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

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

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

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

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

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

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

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

Circumstances of severe and mild Typhus.

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

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

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

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

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

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

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

Ship-Fever.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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