The nervous, putrid and remittent fevers, belonging, to the same group, make up the bulk of the fevers. The hectic fevers were almost all of children. The fatal cases of fever were fourteen, the fatal cases in all diseases for the year having been forty-four. What these putrid, nervous and remittent fevers were, will now appear from some of Lettsom’s descriptions. Fevers with symptoms of putrescency were marked by nausea, bitter taste, and frequent vomiting, by laboured breathing and deep sighing, offensive breath, sweats offensive and sometimes tinged with blood, almost constant delirium, the tongue dry, the tongue, teeth and lips covered with black or brown tenacious foulness, thrush and ulceration in the mouth and throat, the urine with a dark sediment, the stools excessively nauseous and foetid, and blackish or bloody, the eyes horny or glassy, with the whites often tinged of a deep blood colour, spots on the skin like fleabites, or larger haemorrhagic vibices, bleeding from the gums, nose or old ulcers, hiccup near death, often a cough through the fever. Lettsom’s treatment consisted in good liquors, Peruvian bark, and above all fresh, or “cold” air: “When it is considered that putrid fevers originate in close unventilated places, the introduction of fresh air seems so natural a remedy that I have often admired its aid should have been so long neglected[243].” Accordingly he persuaded the poor people to open their windows, and dragged the sick out of doors as soon as it was safe to do so; the effects, he says, were wonderful. His fifty-one cases are most valuable illustrations of the perennial fever in the crowded parts of London:

The year 1773, to which these experiences in a small part of London relate, was one of high febrile mortality, according to the Bills. Two years after, Dr William Grant was moved to write an ‘Essay on the Pestilential Fever of Sydenham, commonly called Gaol, Hospital, Ship and Camp Fever[244],’ which, as he said in his preface, “I often see in this city: and though so common and fatal, appears not at present to be generally understood.” It was, he says, “an indigenous plant, frequent in this city, being produced by close confinement; but it often passes unnoticed, because unknown.” The deaths by “fever” in the London Bills were as follows until the end of the century:

Deaths from Fever and from all causes in London.

There were higher figures in the years immediately before 1771, the years to which the generalities of Fordyce and Armstrong relate. There is a decline in the fever-mortality towards the end of the century; but it is just from the years 1799-1800 that we have an account by Willan of the prevalence and conditions of London typhus, than which nothing can well be imagined worse. The intermediate glimpses we get of typhus in London in the writings of Dr Hunter, physician, and of Dr James Sims, show that the disease was perennial.

Dr James Sims, who had seen much of Irish typhus in Tyrone in his earlier years, and had removed to London, wrote of typhus among the poor there in 1786, ten years before the more systematic and more circumstantial descriptions by Willan[246].

This fever was exceedingly mortal, several medical men, he had reason to believe, falling sacrifices to it. Sims never saw the cases till the 7th or 8th day, when they were desipient, insensible, with pulse scarcely to be felt and not to be counted, all having petechiae. None had scarlet rash or sore-throat. They sank and died quietly; the strongest cordials did not produce the smallest effect, and blisters in many did not even raise the skin[247].

It is in the year 1796 that we begin to have the full and accurate records by Willan of the prevailing diseases of London month by month as he saw them at the Carey Street Dispensary, situated in the crowded quarter between Holborn and the Strand[248]. His first reference to typhus is as follows:

Willan says little more of fever in London until September, 1798, when these contagious malignant fevers became more numerous, both in the city and adjacent villages, than had been known for many years before; also the fever was more fatal than usual, one in five or six dying, whereas one in seven was formerly a very unfavourable death-rate, and one in twenty not unknown. Haemorrhages, aphthae, diarrhoea, starting of the tendons, picking the bedclothes, violent delirium, ending in deafness, stupor, hiccough and involuntary evacuations, were the usual accompaniments of this fever. In the corresponding months of 1799 he recurs to the symptoms of this “malignant contagious fever,” and depicts typhus as clearly as may be. In September, 1799, it was “attended with a dull pain of the head, great debility or sense of lassitude and pains referred to the bones, tremblings, restlessness with slight delirium, a querulous tone of voice, a small and frequent pulse, heat of the skin, thirst and a fur upon the tongue, first of a dirty white colour, but turning in the latter stage of the disease to a yellowish brown. In this form the fever continued thirteen days without any dangerous symptoms, and then suddenly disappeared, leaving the patient, for some time after, languid and dispirited. All the individuals of a family were successively affected with the same train of symptoms; many of them so slightly as not to be much confined to their beds.” In October and November he describes the symptoms of the disease in a more dangerous form. By this fever, he was informed, some houses of the poor had been almost depopulated, the infection having extended to every inmate. “The rumour of a plague was totally devoid of foundation.”

He then describes the state of the dwellings where such fevers occurred—the unwashed bed-linen, the numbers in one bed, the rooms encumbered with furniture or utensils of trade, the want of light and air in the cellars and garrets and in the passages thereto, the excremental effluvia from the vault at the bottom of the staircase. It cannot be wondered at, he concludes, that contagious diseases should be thereby formed, and attain their highest degree of virulence; and he estimates that “hundreds, perhaps thousands” of labourers in and near London, heads of families and in the prime of life, perished annually from such fevers. He denies that his account is exaggerated, and appeals for the truth of it to medical practitioners whose “situation or humanity has led them to be acquainted with” the localities[249].

Typhus in Liverpool, Newcastle and Chester in the last quarter of the 18th century.

Liverpool, in the last quarter of the 18th century, came next in size to London, having a population (in 1790) of 56,000 to the capital’s estimated 800,000. According to a medical author, whose experiences lay among the middle classes, it was everything that could be wished in the way of healthfulness and prosperity; but it had a dark side as well. About 7,000 of the people lived in cellars underground, and nearly 9,000 in back houses, in small confined courts with a narrow passage to the street. “Among the inhabitants of the cellars,” says Currie[250], “and of these back houses, the typhus is constantly present; and the number of persons under this disease that apply for medical assistance to the charitable institutions, the public will be astonished to hear, exceeds three thousand annually.... In sixteen years’ practice I have found the contagious fever of Liverpool remarkably uniform among the poor. Seldom extending itself in any considerable degree among the other classes of the community, it has been supposed that Liverpool was little subject to fever; but this will be shewn from authentic documents to be a great and pernicious error.” At the Dispensary in the year 1780 the cases of typhus averaged 160 per month, the numbers being as remarkably steady from month to month as from year to year. In the ten years from 1 January, 1787, to 31 December, 1796, 31,243 cases of fever were entered on the books of the Dispensary, an average of 3124 per annum[251].

Of 213,305 cases of all diseases at the Dispensary in seventeen years, 1780 to 1796, 48,367, nearly one-fourth, were labouring under typhus. Supposing that these were all the cases of typhus in Liverpool, and that 1 in 15 died, we should have some 150 deaths from typhus in a year. Supposing also that typhus was relatively as common at that time in London, it will follow that nearly all the deaths under “fever” in the bills of mortality might well have been from typhus fever; for London in its several densely populated out-parishes was the fever-quarter of Liverpool a dozen times over[252].

The Newcastle Dispensary was opened in October, 1777, by the exertions of Dr John Clark, who was in correspondence with Lettsom in London[253]. Dr Clark had been in the East India Company’s service, and had seen much of ship-fever and of the fevers of the East. During a visit to his home in Roxburghshire in the summer of 1770, between his voyages, he attended several persons in continued fever. When he settled at Newcastle he saw the worst kinds of contagious fever, in workhouses and “in the sordid and crowded habitations of the indigent.” Putrid fever, or typhus, was by far the most common disease attended from the new dispensary, although less than at Liverpool, the operations of the charity being on a much smaller scale. It was seldom out of Newcastle a whole year; and in some years, as 1778, 1779, 1783, 1786 and 1787 it was unusually rife in particular districts, often attacking whole families. Scarlet fever was epidemic and very fatal in 1778 and 1779, while dysentery attacked great numbers of the poor in the autumns of 1783 and 1785. The following Table shows the principal diseases attended from the Dispensary during the first twenty-three months of its working, 1 Oct. 1777, to 1 Sept. 1779:

Newcastle Dispensary 1777-79.

From 1 Oct. 1777, to 1 Sept. 1789, the cases of typhus visited were 1920, of which 121 were fatal. During the winter of 1790 and the spring and summer of 1791 it was prevalent amongst the poor, and was frequently introduced into genteel families and sometimes even into those of the first distinction. That outbreak was supposed to have been generated in the Gateshead poorhouse. For some time its ravages were confined chiefly to the low, ill-aired, narrow street called Pipewell Gate. In September it made its appearance in Newcastle; at first the contagion was easily traced from Pipewell Gate, and afterwards from one house to another. In that outbreak, 188 poor persons were visited from the Newcastle Dispensary, the Gateshead poor having been attended by the parochial surgeon. Clark’s ten cases recorded of the epidemic were all of people in good circumstances. The Dispensary Tables show cases of typhus every year down to 1850, the largest totals being in 1793 (374, 18 deaths), 1801 (435, 20 deaths), and 1819 (368, 14 deaths); and these, we may take it, were but a small fraction of all the cases in Newcastle.

Perhaps the most unexpected revelation of typhus is at Chester, from the time when Haygarth began to write upon its public health in 1772. Chester was then one of the most desirable places of residence in England. Boswell wrote to Johnson, “Chester pleases me more than any town I ever saw.” The old city within the walls was occupied by a superior class of residents, including the cathedral clergy, county families, retired officers and Anglo-Indians, professional men, merchants and tradesmen. It had the best theatre out of London. Squares, crescents and broad streets were replacing most of the old buildings. The six parishes that lay entirely within the walls had a population, in 1774, of 3502, and an annual average death-rate (in the ten years 1764 to 1773) of 1 in 58 or 17·2 per 1000, the central parish of St Peter having a rate of 1 in 62, and the cathedral parish 1 in 87. It passed as one of the healthiest cities in the kingdom, being far before Shrewsbury and Nottingham, to say nothing of the large towns where the burials exceeded the baptisms. But its moderate death-rate over all, 1 in 42 living, would have been much lower but for the four poor suburban parishes, with a population of 11,211, which had a death-rate of 1 in 35. Haygarth gives a deplorable account of them. The houses were small, close, crowded and dirty, ill supplied with water, undrained, and built on ground that received the sewage from within the walls. The people were ill-fed and they seldom changed or washed their clothes; when they went abroad they were noisome and offensive to the smell. Many of them worked on the large farms around Chester, others at shipbuilding and shipping (Chester had then a considerable foreign trade), others at the mills and markets, others at a nail-factory, while others were employed by the tradesmen within the walls. Fever seems to have been perennial among them, the deaths from typhus having been 23 in 1772, 33 in 1773 and 35 in 1774. “In these poor habitations,” says Haygarth, “when one person is seized with a fever, others of the family are generally affected with the same fever in a greater or less degree.” It became rifer than usual in August, 1773, and attacked 285, proving fatal to 28, or to one in ten. It had the common symptoms of malignant fevers produced by human effluvia, and particularly affected the head with pain, giddiness and delirium. It attacked in general the lowest, few of the middle rank, and none (or only one) of the highest rank[254].

Chester had no manufactures. Its population had grown rapidly of late, as that of Liverpool had grown, the poorer classes being the prolific part of the community; but it had no share in the industrial revolution, it did not employ its women and children in factories, and it was in some respects better than Leeds, Warrington, Manchester, or Carlisle. It is a good illustration of a town growing rapidly without manufactures, and of a community divided by the old walls into two quite distinct sections, a rich and a poor. Such had been the drift of things in England apart from the industrial revolution; but it is the latter which furnishes the best illustrations of a poor prolific populace, of a growing struggle, and of the attendant typhus fever.

Fever in the Northern Manufacturing Towns, 1770-1800.

The prosperity of the first two-thirds of the 18th century had been attended with a very small increase of population. From 1700 to 1750 the numbers in England are estimated to have grown no more than from about six millions to six millions and a half. The fecundity of many rural parishes was swallowed up by emigration to the American and West Indian colonies, by the army and navy, and by the great waste of life in London and some other towns. The increase was nearly all north of the Trent, while the old weaving towns of the south-west had actually declined. Gloucestershire, Somerset and Wilts were the most crowded counties in 1700. During the next fifty years, the greatest increase was as in the following rough estimate[255]:

In the counties where population had increased most, much of the increase was still rural or semi-rural. Defoe describes how the land near Halifax was divided into lots of from two to six or seven acres, hardly a house out of speaking distance from another, at every house a tenter, and on almost every tenter a piece of cloth, or kersey or shalloon. Every clothier kept one horse at least, to carry his manufactures to the market, and nearly every one kept a cow, or two or more, for his family. The houses were full of lusty fellows, some at the dye-vat, some at the looms, others dressing the cloths, the women and children carding or spinning, being all employed from the youngest to the oldest: not a beggar to be seen, nor an idle person[256]. We have no accounts of the health of this population, except Nettleton’s statistics of smallpox in and around Halifax in 1721 and 1722, given elsewhere, and the “epidemic constitutions” recorded by Wintringham at York during the same period, and by Hillary at Ripon.

Before the earliest of the inventions of spinning by machinery, the weavers were gathering to the towns of Yorkshire, Lancashire and other counties north of the Trent. The spinning-jenny of Hargreaves was wrecked by a Blackburn mob in 1768, and a mob wrecked the cotton-mill built by Arkwright at Chorley eleven years later. This was decidedly a time of movement from the country to the towns, a movement which preceded the spinning ingenuity of the sixties and may have been stimulated by the earlier use of the fly-shuttle in weaving.

Much of the country round Manchester, though it doubtless retained those farm-houses, hedgerows, and field paths which come into the idyllic opening of ‘Mary Barton’ more than half a century later, was “crowded with houses and inhabitants,” as Percival says: so populous were the environs of Manchester that every house in the township had been found by a late survey to contain an average of six persons. The proportion of deaths was less than in 1757; but that was chiefly due to the accession of new settlers from the country, which raised the ratios of marriages and births[257]. Manchester had increased from a population of about 8000 in 1717 to one of 19,839 (inclusive of Salford) in 1757. When the inhabitants were next counted in 1773, they were found to be 22,481 in Manchester (5317 families in 3402 houses) and 4765 in Salford (1099 families in 866 houses). According to Percival, who gives these figures, the death-rate in 1773 was 1 in 28·4, the births exceeding the deaths by forty in a year. The poor, he says, were now better lodged, and some of the most dangerous malignant distempers were less violent and less mortal. Manchester, however, was still an unhealthy place compared with the country, especially to young children. Thus, the thirty-one townships in the parish of Manchester contained, exclusive of the city, 13,786 inhabitants (2525 families in 2371 houses), and of these only 1 in 56 died annually (compared with 1 in 28 in the city)—the births being to the deaths as 401 to 246 in the year 1772.

Again, the bleak upland parish of Darwen with a population in the year 1774 of 1850 souls mostly occupied in the cotton manufacture, had, during the seven years before, more than twice as many baptisms as burials (508 to 233), the birth-rate (1 in 25·5) being high and the death-rate (1 in 56) low.

Leeds had a population of some six or seven thousand at the time of the Civil Wars, and lost 1325 in nine months of the year 1645 from plague, all of them the poorer class. A generation or two later, in the time of Thoresby’s ‘Diary,’ it was a centre of the cloth trade; and it appears to have grown steadily throughout the 18th century. In 1775 it had a population of 17,117. We hear from Lucas of an epidemic typhus in it previous to 1779[258]. Eighty persons had died of that fever in one year, and many who struggled through the disease died afterwards of lingering complaints. In two courts or yards (such as might have been the Lantern Yard which Silas Marner found pulled down when he revisited Leeds) forty persons were affected with the fever; some families had received ten shillings a week from the assessment for the poor. As early as 1779 Lucas proposed a house of reception for contagious fever, a proposal which was carried into effect in 1804, after a whole generation of typhus and at a time when there was little fever in Leeds or elsewhere. The infectious fevers, being chiefly confined to the poor, often prevailed, says this writer, for a length of time without exciting much alarm, or without their fatality being attended to; but, he adds about the year 1790, “should a few of the higher rank receive the infection, then the disease is described in most exaggerated terms.”

Carlisle was a good instance of the increase of urban population and the breeding of typhus. In seventeen years, from 1763 to 1780, the inhabitants had increased from 4158 to 6229, many of the immigrants being Scots and Irish with their families. The chief industry was the making of calico, in which the women and children were employed as well as the men. When Dr Heysham surveyed the town and suburbs for his census of 1779, he had “opportunity of seeing many scenes of poverty and filth and nastiness[259]”; and in the bill of mortality for that year he confesses himself astonished that there should be so little fever.

The great outburst of typhus at Carlisle began in the end of March, 1781, with no very obvious special provocation[260]. Upwards of 600 had typhus to February 7th, 1782, at which date 12 or 15 were still suffering from it. The deaths were less than 1 in 10 of all attacked: viz. 2 in May, 4 in June, 8 in July, 8 in August, 7 in September, 9 in October, 8 in November, 6 in December, and 3 in January, 1782, a total of 55. Of this total of fatal cases, 3 were boys, 4 bachelors, and 15 husbands: 3 girls, 2 maids, 22 wives, and 6 widows. Two-thirds of all the deaths were of married people; Heysham saw no case in a child under three years. It affected about a tenth part of the inhabitants of Carlisle (6299), and raged most among the lower class who lived in narrow, close, confined lanes and in small crowded apartments, of which there were a great many in Carlisle, generally going through all the inmates of a house where it had once begun. On seeking to trace the origin of the epidemic, he found that it began in the end of March, 1781, in a house in Richard-gate, which contained about half-a-dozen very poor families. Every window that could be spared was shut up, to save the window-tax. The surgeon who attended some of these poor wretches told Dr Heysham that the smell was so offensive that it was with difficulty he could stay in the house. One of the typhus patients in this house was a weaver, who, on his recovery, went to the large workshop where he worked, and there, it was supposed, gave the infection (in his clothes) to his fellow workmen, by whom new centres of infection were made in various other houses. In August, a young man just recovered from the fever went to his mother’s in the small village of Rockliffe, four or five miles from Carlisle, to get back his strength in the country air; his mother soon took the fever and died, and a neighbour woman who came to her in her sickness likewise caught it and died. These were all the cases known in the village, and they show the enormously greater fatality of typhus in those not inured to its atmosphere and conditions.

The state of population and health at Warrington was peculiar, and is given fully in another chapter. There could be no more striking instance of the growth of what the foreign writers call the proletariat; an old market-town, with a small sail-cloth industry from Elizabethan times, it became a busy weaving town owing to the demand for sail-cloth during the war with the American colonies. The whole population of some 9000 men, women and children, were wage-earners; the women were all the while unusually prolific, and the sacrifice of infant life was enormous, especially by smallpox. We have no particular accounts of fevers; but in the bill of mortality for 1773, the year of a disastrous smallpox epidemic, there were 25 deaths from fever, of which 10 were of “worm fever,” or the remittent of children[261].

By the year 1790, when Ferriar’s accounts of fever in Manchester begin, the industrial revolution had been accomplished, mills were everywhere, and the characteristic hardships and maladies of a prolific working class in a time of slack trade were already much the same as we find them pictured with fidelity and pathos in the pages of Mrs Gaskell half a century after.

But, so as not to exaggerate the ill health of the working class in Manchester at the end of the 18th century, let us compare the births with the deaths according to the doubtless imperfect registers[262]:

Manchester, Births and Deaths, 1770-91.

The mean lodging-houses in the outskirts of the town, says Ferriar, in 1790[263], were the principal nurseries of febrile contagion: some of these were old houses with very small rooms, into each of which four or more people were crowded to eat, sleep, and frequently to work. They commonly bore marks of a long accumulation of filth, and some of them had been scarcely free from infection for many years past. As soon as one poor creature dies or is driven out of his cell he is replaced by another, generally from the country, who soon feels in his turn the consequences of breathing infected air. There was hardly any ventilation possible, many of these old houses being in dark narrow courts or blind alleys. In other parts of the town the lodging-houses were new, and not yet thoroughly dirty; but in these there was a long garret under the tiles, in which eight or ten people often lodged, the beds almost touching. Again, many lived in cellars, sleeping on the damp floor with few or no bedclothes; the cellars of Manchester, however, were better ventilated than those of Edinburgh, and freer from fever. These cellar-tenants were subject to the constant action of depressing passions of the mind. “I have seen patients,” says Ferriar, “in agonies of despair on finding themselves overwhelmed with filth and abandoned by everyone who could do them any service, and after such emotions I have seldom found them recover.” Addressing the Literary and Philosophical Society of Manchester previous to 1792, he pointed out in an argumentum ad hominem that “the situation of the poor at present is extremely dangerous, and often destructive to the middle and higher ranks of society[264].” And again, “the poor are indeed the first sufferers, but the mischief does not always rest with them. By secret avenues it reaches the most opulent, and severely revenges their neglect or insensibility to the wretchedness surrounding them[265].”

In an address to the Committee of Police in Manchester, he instances the following cases:

The fever in Manchester was not always malignant typhus: sometimes it had the symptoms and low rate of mortality that suggest relapsing fever. Thus, in the winter epidemic of 1789-90, very prevalent in Manchester and Salford, out of Ferriar’s first ninety patients only two died; in some the skin had a remarkable, pungent heat, in others there were profuse watery sweats; women were commonly affected with hysterical symptoms during convalescence, which was often tedious[267]. A certain number of these cases would run into “a formed typhus,” with petechiae and all the other signs of malignity; and in some seasons, as in the distressful year 1794, typhus was the usual form. Two fatal cases in children, examined after death, had peritonitis; “in the one no marks of the disease were discernible within the cavity of the [intestinal] tube;” in the other, the patient was covered with petechiae[268]. These cases of localized inflammation in typhus he compares with Pringle’s cases of spotted fever complicated with abscess of the brain.

The years 1792 and 1793 passed, says Ferriar, without any extraordinary increase of fever patients, although the noxious influences were always present. But in the summer and autumn of 1794 “the usual epidemic fever” became very prevalent among the poor in some quarters of the town, particularly after a bilious colic had raged among all ranks of people. This was a time when work was slack; many workmen enlisted and left their families. In November and December 1794, as many as 156 sent applications to the Infirmary in a week to be visited in fever at their homes.

This was a memorable time of scarcity and distress all over the country, the beginning of a twenty-years’ period of so-called “war-prices,” when farmers’ profits were so large that they could afford to double or treble their rents to the landlords. The history of epidemics comes at this point into close contact with the economic history, which I shall touch on in the sequel, after giving a few more particulars of typhus in England and Scotland generally, previous to the outbreak of the war with France in 1793.

Typhus in England and Scotland generally, in the end of the 18th century.

The introduction of machinery and the building of mills brought typhus fever to places much less crowded than Leeds, or Manchester, or Carlisle.

Dr David Campbell of Lancaster saw much of typhus in that town, and in mill villages near it, in the years 1782, 1783, and 1784. In Lancaster town he saw about 500 cases, of which 168 were in men, with 20 deaths, 236 in women, with 11 deaths, and 94 in children under fourteen, with 3 deaths. At Backbarrow cotton mill, twenty miles from Lancaster, there were 180 cases, of which 38 were in men, with 5 deaths, 11 in women, with 2 deaths, and 131 in children under fourteen, with no deaths[269]. At this mill there was an extremely offensive smell in the rooms, which came from the privy; the doors of the latter, “for indispensable reasons in the economy of these works, where so many children are employed, always communicate with the workrooms.” Every care had been taken to keep the air sweet, but without effect. The offensive smell was in all the cotton mills from the same cause; and in the Radcliffe mill belonging to Mr Peel, the typhus was ascribed to that source, the nuisance having been at length got rid of. Both at Backbarrow and Radcliffe the houses of the workpeople were new, airy and comfortable. In the same years typhus raged with uncommon severity at Ulverston and in various parts of Lancashire, where cotton-mills had been set up[270].

The typhus of Liverpool and Newcastle was reproduced in Whitehaven and Cockermouth on a scale proportionate to their size. Whitehaven, the port of the Cumberland coal-field, was the Newcastle of the west coast, and had a large trade with Ireland. Many of the labourers lived in cellars. Brownrigg’s experiences of typhus fever in it went back to near the middle of the 18th century. The Whitehaven Dispensary was opened in 1783, the occasion for it being thus explained:—