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.
The fever at Rouen which Le Cat specially described to the Royal Society was an outbreak from the end of November, 1753, to February, 1754. This outbreak was only one of a series; but as it attacked a great number of persons of distinction and made great havock among them, it attracted unusual notice and was regarded as something new, the rumour spreading over Europe that Rouen had been visited by plague. The same fever, however, had occurred there in previous years; and allied forms of sickness, of the same gangrenous character, including gangrenous sore-throat, could be traced back for twenty or thirty years. It will suffice to mention of these the malignant fever which appeared in 1748 and continued in 1749, 1750 and 1751. There was a fixed pain in the head, pain about the heart, a low fever with delirium, often miliary eruptions, continual faint sweating, drowsiness, scanty or suppressed urine, abdominal distension. After death the stomach was found “inflamed” at places, as well as the small intestine. In some cases there were ulcerations which almost penetrated the coats. The lungs were engorged with blood. In one case, of a young woman aged twenty, the mesentery was filled with obstructed glands and the intestines mortified in different places. In another, almost the whole mesentery was mortified and there was an anthrax or carbuncle at the upper fore part of the armpit. At the same time some cases of smallpox, with miliary eruption, also had ulcerations of the stomach, with inflammatory spots on other parts of it and of the intestine, the mesenteric glands being enlarged and hard. Some of the cases at the Hôtel Dieu in 1750 were traced to infection from bales of horse-hair; but the type of the disease in those cases did not differ essentially from that of other cases. Some rapidly fatal cases in the winter of 1752-53 had suppurative inflammation about the heart. (In 1739 there had been deaths from continued fever at the Hôtel Dieu, after an illness of six or seven days, marked by frequent faintings, small abscesses being found after death in the substance of the heart near the auricles.) The fever among the upper classes in the winter of 1753-54 was marked, in its most mortal form, by lowness, continued fever, pain in the head, cough, sore-throat, nausea, dry black tongue, delirium, sweats, stupor, some oppression of the heart, spitting of blood, sometimes swelling of the belly, these symptoms being followed often by miliary eruption, and sometimes by a slight flux with blood. Many were affected with a dejection of spirits, and with a feeling of terror which made them tremble at the ordinary sound of the voice. The fever ran a full course of thirty or forty days (the miliary eruption coming about the 21st day), while death usually ensued about the 25th. The appearances after death were remarkable (many bodies were opened): “In some a part of the villous coat of the stomach and of the small guts was inflamed; and the rest of these organs were filled with an eruption of the miliary crystalline kind, except that it was larger; and there was likewise an obstruction in the glands of the mesentery. In others a strong inflammation had seized the whole stomach and a small portion of the oesophagus, but the intestines were free.... In those cases where the delirium had continued long and violent, we found either ulceration on the stomach, or its villous coat separated, together with a great inflammation, and even some gangrenous spots, on the other coats of that organ.” Some recovered by critical abscesses. Others who escaped death by the poison carried its terrible effects for many months; their limbs and joints were feeble, and they were troubled with vertigo, lassitude and fears[213].
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:
“In all sorts of fevers,” he writes, “there was a surprising disposition to eruptions of some kind or other [including miliary], to sweats, soreness of throat and aphthae.” It is hardly possible to make out all his cases of “malignant anginose fever” to have been scarlet fever with sore-throat. Thus there occurred stench, swelling, and samious haemorrhages “commonly in those that died of malignant anginose fever above described. I have known the whole body swell vastly, even to the ends of the fingers and toes, with a cadaveric lividity, though almost quite cold, and an intolerable stench, even before the person was actually dead, blood issuing at the same time from the ears, nose, mouth and guts[217].”
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.
It went through whole families, who succumbed either all together or one member after the other, and was carried from place to place by the attendants on the sick. “It prevailed chiefly in poor families, where numbers were lodged in mean houses, not always clean, but sordid and damp. It seemed to affect such poor families most where there was reason to think a sufficiency of the necessaries of life, on account of the dearth, had for some time been scantily supplied; yet the other poor persons, given to the intemperate use of malt liquors and ardent spirits, were observed to be very much liable to its influence. And not a few persons in easy circumstances of life were affected with this fever like others.”
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.
“But in other neighbouring villages and market towns it has since the spring hitherto (Dec. 1757) been very frequent in places that were little affected with it last year. The families of the poorer sort of people universally are the most subject to it. And it is observable that the fever in some places first broke out in the parish workhouses, and from thence spread among the neighbouring people with great malignity. Wherever it has appeared it has given very apparent and fatal evidence of its infectious nature[220].”
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:
The tremulousness of the wrists, he says, extended to all the body, “insomuch that I have seen the bed-curtains dancing for three or four days, to the no small terror of the superstitious attendants, who, on first perceiving it, thought some evil spirit shook the bed. This agitation was so constant a concomitant of the fever as to be almost a distinguishing symptom.” These were not the shakings of an ague, for there might be no intermission for days[223].
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.