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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Miliary Fever.

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

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

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

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

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

Mortalities in London from fever and all causes.

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

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

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

Typhus Fever in London, 1770-1800.

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

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

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

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

Lettsom’s practice in Fevers at the Aldersgate Dispensary.