1864, of 2,190 cases of fever, 2,150 were reported to be

cases of typhus fever, while only 40 were cases of enteric fever. In

the Aberdeen Royal Infirmary not a case of enteric fever was observed:

of 396 cases in the year 1863, 387 were pure typhus, and 9 febricula;

and in 1864, of 926 cases, 897 were pure typhus and 29 febricula. In

the Royal Infirmary of Dundee, of 355 cases of fever treated in 1864,

318 were typhus, 16 enteric fever, and 21 febricula. It was only at

Perth, and there not exclusively in hospital practice, that an excess

of typhoid fever was observed; from 1st August, 1863, to 30th April,

1864 (months which included the special typhoid season), there were

101 cases of gastro-enteric or typhoid fever, 46 cases of typhus, 19

of relapsing fever, and 59 of simple continued fever[398].

The last considerable prevalence of contagious fever in England and

Scotland was in 1869 and 1870. It was relapsing fever, mixed with some

typhus, and it was restricted almost to a few large towns, including

London, Liverpool, Manchester, Leeds, Bradford, Glasgow, and

Edinburgh[399]. It was first seen in London in 1868 among Polish Jews. It

was heard of as late as 1872 at Newcastle. It was observed during this

epidemic in Liverpool, Bradford and Edinburgh that the subjects of the

relapsing fever were not suffering from want[400]. The same observation

has been made in some foreign countries. Still, on the great scale and in

a broad view, relapsing fever has been _typhus famelicus_ or famine-fever,

occurring in association with other maladies due to want, and especially

in the circumstances which have been discussed fully in the chapter on

fevers in Ireland.

Relative prevalence of Typhus and Enteric Fevers since 1869.

It was not until the year 1869, or about the time when typhus fever ceased

to be epidemic or common, that the deaths from typhus fever, simple

continued fever and enteric fever began to be tabulated separately in the

Registrar-General’s reports. The following tables show for England and

Wales and for London a steady decline of the deaths from typhus and simple

continued fever since the end of the epidemic period 1869-71, which was

the last epidemic of typhus and relapsing fever in this country hitherto.

The deaths from enteric fever, it will be seen, remained somewhat steady

(in a growing population) for about ten years after the separation, and

then began to decline.

_Continued-fever Deaths in England and Wales, 1869-91._

Simple or

Year Typhus Ill-defined Enteric

1869 4281 5310 8659

1870 3297 5254 8731

1871 2754 4248 8461

1872 1864 3352 8741

1873 1638 3081 8793

1874 1762 3089 8861

1875 1499 2599 8913

1876 1192 1974 7550

1877 1104 1923 6879

1878 906 1776 7652

1879 533 1472 5860

1880 530 1490 6710

1881 552 1159 5529

1882 940 1016 6036

1883 877 963 6068

1884 328 768 6380

1885 318 662 4765

1886 245 505 5061

1887 211 502 5165

1888 168 436 4848

1889 140 413 4971

1890 160 361 6146

1891 148 325 5075

_Continued-fever Deaths in London, 1869-91._

Simple or

Year Typhus Ill-defined Enteric

1869 716 615 1069

1870 472 570 976

1871 384 436 871

1872 174 322 867

1873 277 325 968

1874 312 337 879

1875 128 272 817

1876 159 202 769

1877 157 194 901

1878 151 197 1033

1879 71 160 849

1880 74 134 702

1881 92 134 971

1882 53 95 975

1883 55 102 963

1884 32 75 925

1885 28 78 597

1886 13 73 618

1887 19 44 612

1888 9 35 694

1889 16 42 538

1890 10 35 604

1891 11 44 557

Such being the proportions of typhus and enteric fever since 1869, when

the separation was made, it remains to ask what share each of them may

have had in the total of “typhus,” or of continued fever generally, in the

years before the two forms were distinguished in the annual registration

reports. Of course, they were distinguished by many of the profession long

before that; so that there are means of forming a judgment. At the London

Fever Hospital, enteric fever and typhus were distinguished after 1849. If

the admissions of each kind of fever to that hospital be assumed to have

been proportionate to the prevalence of each in London from year to year,

we should get in the following table a means of estimating which of the

two forms of continued fever furnished most of the deaths in all London,

as given in the first column:

Admissions to London

Deaths in Fever Hospital

London from

Year both fevers Typhus Typhoid

1838 4078 -- --

1839 1819 -- --

1840 1262 -- --

1841 1151 -- --

1842 1184 -- --

1843 2094 -- --

1844 1721 -- --

1845 1324 -- --

1846 1838 -- --

1847 3297 -- --

1848 3685 -- --

1849 2564 155 138

1850 2032 130 137

1851 2374 68 234

1852 2183 204 140

1853 2617 408 212

1854 2816 337 228

1855 2410 342 217

1856 2717 1062 149

1857 2195 274 214

1858 1919 15 180

1859 1840 48 176

1860 1476 25 95

1861 1848 86 161

1862 3673 1827 220

1863 2871 1309 174

1864 3782 2493 253

1865 3217 1950 523

1866 2688 1760 582

1867 2184 1396 380

1868 2468 1964 459

From this it will appear that every great annual rise in the London deaths

from “fever,” since the last great typhus epidemic of 1847-48, has

corresponded to a greatly increased admission, not of enteric cases, but

of typhus cases into the London Fever Hospital. On the other hand, enteric

fever has been at a somewhat steady or endemic level for a good many

years. Even at that level it would have had a small share of the whole

fever-mortality in the old London; in modern London, especially in its

residential quarters, its rate has probably been higher than in former

times; while in recent years, owing to the absolute decline of typhus, it

has been by far the most common continued fever. If the conditions were

the same in London as in Edinburgh, it was the very creation of

residential streets and new quarters of the town that called forth typhoid

fever; while the more the town was remodelled, the more were the _fomites_

of typhus destroyed. Thus it seems probable that the same progress in

well-being among all classes, which has gradually brought typhus down

almost to extinction (or apparently so for the present), has been attended

with an increase of typhoid, an increase which has happily fallen within

the last few years from its highest point.

The disappearance, during the last twenty years, of typhus and relapsing

fevers from the observation of all but a few medical practitioners in

England, Scotland and Ireland, is one of the most certain and most

striking facts in our epidemiology. Most of the recent English cases have

occurred in Lancashire, especially in Liverpool, and in Sunderland,

Gateshead, Newcastle and other shipping places of the north. In the

decennial period 1871-80 the death-rate from typhus, per 1000 living, was

0·58 in Liverpool and 0·33 in Sunderland, rates which were about the same

as those from enteric fevers. The rates in 1881-83 were also high in the

same group of towns. As to other industrial centres, including the

coal-districts of Cumberland, Wales and Scotland, it is probable that a

good deal of typhus passes under the name of “typhoid,” the change in

medical fashion having outrun somewhat the real change in the relative

prevalence of each fever[401]. In Scotland the disease is still heard of

from time to time in Glasgow, Edinburgh, Leith, Dundee, Aberdeen,

Inverness and Thurso. In London the recent immunity from it is remarkable,

but intelligible. First, the populace is better housed: we have got rid of

the window-tax, rebuilt the houses in regular streets opening upon wide

thoroughfares, pulled down most of the back-to-back houses, dispersed the

working population over square miles of suburbs easily accessible from the

heart of the town by tramways and railways, perfected the sewerage and the

water-supply. These great structural changes are so far an earnest that

typhus cannot come back in the old way. Secondly, food has been for a long

time cheap and wages good. During the remarkable lull in typhus from 1803

to 1816, Bateman pointed out that the unwholesome state of the dwellings

of the working class remained the same as before, but that money was

flowing freely among all classes (thanks to the special war-expenditure).

Under free trade, the same abundance of the necessaries of life has been

secured in another way. Typhus, it need hardly be said, is an indigenous

or autochthonous infection; the conditions of its engendering are never

very far off. In a small and remote island off the coast of Skye, which I

happened to know in its pleasing aspects from having landed upon it during

a summer vacation, typhus fever was reported by the newspapers a few

months after to have broken out in the hamlet of twenty or thirty

families, the winter storms having prevented the fishers from leaving

their cottages or any stranger from approaching the island. In a sparsely

populated parish of the east coast of Scotland, two cases of genuine

typhus (one of them fatal), and two only, have occurred, to medical

knowledge, within the last ten years, each in a very poor cottage in a

different part of the parish and in a different season. So long as our

cheap supplies of food, fuel and clothing are uninterrupted, there is

small chance of typhus or relapsing fever. But the population of England

being now twice as great as the home-grown corn can feed, a return of

those fevers on the great scale is not out of the question in the event of

the foreign food-supply being interfered with, or the necessaries of life

becoming permanently dearer from any other cause.

The following Table of the fever-deaths in Scotland since the beginning of

Registration does not distinguish enteric from typhus, relapsing and

simple continued during the first ten years of the period; but it is

probable, from all that is known non-statistically or by hospital figures

only, as to the history of enteric fever in Scotland, that it made the

smaller part of the generic total of fever-deaths so long as typhus and

relapsing fevers were common.

_Scotland--Deaths from the Continued Fevers since the beginning of

Registration._

Year

1855 2419 }

1856 2363 }

1857 3087 }

1858 2790 }

1859 2436 } Inclusive of typhus, relapsing, enteric

1860 2344 } and other continued fevers.

1861 2579 }

1862 3021 }

1863 3441 }

1864 4804[402]}

Simple Infantile Cerebro-Spinal

Typhus Enteric Relapsing continued Remittent

1865 3272 1048 62 839 164 --

1866 2172 1404 34 249 159 --

1867 1745 1378 40 105 119 --

1868 1561 1404 45 100 132 --

1869 2059 1335 29 121 157 --

1870 1460 1207 205 151 141 --

1871 1129 1234 411 108 124 --

1872 795 1223 115 103 118 --

1873 628 1495 31 192 117 --

1874 726 1455 27 104 80 --

1875 615 1625 17 98 85 --

1876 471 1448 18 65 88 --

1877 265 1427 5 164 -- --

1878 263 1477 2 147 -- --

1879 210 1013 5 133 -- --

1880 170 1338 4 155 -- --

1881 229 1004 0 115 -- --

1882 180 1204 2 90 -- --

1883 152 998 1 71 -- 7

1884 138 1050 2 63 -- 9

1885 111 889 1 58 -- 8

1886 80 755 2 62 -- 10

1887 126 835 7 65 -- 4

1888 102 665 6 58 -- 6

1889 69 795 1 45 -- 2

1890 77 777 -- 30 -- 3

1891 107 799 4 23 -- 6

Circumstances of Enteric Fever.

The circumstances of typhus and relapsing fevers need no general stating

after what has been said of particular epidemics in England and Scotland,

or remains to be said, for the most distinctive instances of all, in the

chapter on fevers in Ireland. There has been so little typhus in the

country at large since the disease began to be registered apart in the

mortality returns, in 1869, that hardly anything can be inferred except

the fact of its disappearance. It is significant, however, that

Sunderland, one of the two great towns which have kept typhus longest and

in largest measure (Liverpool being the other) is distinguished for the

overcrowding of its dwelling-houses (7·24 persons to a house in the Census

of 1881, 7·00 in the Census of 1891).

But the circumstances of enteric fever are not only not so obvious as

those of typhus in the historical way; they are also more complex and

disputable. One fact in the natural history of enteric fever has been made

clear in the chronology, namely, its greater frequency after a severe

drought. It was in the autumn of 1826, after the driest and hottest summer

of the century, that cases of fever with ulceration of the bowel were

first described and figured in London. It was in the autumn of 1846, after

the next very dry and hot summer, that cases of the same fever again

became unusually common in many parts of England and Scotland. The same

sequence has been remarked on more recent occasions and in various

countries. It is explained by taking into account some other facts in the

natural history of enteric fever. In nearly all countries in our

latitudes, autumn is its principal season, and autumn is the season when

the level of the water in the soil, or in the wells, is lowest. Virchow

states the law of enteric fever in the following simple and concrete way:

“We [in Berlin] have a certain number of cases of typhoid at all times.

The number increases when the sub-soil water falls, and decreases when it

rises. Every year, at the time of the lowest level of the sub-soil water,

we have a small epidemic.” A sharp rise above the mean level of the year,

from the first week of September to the end of October, has been well

shown for London from the admissions to the hospitals of the Metropolitan

Asylums Board, 1875-1884. The curve has an equally sharp descent, passing

below the mean line of the year in the second week of December[403]. There

are indications that it is the partial filling of the pores of the

sub-soil with water, after they have long been occupied with air only,

that makes the virus of typhoid active, or, in other words, that the

rains of late summer and autumn are the occasion of the seasonal increase

of the infection.

Yet it is not the changes in the ground-water by themselves, just as it is

not rainfall and temperature by themselves, that make enteric fever to

prevail. The soil in which those vicissitudes of drought and saturation

are potent for evil must be one that is befouled with animal organic

matters, more especially with excremental matters. For that and other

reasons (such as the geological formation), enteric fever shows, in its

more steady or endemic prevalence from year to year or from decade to

decade, certain marked preferences of locality. Since 1869, when the

deaths from it began to be registered apart, it has been much more common,

per head of the population, in the quick-growing manufacturing and mining

towns than in any other parts of England and Wales, the districts with

highest enteric death-rates being the mining region of the East Coast from

the mouth of the Tees to somewhat north of the Tyne, the mining region of

Glamorgan, certain manufacturing towns of Lancashire and the West Riding

of Yorkshire, and some districts in the valley of the Trent in

Staffordshire and Nottinghamshire. The following Table shows, by

comparison with all England and Wales and with London, the excessive

death-rates from enteric fever in the registration divisions which head

the list:

_Highest mortalities from Enteric Fever in Registration Divisions of

England and Wales_[404].

------------------------------------------------------------------

Decennium | Decennium

1871-80 | 1881-90

-------------------------------------------------------|----------

| Annual | Annual | |

|death-rate,|death-rate,|Enteric| Deaths,

|all causes,| Enteric, |Deaths | Enteric,

| per 1000 | per 1000 | in 10 | in 10

| living | living | years | years

-----------------------|-----------|-----------|-------|----------

England and Wales | 21·27 | 0·32 | 78421 | 53509

London | 22·37 | 0·24 | 8536 | 7497

-----------------------|-----------|-----------|-------|----------

Durham co. | 23·77 | 0·56 | 4525 | 2590

South Wales | 21·09 | 0·45 | 3715 | 2550

W. Riding, Yorks. | 23·24 | 0·45 | 9166 | 5170

N. Riding, Yorks. | 19·68 | 0·44 | 1259 | 896

Nottinghamshire | 21·23 | 0·43 | 1707 | 1263

Lancashire | 25·17 | 0·39 | 12388 | 9874

_Durham Mining Districts._

Stockton incl. part of | | | |

Middlesborough | | | |

(4¾ years) | 26·64 | 1·09 | 561 | --

| | | |

Stockton (5¼ years) | 22·49 | 0·62 | 208 | 258

| | | (5¼ |

| | | years)|

Guisborough, incl. part| | | |

of Middlesborough | | | |

(4¾ years) | 24·80 | 1·17 | 251 | --

| | | |

Guisborough | | | |

(5¼ years) | 20·45 | 0·38 | 71 | 106

| | | |

Middlesborough[405] | | | |

(5¼ years) | 19·93 | 0·63 | 272 | 460

| | | (5¼ |

| | | years)|

| | | |

Auckland | 24·52 | 0·71 | 541 | 318

_South Wales Mining Districts._

Pontypridd[406] | 23·16 | 0·71 | 515 | 541

Merthyr Tydvil | 24·23 | 0·62 | 639 | 249

Swansea | 22·38 | 0·63 | 505 | 387

Llanelly | 20·93 | 0·8 | 330 | 165

In the second decennium of the Table, 1881-90, the total deaths from

enteric fever (the death-rates are still unpublished) are much below those

of 1871-80. All the counties of England and Wales have shared in that

notable decline, including Durham and Glamorgan. But these two great

districts of the coal and iron mining are, by the latest returns, still

keeping the lead; and it is probable that we shall find in them, or in

particular towns within them, the conditions that have been most

favourable to enteric fever in the earlier decennia of this century and

are still favourable to it. First it is to be observed that one of the

most noted of the old typhoid centres in Glamorgan, namely Merthyr Tydvil,

has ceased to be in that class; its enormous rate of growth has been

checked (to 18·9 per cent. from 1881 to 1891) and it has at the same time

become a more uniform and better-ordered municipality.

On the other hand, on the same river Taff, and in the tributary valley of

the Rhondda, there is an immense population of miners, among whom the

enteric fever death-rate will probably be found to have been higher in

1881-90 than in any other registration district. The most populous part of

the district is the town of Ystradyfodwg, which had 44,046 inhabitants in

1881 and 68,720 in 1891, an increase of over fifty per cent., the highest

urban rate of increase in the country. On the mean of the last three

years, 1891-93, its enteric fever death-rate has been ·62 per 1000. There

are several populous towns or townships in the mining districts of the

north-east which have in like manner kept their high rate of typhoid

mortality--Auckland, Easington, Bellington (Morpeth) and Middlesborough.

It is held by many that enteric fever has been most characteristically a

product of the modern system of closet-pipes and sewers. It is, of course,

the defects of the system that are, in this hypothesis, to blame,

including its partial adoption, the transition-state from the older

system, the tardy extension to new streets, as well as cheap and faulty

construction. All those things, together with the inherent difficulty of

connecting with a main sewerage the irregular squattings of a mining

community, are probably to be found in highest degree in those districts

of Durham and South Wales that are most subject to enteric fever. While

enteric fever is in some places steady or endemic from year to year, in

others its force is felt mostly in great and sudden explosions.

One such happened in the city and district of Bangor in the summer of

1882. The registration district had only 95 deaths from enteric fever

in the ten years 1871-80, but in the single year 1882 it had 87 deaths

registered under that name. Of 548 attacks (with 42 deaths) which were

known from 22 May to 12 September, 407 fell in August and the first

twelve days of September[407]. In the following year and throughout

the rest of the decennium the district had its usual low average of

enteric-fever deaths. One thing relevant to the explosion was probably

the excessive rainfall of June and July (9·5 inches, as compared with

4·8 inches about London).

Another explosion, probably unique in the history of enteric fever,

took place at Worthing, on the Sussex coast, in the summer of 1893.

The enteric death-rate of the town had been much below the average of

England and Wales from 1871 to 1880, the rate being 0·15 per 1000 and

the whole deaths in ten years 36. During the next ten years, 1881-90,

the whole enteric deaths were 43 in the entire registration district

(population in 1891, 32,394). In 1891 the typhoid deaths were two, in

1892 they were six. In 1893 a severe outbreak of typhoid took place

within the municipal borough (population 16,606): In the first quarter

of the year Worthing was one of the places mentioned for typhoid,

having had 5 deaths; in April there were no deaths, in May 25, in June

19, in July 61, in August 64, in September 11, and in the last quarter

of the year 8, making 193 deaths in the year. The highest weekly

number of cases notified was 253 in the second week of July. The

enormously wide dispersion of the poison, in a town little subject to

enteric fever, caused suspicion to fall on the water-supply, the more

reasonably that the district of West Worthing, which had a separate

water-supply, was said not to have suffered from the outbreak. A new

water-supply was at once undertaken. A relief fund of £7000 was raised

for the sufferers.

The towns of Middlesborough, Stockton and Darlington, in the lower

valley of the Tees, were together the scene of two remarkable

explosions of enteric fever, the first from 7 September to 18 October,

1890, the second from 28 December, 1890, to 7 February, 1891. The

phenomenal nature of these outbreaks in the autumn and winter of

1890-91 will appear from the following table of deaths by enteric

fever:

Darlington Stockton Middlesborough

Ten years 1881-90 104 258 460

-----------------------------------

1890 21 66 130

1891 17 59 93

In the first of the two explosions the three towns were almost equally

attacked per head of their populations; in the second explosion, in

mid-winter, Darlington had relatively only half as many cases as each

of the other two, which had about the same number of cases as in the

former six-weeks’ period. In both periods, of six weeks each, the

three towns had together 1334 cases of typhoid, while the country

districts near them had a mere sprinkling. A flooded state of the Tees

appeared to be a relevant antecedent to each of the explosions. The

Tees is a broad shallow river flowing rapidly, subject to frequent

inundations, tortuous in its lower course, forming at its mouth, where

Middlesborough stands, a wide estuary bordered by low flat grounds.

The rainfall at Middlesborough was 6·3 inches in August, of which 2·2

inches fell on the 12th of the month, the river being high in flood

thereafter. There were again high floods in November, chiefly caused

by the melting of snow in the upper basin (5 inches fell at Barnard

Castle in November, 3·1 inches at Middlesborough, while the December

fall was 1·2 inches at the former and 1·4 inches at the latter). To

apply correctly the ground-water doctrine of enteric fever to these

explosions, other particulars would have to be known, more especially

the extent of the previous dryness of the subsoil (the rainfall at

Middlesborough was 9·3 inches in the first half of 1890, 15·6 in the

second half, and below average for the whole year). But the flooded

state of the Tees valley in August and November must have changed

abruptly the state of the ground-ferments within the areas of the

respective towns and so afforded, according to the general law, the

conditions for an abrupt increase of enteric fever in these its

endemic or perennial soils[408].

While the more or less steady or endemic prevalence of typhoid fever is

due to the formation and reproduction in the soil of an infective

principle (probably of faecal origin) which affects more or less

sporadically the individuals living thereon, after the manner of a miasma

rising from the ground, there have been some hardly disputable instances

of the infection being conveyed to many at once from a single source in

the drinking water and by the medium of milk[409]. But such instances,

suggestive though they be and easy of apprehension by the laity, must not

be understood as giving the rule for the bulk of enteric fever. In like

manner, the escape or reflux of excremental gases from pipes or sewers, or

the leakage into basements or foundations from faulty plumber-work, are

causes, real no doubt, but of limited application, which do not conflict

with, as they do not supersede, the more comprehensive and cognate

explanation of enteric fever as an infection having its habitat in the

soil and an incidence upon individuals after the manner of other miasmatic

infections. Sex has little or nothing to do with the incidence of the

infective virus. As to age, enteric fever rarely befalls infants, and, in

the general belief of practitioners, is a less frequent cause of death

among children than among adolescents and adults.

In the following Table from the Registrar-General’s Decennial Review,

1871-80, enteric fever is not separated from other continued fevers.

It is probable that a considerable ratio of the deaths from 0 to 5

years are due to febrile disorders other than enteric.

_Annual Mortality per million living at all ages and at eleven groups

of ages, males and females, from fever (including Typhus, Enteric

Fever and Different Forms of Continued Fever) 1871-80._

All

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

Both sexes 484 651 518 439 543 509 411 379 402 458 553 498

Males 494 644 483 390 513 579 436 395 437 503 629 593

Females 477 658 550 487 573 445 387 362 369 418 488 425

The cases notified under the Act in 1891 and 1892 have been found to

average five or six for every death registered in the corresponding

districts, the rate of fatality ranging widely. It is matter of familiar

knowledge that many of the attacks and fatalities occur among the richer

classes. New comers to an endemic seat of the disease are most apt to take

it (this has been elaborately shown for Munich, and holds good for the

British troops in India). There are undoubtedly constitutional

proclivities to it among individuals, which may run strongly in families.

As in other miasmatic infective diseases, such as yellow fever, Asiatic

cholera, and (formerly) plague, there seem to be occasions in the varying

states of body and mind, as well as in the external circumstances, when

the infection of enteric fever is specially apt to find a lodgement and to

become effective. The old plague-books gave lists of the things that were

apt to invite venom or to stir venom (see former volume pp. 212, 674); and

it is probable that some of these hold good also for the incidence of

enteric fever.