FOOTNOTES:
[9] Ovarian and Uterine Tumours: 1882.
[10] Address to Midland Medical Society, Birmingham, November 5, 1884.
[CHAPTER XVII.]
SIR WILLIAM JENNER, BUDD, MURCHISON, AND TYPHOID FEVER.
In no department of medical knowledge has recent progress been more marked than in the discrimination and the tracing of the natural history of the diseases known as zymotic: and no man takes higher rank in this department of investigation than Sir William Jenner. He was born at Chatham, January 30, 1815, being the son of Mr. John Jenner, and educated at University College, London. After qualifying as a general practitioner, he commenced practice and obtained the appointment of Surgeon-Accoucheur to the Royal Maternity Charity. Before long he graduated M.D. at London University (1844), and retired from general practice. His studies in pathology became more and more extensive, and his merits were so far recognised that in 1849 he was elected Professor of Pathological Anatomy to University College, and Assistant-Physician to University College Hospital.
For some years Dr. Jenner had been assiduously studying in the London Fever Hospital, seeking to make a straight path through the many knotty questions then, in debate. In April 1849 he commenced the publication, in the Monthly Journal of Medical Science, of his classic paper on “Typhoid and Typhus Fevers, an attempt to determine the question of their identity or non-identity, by an analysis of the symptoms, and of the appearances found after death in sixty-six fatal cases of continued fever, observed at the London Fever Hospital from January 1847 to February 1849.” In this he states that “with few exceptions, British physicians have laboured to prove that typhoid and typhus fevers are identical. The results obtained by this analysis justify the assertion that they are essentially distinct diseases.... For two years, in distinguishing the two diseases by the eruption alone not a single error has been made, so far as could be proved by examination after death of the fatal cases, or by the progress of the non-fatal cases after their diagnosis was recorded.”
The history of previous investigations and the fluctuations of opinion are excellently given by Dr. Murchison in his great work on the “Continued Fevers of Great Britain,” 1862, 2d ed. 1873. Dr. H. C. Lombard of Geneva appears to have been the first to state positively (in 1836) that “there were two distinct and separate fevers in Great Britain; one of them identical with the contagious typhus, the other a sporadic disease, identical with the typhoid fever of the French.” He failed, however, to point out the distinctive eruptions and other characteristics of the two fevers. At the same period Drs. Gerhard and Pennock in Philadelphia arrived at more definite conclusions, and distinguished the typhus of Philadelphia as being the same as British typhus, the old gaol, camp, and ship fever, so direfully contagious and fatal; while certain intestinal phenomena were invariably found in the other or typhoid fever, which was rarely contagious. The characteristic eruptions and many of the symptoms were also accurately discriminated. These observers were followed by others who with more or less success and emphasis insisted on the same views. Among these were Drs. H. C. Barlow and A. P. Stewart, both of whom read important papers on the subject before the Parisian Medical Society in 1840. In 1841 the celebrated Louis in the second edition of his great work on typhoid fever accepted the view that the English typhus was very distinct from the fever which he had so largely elucidated. Nevertheless many physicians of authority strongly maintained their identity, and the majority of the medical schools taught this doctrine, which could not fail to retard progress. It is obvious how much uncertain and injurious treatment must have existed for a long period owing to the confusion of these two diseases.
In his series of papers published in 1849 and 1850 Dr. Jenner confirmed and extended the distinctions between the symptoms of the two fevers, comparing the selected cases most minutely as regarded previous health, complexion, sex, age, mode of attack, duration, eruption, expression during disease, manner, hue of face, presence of headache, delirium, loss of muscular power, sensation, appearance of the tongue, suffering of pain, appetite, thirst, pulse, cough, and lung symptoms, and many other particulars, and detailed most carefully the post mortem appearances of the diseased action in every organ.
As regards the age of patients, he showed by calculation that typhoid usually attacked much younger patients than typhus, the average age of his cases of the one being 22 years, of the other 42 years. In typhus, death took place on the average on the fourteenth day, while in typhoid the average was the thirty-second day of residence in the hospital. The rose rash of typhoid, disappearing completely on pressure, resuming the original appearance on the withdrawal of pressure, was clearly discriminated from the mulberry rash of typhus. His post mortem observations may be considered to have given the death-blow to the idea that typhoid was merely typhus fever with abdominal complications. In closing the series of papers (April 1850) Dr. Jenner remarked, as to the suggestion that he had drawn general conclusions from a too limited number of facts, “A few facts, impartially observed, minutely recorded, and carefully analysed, are, I believe, more likely to give correct results than a multitude of general observations; and moreover, I believe most men would be astonished if they had in numbers all the cases of any given disease they had ever seen, yet concerning which they have generalised. The method I have adopted—however prolix it may be, however difficult to conform to, however tedious the details into which it leads—has this advantage, that if the observer be honest, and capable of noting what is before him, thinking men may judge of the value of his facts, the force of his reasoning, and the correctness of his conclusion; whereas general observations, while they are totally incapable of proving anything, are exposed to all the fallacies of definite statements, because the one, like the other, rests ultimately on the accuracy of the facts observed. If the observations on which any reasoning is founded be erroneous, no cloaking of those observations in general terms can render the conclusions correct. It has been objected to definite numerical statements that they mislead the reader by an appearance of accuracy in cases where there has been great inaccuracy in observation. This objection appears to me to lie against the condition of the reader’s mind, and not against the method.... The more complicated the problem to be solved, the more careful ought we to be that every step in its solution is made correctly. How complex questions, such as arise in medicine, are to be determined mentally—i.e., without the aid of figures—by ordinary men, I am at a loss to conceive. Yet physicians think to solve, by mental reveries, problems in comparison with which the most difficult that the most renowned calculators ever answered were child’s play; and not only do they think to solve these problems, but to carry in their minds for years the complicated materials by which they are to be solved.”
Another important branch of Dr. Jenner’s inquiry dealt with the question as to whether the specific cause of these diseases is distinct or the same, the latter being then the preponderant opinion. In a paper on this subject communicated to the Royal Medical and Chirurgical Society, on December 11, 1849, he showed that in 1847-8-9, on analysing all the cases in which two or more fever patients came from the same house, scarcely a single instance occurred where typhus and typhoid came at the same period from the same house. In nearly all cases the two diseases came from quite distinct localities. No transitional cases occurred between the two; the rash of typhoid did not graduate into that of typhus. It was several times observed that when a succession of cases came from the same locality, or arose apparently from the same cause, they agreed remarkably in symptoms or other features. Thus Dr. Jenner considered he had definitely proved that typhus and typhoid proceeded from perfectly distinct causes, a result which recent medical science accepts without reserve.
Although the contributions of this distinguished physician have been of such high worth, and his subsequent success so great in practice, he is far from being wedded to the view that any great step forward in medicine has been the direct result of the labours of a single man. Long after his early papers, in addressing the British Medical Association in 1869, Sir William Jenner said: “The silent workers render most efficient aid, the results of their unspoken experience confirming or refuting the published assertions of the few.” He believes that no science has advanced more during the present epoch than medicine, and that it has progressed equally as a practical art.
Dr. Jenner’s appointments include, among a crowd of others, those of Physician to University College Hospital (1854), Professor of Clinical Medicine (1857) and of the Principles and Practice of Medicine (1862), Physician to the Hospital for Sick Children (1852), Assistant-Physician to the Fever Hospital (1853). In 1864 he was elected Fellow of the Royal Society, and became President of the College of Physicians in 1881. In 1861 he was appointed Physician-Extraordinary to the Queen, and attended the Prince-Consort in his last illness. In 1862 he became Physician-in-Ordinary to the Queen, and has frequently attended her Majesty. He was made a baronet in 1868, and further advanced to the dignity of a K.C.B. in 1872 for his services during the Prince of Wales’s illness from typhoid fever.
Sir William Jenner has published eminently valuable clinical systematic lectures in the medical journals, and a small treatise on Diphtheria (1861). His addresses to the British Medical Association (1869), and to the Epidemiological Society (1866), published together, are most excellent as summaries of the modern progress of medicine, and as pointing out the directions in which future advances may be made. He insists most strongly on and desires most ardently the prevention of disease, and shows a striking readiness to welcome new discoveries.
Few more striking individualities have been seen among the provincial physicians of our day than that of William Budd, of Clifton. He was one of the younger sons of Mr. Samuel Budd, a successful medical practitioner at North Tawton in Devonshire, who having very considerable culture and foresightedness, brought up most of his large family at home, and was ultimately enabled to introduce seven out of nine sons to the medical profession, sending seven to Cambridge, where five became wranglers. One of the elder brothers, George Budd, was long Professor of Medicine at King’s College, London, the author of an excellent treatise on Diseases of the Liver, and a most successful London physician. William Budd was born in September 1811; his medical studies were pursued in London, Edinburgh, and Paris, in the latter of which cities he spent four years. Graduating M.D. in 1838 at Edinburgh, he for some time afterwards assisted his father in his practice at North Tawton, and here in 1839 commenced his lifelong studies on typhoid fever, having himself been already a sufferer by that malady. He had peculiar advantages in this study, for he was personally acquainted with every inhabitant of the village, and being as medical practitioner in almost exclusive possession of the field, nearly every one who fell ill, not only in the village itself, but over a large area around it, came immediately under his care. At the date of the outbreak the population of eleven or twelve hundred had been extremely exempt from fevers. Yet there was no sewerage system; cesspools prevailed; pig styes were close to the houses; and all conditions of decomposition were to be found;—but fever did not arise till it had been specifically introduced. In July 1839 the first case of typhoid occurred, and before the beginning of November over eighty of the inhabitants had suffered from it. Young Budd kept an accurate and detailed record of every essential fact, and spared no pains in tracing out all extraneous facts that he required to know. He was extremely struck by the fact that three persons left North Tawton after they had been infected, and all three communicated the disease to one or more of the persons by whom they were surrounded. The narrative which Dr. Budd gave many years afterwards, in his “Typhoid Fever: its Nature, Mode of Spreading, and Prevention” (1873), is like a romance for its interesting detail, though melancholy with its tale of pain and death. He shows that there is evidently a specific poison which breeds and multiplies in the living human body, and that this process of breeding and multiplying constitutes the fever itself. This essentially is its contagiousness, the communication from body to body of the specific matter or germ, which when bred and multiplied produces the fever. This he called the master-fact in its history. He further believed that all the emanations from the typhoid patient are in a certain degree infectious, but that what is cast off from the intestine is incomparably more virulent than anything else. Wherever no sufficient provision was made for preventing such material from contaminating the soil and air of the inhabited area around, notwithstanding the most spacious rooms, the freest ventilation, and careful nursing, he found there was no real security against the spread of the fever. The fact alleged against Dr. Budd’s views, that typhoid is seldom taken by attendants on the sick, does not at all militate against his teaching, for unless they received into their system through milk, water, food, or air, some of the specific poison of typhoid, they would certainly not suffer.
In 1842 Dr. Budd settled in Clifton, and was in 1847 elected Physician to the Bristol Royal Infirmary. He lectured for a number of years in the Bristol Medical School, and worked incessantly at maturing and propagating his views on the nature and mode of propagation of zymotic disease. He was no mere theorist, but in all his pursuits had most practical objects in view, seeking to enforce on his medical brethren, public authorities as well as private persons, the urgent necessity of the most careful, well-advised, and continuous methods of disinfection. He was in effect a great sanitarian and champion of preventive medicine. Pure water was one of his great panaceas. The Bristol Waterworks were among his cherished objects of promotion and watchfulness. His remarkable clearness of vision and strength of conviction made him somewhat impatient of the strenuous opposition with which his views were met. For a long period he was almost alone in his uphill fight. He did not fully put his views before the profession till 1857-60, when he published a series of papers in the Lancet, afterwards embodied in his work on typhoid fever; but he had long before taught them in the Bristol Medical School, and practically acted upon them himself. During the depressing period of opposition which he encountered, almost the only sympathy he could count on was that of the late Sir Thomas Watson, who encouraged him greatly, believing his investigations to be of priceless value. Cheered in this way, Budd continued to promulgate his views, dogmatically it is true, but in a manner singularly attractive, for he had a natural kindliness of disposition and freedom from all jealousy. His impressive eloquence was not more striking than his logical power, which is evident in all his works.
Asiatic cholera, when it broke out in Bristol in 1866, found William Budd and Bristol prepared. The deaths from this destroyer in 1849 had been 1979, in 1866 they were but 29, notwithstanding that the disease broke out very severely, and occurred in twenty-six different localities. Budd’s preventive measures, and his stringent plans of disinfection, proved victorious. He made the contagious diseases of animals subjects of special study; and his conclusion was that several of them could only be adequately dealt with by immediately slaughtering the infected animals. This view he took in regard to the terrible rinderpest of 1866: and his advice of “a poleaxe and a pit of quicklime,” though at first ridiculed, had to be followed, after great loss had taken place through not following it earlier.
Dr. Budd was elected a Fellow of the Royal Society in 1870. Besides his famous work on typhoid fever, and many scattered contributions to medical journals and societies, Dr. Budd was the author of the following works, many of which are of very great value:—“Malignant Cholera: its Mode of Propagation and its Prevention” (1849); “Scarlet Fever and its Prevention” (1869); “The Siberian Cattle Plague, or the Typhoid Fever of the Ox” (1865); “On Diseases which affect Corresponding Parts of the Body in a Symmetrical Manner” (1842); “Researches on Gout” (1855); “Cholera and Disinfection, or Asiatic Cholera in Bristol in 1866” (1871); “Variola Ovina—Sheep’s Smallpox—or the Laws of Contagious Epidemics Illustrated by an Experimental Type” (1863). He was an accomplished draughtsman and an excellent photographer, and made great use of these arts in his researches. He was well skilled in French, German, and Italian, and kept himself well up in Continental as well as English medical literature. He worked with untiring energy and industry, having a large practice extending far beyond Bristol: but the attempt to combine this with so much original research proved too much for his constitution. He had been originally strong, but was weakened by two attacks of fever, and finally in 1873 his health broke down, and this led to his finally retiring from practice and settling at Clevedon, where he died January 9, 1880. Just previously to his retirement he had committed to his friend Dr. Paget of Cambridge a brief summary of the results of many years’ study of pulmonary consumption, as to its communicability from person to person by organic germs. This was published in the Lancet at the time, but unfortunately the fuller researches therein referred to have never been given to the public. But in connection with typhoid and other zymotic fevers he has left on the subject the indelible impression of his great genius.
The exertions of Charles Murchison, who died before Budd, though much younger, were largely devoted to controverting Budd’s views on the germ theory of zymotic diseases. He belonged to the same Aberdeenshire family from which Sir Roderick Murchison the geologist sprang, and was born in Jamaica in 1830. His father, himself a physician, spent his latter days in Elgin, where his son Charles was at first educated. As early as 1845 he entered Aberdeen University, but in 1847-8 he commenced medical study at Edinburgh, and in successive years gained numerous distinctions and considerable note as a diligent and successful student. In 1850 he was Syme’s house-surgeon. In August 1857, when he graduated, he received the gold medal for his thesis on the Pathology of Morbid Growths. He further studied at the Rotunda, Dublin, and in Paris, whence he went to India, being appointed Professor of Chemistry to the Medical College, Calcutta. In this office he was both successful as an experimenter and as an expositor. Later, he went with the army on the British Expedition against Burmah, and utilised the opportunity to make valuable observations on the climate and diseases of Burmah, which he afterwards published.
Returning to England in 1855, Murchison became a member of the London College of Physicians, Physician to the Westminster General Dispensary, and Demonstrator of Anatomy at St. Mary’s Hospital. In 1856 he was appointed Assistant-Physician to King’s College Hospital, which office he resigned in 1860, and joined the staff of the Middlesex Hospital. He further held from 1856 the post of Assistant-Physician to the London Fever Hospital, steadily pursuing there as elsewhere his investigations into the nature and causes of zymotic diseases, from which he himself twice suffered in the form of typhus fever, which left in him heart-mischief that ultimately caused his death.
In 1862 appeared Murchison’s work on “The Continued Fevers of Great Britain,” dealing especially with typhus, typhoid, and relapsing fevers. In this he treats exhaustively the history, geographical range, causation, symptoms, treatment, and many other questions connected with fevers, and endeavours especially to reduce his observations to a numerical expression. His strong conviction was that these diseases are preventable, and that they originate in certain unhealthy and impure conditions capable of generating specific poisons in each case. But as he commenced his work at the London Fever Hospital believing that typhus and typhoid fever were mere varieties of one disease, in spite of Stewart’s and Jenner’s publications, so he maintained to the last that Budd’s view as to the germ origin of typhoid fever was erroneous, and that even if typhoid were communicable by germs, it could arise anew when favouring conditions of decomposition occurred. He regarded it as proved that typhoid fever is constantly appearing where decomposing sewage is present, but where every effort fails to detect contamination from a previous typhoid patient.
Murchison’s work was at once recognised as a standard one. The first edition was rapidly sold, and it was translated into German. The publication of a second edition was, however, delayed till 1873, owing to Murchison’s strong desire to make his book as complete statistically as possible. The first edition was based on 6703 cases of continued fever admitted into the London Fever Hospital in the years 1848-57, but the second included the results of a far larger number, 28,863, admitted during 1848-70, thus giving the entire medical history of the fever hospital from the time that the different continued fevers were first distinguished in 1848. Energy and resolution of the most intense description are indicated by such a labour. This work had to be done in the intervals of growing practice and hospital teaching. By the time he was forty years old Murchison was one of the leading London physicians, and continued in full work till his death.
It was not only in regard to fevers that Murchison held a conspicuous place and published works of great value. In 1868 he published an excellent series of “Clinical Lectures on Diseases of the Liver,” which reached a second edition in 1877, when he added to them the Croonian Lectures on “Functional Derangements of the Liver,” delivered at the College of Physicians in 1874. In 1871, when St. Thomas’s new hospital was opened, Murchison was invited to join its staff as full physician and joint-lecturer on medicine. In this growing school he found full scope for his great talent as a clinical teacher. Of his success in this capacity the Lancet said[11]—“His teaching was a reflex of his singular lucidity of thought and expression, which not only attracted the student with its distinctness and brilliancy, but furnished him with a method on which to found his own facts and observations.” His inaugural address as President of the Pathological Society in 1877 gave further proof of his marked originality of thought.
Murchison’s accomplishments and personal attractiveness were as remarkable as his professional talents and industry. In botany, zoology, chemistry, and geology he had very wide knowledge, and he edited the palæontological memoirs of his friend Hugh Falconer, the explorer of the Miocene fauna of the Siwalik Hills. Fly-fishing was his favourite recreation. “In personal appearance,” says the Lancet, “Dr. Murchison was slightly below middle stature, and before the commencement of his fatal illness, of sturdy robust build, with the appearance of one well fitted to bear the trials and struggles of life. His head was large, the forehead high and full, the hair black, and eyes of surprising brilliancy and power of expression. In manner he was reserved, sparing of speech, and free from that impulsiveness which hails the ordinary acquaintances of life as esteemed friends. To those who knew him intimately, however, his full character was revealed, and they found in him a depth of love, tenderness, and sympathy, together with a constancy and devotion in friendship, rarely found in more demonstrative natures.” He attached himself particularly to the younger members of his profession, and never spared time or trouble in assisting them with his counsel and sympathy. He suffered severely from heart disease for several years before his death, which took place suddenly in the interval between the departure of one patient and the announcement of another, on the 23d April 1879.