Enteric Fever mixed with the prevailing Typhus, 1831-42.
While there is complete agreement among the hospital physicians of the great towns that the fever of 1837-39 was maculated typhus, to the total exclusion of cases with ulceration of the bowel, as in the experience of Watson at the Middlesex Hospital and of West (under Latham) at St Bartholomew’s, yet some allowance should be made, in interpreting the figures of fever mortality in those years throughout England and Wales, for admixture of enteric fever. Budd’s statement that the only case which was dissected in the epidemic at North Tawton, Devonshire, in 1839, had the bowel-lesion of enteric fever, if it is to count in the absence of the usual details (place, date, objective description), would mean that at least one case there was not of the prevailing type of contagious epidemic typhus. The coincidence of some such cases is made the more probable by the evidence from Anstruther, Fifeshire, reported by John Goodsir, afterwards Professor of Anatomy at Edinburgh, who was assisting his father in practice there from 1835 to 1839. During that period, which was the time of the typhus epidemic in the larger towns of Scotland, he attended about one hundred cases of fever annually in Anstruther and the neighbourhood; the fever was usually mild, only some sixteen of the cases having proved fatal; of those sixteen he examined ten after death, finding “ulceration” of the Peyer’s patches in all, and perforation of the intestine in four of them. These facts he gave orally to Dr John Reid, pathologist to the Edinburgh Infirmary, whose experience of the morbid anatomy of fever was altogether different. Goodsir, having kept the specimens, made them the subject of a paper some years after (1842), in which he described very minutely the stages and degrees of congestion, ulceration, sloughing and perforation in the lymph-follicles of the intestine in fever, placing congestions at one end of the scale and sloughing at the other, as the French pathologists then did[379]. Reid examined, at the Edinburgh Infirmary from October, 1838, to June, 1839, forty-one bodies dead of fever, to see whether the intestinal lesion, which Goodsir had told him of, occurred in them. The distinctness of the Peyer’s patches varied a good deal (differences which are known to be in part congenital and in part to depend on age), and in only two instances were they elevated and seemingly “ulcerated.”
One of these was the case of an Irishman, from Sligo, aged 25, who had been so constipated that he was purged with colocynth, etc.: “at the lower part of the ileum, the elliptical patches were irregular on the surface, and presented several superficial and ill-defined depressions (ulcerations).” The other was the case of a girl, aged 15, who had not suffered from diarrhoea, but had the intestinal patches elevated and superficially “ulcerated[380].” Neither of these cases would probably be reckoned typhoid or enteric fever at the present time on the anatomical evidence only. The early French observers, Chomel, Louis, Andral and others, included in a scale all the appearances of the Peyer’s patches in fever that they thought morbid, from mere prominence of the lymphatic tissue and distinctness of the follicular pits, up to extensive sloughing and ulceration of the same, as if they were all the signs of one and the same fever in its various stages of development. But simple prominence or congestion of Peyer’s patches may occur in typhus fever, or in relapsing fever; nor would a slight erosion, or “superficial ulceration” raise in all cases a suspicion of enteric fever.
The observations of Home, Reid’s predecessor as pathologist to the Edinburgh Infirmary, from 1833 to 1837, were however conclusive that true enteric fever had occurred now and again during the steady prevalence of typhus fever from year to year. In that space he made 101 post-mortem examinations in fever-cases; in 29 the Peyer’s patches were distinct, in 7 of those 29 there was “a greater or less degree of ulceration,” and in 2 of those 7 there was perforation[381]. Murchison examined the post-mortem register of the Edinburgh Infirmary for the years 1833 to 1838, and found only fifteen cases of fever with ulceration of the bowel. But in the eight months from 1 November, 1846, to June, 1847, there were nineteen dissections with the characteristic lesion of typhoid, the season having been remarkable everywhere for that disease.
In the following series of years the fatal cases of fever in the Edinburgh Infirmary with ulceration were few[382]:
| Year | Enteric deaths | |
| 1854 | 5 | |
| 1855 | 2 | |
| 1856 | 1 | |
| 1857 | 8 | |
| 1858 | 1 | |
| 1859 | 2 | |
| 1860 | 1 | |
| 1861 | 6 |
It was thought remarkable that the form of continued fever which was most usually found in the great continental cities, in Paris, Berlin, Prague and Vienna, namely that with ulceration of the lymph-follicles of the intestine, should be but occasionally mixed with the old typhus in England, Ireland and Scotland in the very same years. But there was nothing to discredit the British observations, anatomical and clinical; and in 1836 Dr Lombard, of Geneva, having visited various cities in England, Scotland and Ireland bore witness to the matter of fact, strange as it was to him. Writing to Graves, of Dublin, on 16 June, 1836, he said: “Before I leave Ireland, allow me to express to you my great astonishment at what I have seen in this country respecting your continued fever;” and in a second letter, of 18 July, after his return to Geneva, he added, that in Liverpool, ulceration of the ileum in continued fever was “occasional,” that in Manchester he had been told it occurred “by no means always,” that in Birmingham the cases of fever were not many, but “always” with intestinal ulceration, and that in London “not a fourth part” of the cases of fever had the latter condition, and these mostly in autumn[383]. This was before the great epidemic of typhus had begun in the English towns. To the same non-epidemic period (1834) belongs the statement of Carrick, for Bristol, that fever was often observed to be infrequent or altogether absent in the most crowded and dirty parts of the city at times when there were a good many cases “in institutions and dwellings where cleanliness and free air are most carefully attended to,” and that ulceration of the bowel was the most common post-mortem appearance[384].
The comparative rarity of enteric fever in the chief towns of Scotland and Ireland continued for a good many years longer, indeed until after the differences between typhus and typhoid were perceived and admitted by all. Even at the London Fever Hospital, during twenty-four years (1848-71) after Sir William Jenner’s diagnostic points were strictly looked to in its wards, much the greater part of the admissions were of typhus; in only two periods, 1850-55 and 1858-61, during both of which there was comparatively little fever of any kind in London, did the admissions for enteric fever slightly exceed those for typhus; on an annual average of the twenty-four years ending 1871, the cases of the former were only about a fifth part of the whole. The cases of enteric fever increased decidedly after 1865. Murchison thought that the increase might be accounted for in part by the enlargement of the Fever Hospital, and by the unusually high temperature of certain years, the summers and autumns of 1865, 1866, 1868 and 1870 having been remarkable for their great heat and prolonged drought; but, he adds, “it is not a little remarkable that this increased prevalence of enteric fever in the metropolis has been contemporaneous with the completion of the main drainage scheme[385].”
Still more recently, the relative proportions of typhus and enteric fever have been reversed, so that there have been years with little or no typhus but with a good deal of enteric fever. There are some persons, unacquainted with the history, who cannot imagine that it was ever otherwise than now, who think of the former times of medicine, not as differing in social, economic, and various other respects from their own, but only as being less clever at diagnosis. There are others who realize clearly enough the historical matter of fact, but find it necessary to explain the almost contemporaneous decline of typhus and rise of typhoid by some hypothesis of the latter being “evolved” out of the former. This evolutional doctrine makes the mistake of ascribing to the species of disease the same comparative fixity of characters that belongs to the species of animals and plants. Beside the latter, the species of disease are the creatures of a day. In the nosological field, the origin of species is not analogous to the evolution of a new species of animal or plant out of an old, as in the hypothesis of Darwin, for the reason that every species of disease is evolved directly and, as it were, pro re nata, out of a few simple conditions of human life, variously mixed but always there to give occasion to one infective malady or another, which may have a shorter existence, like sweating sickness, or a longer, like plague. Edinburgh experiences offer a ready criticism of the evolutional doctrine. Typhus declined, and typhoid rose; but it was in the old tenement houses of the Canongate, Cowgate, Grassmarket, and High Street that typhus declined, and it was mostly in the new streets across the valley, or in the New Town of Edinburgh, that enteric fever arose, having sometimes no more mysterious an origin than the results of defective or cheap plumber-work, for example, the leakage of a soil-pipe fermenting, a foot deep, beneath the basement floor. But it was not until a good many years after that these new experiences became common; and meanwhile Edinburgh and other towns in Scotland saw much of typhus and relapsing fever.