“For several days a malignant fever has so near a resemblance to one that is only hysterick, that many physicians and standers by, I am apt to believe, mistake the first for the last, and look upon a great and dangerous disease to be only the spleen, or a fit of the vapors, to the great hazard of the patient[108].”
In 1730, Dr William Cockburn, in a polemic against the physicians whom he styles “the academical cabal” (because they objected to his secret electuary for dysentery), professes to give a history of the mistakes of the faculty in London over this “little fever,” or “hysteric fever,” which often became dangerous[109]:
“The present fever, with a variation in some of its symptoms, has now subsisted twelve years [or since 1718] not in England only, but all over Europe [Manningham says it was peculiarly English]. Few or no physicians suspected the reigning and popular disease to be a fever. Vapours, a nervous disease, and such general appellations it had from sundry physicians. Others, who discovered the fever, knew it was the low or slow fever, first mentioned by Hippocrates.... The last were represented as ignorant for calling the distemper a fever, and affixing to it the name ‘low’ or ‘slow,’ a slow fever being, in their adversaries’ opinion, altogether unheard of among physicians and never recorded in their books. Nothing was more monstrous than calling this distemper a fever, or confining persons afflicted with it to their bed, and dieting them with broth, or other liquid food of good nourishment, and what is easily concocted.... ‘You are not hot, you are not dry; you are in good temper; and therefore you have no fever’ was the common language of the town.... They might have seen physicians practising for a destroying distemper, and yet, after seven years, they confess themselves ignorant of its very name.”
At length, he continues, Blackmore admitted the ambiguity of diagnosis, while Mead, Freind and others, recognized that there was really such a thing as a slow, nervous fever, by no means free from danger to life. It is probably to this insidious fever that Strother refers:
“Thus, having gone on for six or seven days in a train of indolence, they have been surprized on the seventh day, and have died on the eighth lethargick or delirious, whereas, if they had taken due care, the fever would have run its course in fifteen days or more.” It was the remissions, or intermissions, he explains, that often misled patients, by which he seems to mean the clear intervals between relapses. “Others, wearied out with relapses, have hoped their recovery would as certainly ensue as it had hitherto, and have deferred asking advice until it was too late.” These relapses, he thought, were brought on by venturing too soon into the air: “it is too well known that the fever has been cured, and patients have soon, after they have ventured into the air, relapsed and have again run the same circle of ill symptoms, if not worse than before.” Bark failed conspicuously in these “remittents:” “it is therefore incumbent on me to examine into the reason of this new phenomenon. I call it new,” he explains, because bark had hitherto succeeded. “Perhaps we may find reason to lay some blame on the air for the frequent relapses.... Periodical comas have of late been common; so soon as the fit was over, the drowsiness abated till the fit returned.”
Elsewhere he speaks of the frequent relapses as belonging to a “quartan,” under which diagnosis bark had been tried. The fevers were less apt to “relapse” when treated by mild cathartics. Another symptom of this fever was jaundice: “If jaundice breaks forth on the fourth day of a fever, it is much better than if it comes at the conclusion of a fever.... Jaundices are now very common after the cure of these fevers.”
These indications, dispersed throughout the rambling essay of Strother, point somewhat plainly to relapsing fever[110]. But his theoretical pathology comes in to obscure the whole matter. He explains everything by obstructions. The jaundice was due to obstruction of the liver by “styptics,” the hysteric symptoms to obstructions of the nerves; there were also theoretical obstructions of the mesentery, part of the matter being sometimes “thrown off into the mesenteric glands”; also “congestions” or phlegmons of the liver, spleen and pancreas. But it is when he comes to the bowels that his subjective morbid anatomy becomes truly misleading. There is nothing to show that Strother examined a single body dead of this fever. He says, however, in his à priori way: “The crisis of these slow fevers is generally deposited on the bowels.... The lent fever is a symptomatical fever, arising from an inflammation, or an ulcer fixed on some of the bowels. A lent fever, depending on some fixed cause of the bowels, must be cured by having regard to those causes some of which I shall enumerate”:—the first supposition being that the fever depends on phlegmons by congestion of “the liver, spleen, pancreas, or the mesentery”; the second, if it depends on extravasations in an equally comprehensive range of viscera; the third, “if it depends on an ulcer, then all vulneraries must be administered internally; but to speak truth, when the viscera are ulcerated, there remains but small hope of life”; the fourth supposition is worms, the fifth corruption of the humours. All this is paper pathology. There is not a single precise fact relating to ulcerated Peyer’s patches, or to swollen mesenteric glands, or to enlarged spleen, which last would have been equally distinctive of relapsing as of enteric fever; it is “the viscera” that are ulcerated, or congested, or extravasated, or it is “some of the bowels,” or the pancreas and liver obstructed as well as the spleen, the obstruction of the liver being invoked to explain the highly significant jaundice.
It is not quite clear whether Strother’s fever with relapses and jaundice corresponded exactly to the little fever, hysteric fever, or nervous fever of the same years; but it is worthy of note that relapsing fever in Ireland a century later was called febricula or the “short fever.” It was not until 1746 that the excellent essay upon it by Sir Richard Manningham was written. By that time a good deal was being said in various parts of Britain of a slow, nervous, or putrid fever, Huxham, in particular, identifying the nervous fever with Manningham’s febricula or little fever[111]. Some have supposed that the nervous fever of the 18th century included cases of enteric fever, if it did not stand for that disease exclusively. Murchison takes Manningham’s essay to be “an excellent description of enteric fever, under the title of febricula or little fever, etc.[112]” The following are brief extracts from his description, by which the reader will be able to form his own opinion on the question of identity[113].
At the beginning patients feel merely languid or uneasy, with flying pains, dryness of the lips and tongue but no thirst; in a day or two they find themselves often giddy, dispirited and anxious without apparent reason, and passing pale urine. They have transient fits of chilliness, a low, quick and unequal pulse, sometimes cold clammy sweats and risings in the throat. They go about until more violent symptoms come on, simulating those of quotidian, tertian or quartan fever; sometimes the malady simulates pleurisy. There may be attacks of dyspnoea, nausea and haemorrhage; the menses in women are checked. A loss of memory and a delirium occur at intervals for short periods. The malady is very difficult to cure and too often becomes fatal in the end. It will last thirty or forty days, unless it end fatally in stupor or syncope. A form of mania is a consequence of it, where it has been neglected or badly treated; “of late years this species of madness has been more than ordinarily frequent.” All sorts were liable to it, but mostly valetudinarians, delicate persons, and those in the decline of life; the fatalities were “especially among the opulent families of this great metropolis[114].”
This fever-period in London corresponds on the whole closely with a series of unhealthy years in Short’s tables from the registers of market towns and country parishes, and with high mortalities in the Norwich register. It was not specially a smallpox period, as the last unhealthy year, 1723, was. On the other hand the epidemiographists in Yorkshire, Devonshire and Ireland dwell most upon fevers of the nature of typhus, some of which were due to famine or dearth, and upon “agues.”