In the London bills of mortality the item of fevers diminishes steadily during the latter part of the 18th century, the deaths from all causes diminish, the births come nearer to the number of the deaths, and in three years of the last decade they exceed them. This statistical result is doubtless roughly correct; but the bills were becoming more and more inadequate to the whole metropolitan area; and even for the original parishes which they included they have not the same value for fever in the later period as they had for plague at their beginning[236]. On the other hand, from about the year 1770 we begin to have more exact medical accounts of fever in London, which are not indeed numerically exhaustive, but good as samples of what was going on. Whatever improvement there was in the prevalence of typhus fever touched the richer classes. The Paving Act of 1766 is credited with having improved the health of the City, and there were many new streets and squares being built in the west end that were, of course, free from typhus. It is to these desirable residential quarters that the eulogies of Sir John Pringle[237], Dr John Moore[238] and others apply. The slums of London were as yet unimproved, and but little known to the physicians. Lettsom, who was one of the first of his class to visit among the poor in their homes, has much to say of typhus fever; but he is emphatic that it was nearly all an infection of the poor. “In the airy parts of this city,” he writes in 1773, “and in large, open streets, fevers of a putrid tendency rarely arise.... In my practice I have attentively observed that at least forty-eight out of fifty of these fevers have existed in narrow courts and alleys.” The same is remarked by Currie for Liverpool, by Clark for Newcastle, by Percival and Ferriar for Manchester, by Haygarth for Chester, and by Heysham for Carlisle.
The quarters of the rich had gradually become detached from those of the poor. I have shown this more especially for Chester, where the old walls made a clear division; but it was general in the second half of the 18th century[239].
Medical practice lay mostly among the richer classes; the physicians knew little of the state of health in the cellars and tenement-houses of large towns. Those physicians who did know how much typhus fever there was in these purlieus had to enter a caveat against the incredulity of the rest. Dr Currie of Liverpool, whose facts I shall give in their place, protested that he was not exaggerating; a protest the more necessary that a contemporary of his own, Mr Moss, a middle-class practitioner, who wrote a book specially on the medical aspects of Liverpool, declares that fever is “rare” in that city, while Currie was treating from his dispensary a steady average of three thousand cases of typhus every year. In the same years, in February, 1779, a physician to the army, Dr John Hunter, who had commenced practice in Mayfair, found on visiting in the homes of the poorer classes in the west of London cases of fever for which he had no other name than the gaol or hospital fever of his military experience; it was so much a novelty to him, apart from campaigns or transport ships, that he gave an account of his discovery of domestic typhus to the College of Physicians[240]. At length he found so many cases steadily winter after winter that he had them sent to the infirmary of the Marylebone Workhouse. The practitioners who knew most of the sicknesses of the poor were such as Robert Levett, Dr Samuel Johnson’s dependant, who lived with the doctor in the house in Gough Square. Levett had been a waiter in a Paris coffee-house frequented by the medical fraternity, and had acquired a taste for and perhaps some knowledge of the healing art. He made his modest living by the small fees or articles of food and drink which his poor patients gave him. He had only to issue from the back of Gough Square by the courts and alleys behind Fleet Street, and he would find in the region between Chancery Lane and Shoe Lane hundreds of families seldom visited by a physician or by a qualified surgeon-apothecary. The good Levett was only one of a class. There had always been such humble medical attendants of the poor in London. An Act of the third year of Henry VIII. was directed against them at the instance of the privileged practitioners; but the regular faculty is said to have proved in the sequel both greedy and incompetent, and after thirty years there came another Act, couched in terms that the bluff king himself might have indited (31-32 Henry VIII.), which asserts those qualities of the profession in so many words, and establishes the right of any subject of the king to practise minor surgery and the medicine of simples upon his or her neighbours. That Act is still part of the law of England, and under it Levett exercised a statutory right, perhaps without knowing it[241]. There were many other regions of courts and alleys all round the City on both sides of the water, which must have been medically served by such as Levett, if served at all. It was there that typhus was found and at length clinically described by competent physicians, among the earliest of whom was Lettsom.
The General Dispensary in Aldersgate Street having been started in 1770 with one physician, Lettsom was chosen additional physician in 1773, and threw himself into the work with great zeal[242]. In the first twelvemonth he saw many cases of fever, as in the following table:
Lettsom’s practice in Fevers at the Aldersgate Dispensary.
| 1773 | 1774 | |||||||||||||||||||||||||||
| Febris | April | May | June | July | Aug. | Sept. | Oct. | Nov. | Dec. | Jan. | Feb. | March | Total in 12 months | Died | ||||||||||||||
| hectica | 2 | 2 | 4 | 13 | 4 | 2 | 3 | 4 | 9 | 12 | 18 | 13 | 86 | 3 | ||||||||||||||
| inflammatoria | — | — | — | — | — | — | — | 1 | 1 | 1 | — | 2 | 5 | — | ||||||||||||||
| intermittens | 3 | 1 | 7 | 1 | 1 | 1 | 1 | — | 2 | 1 | 2 | 2 | 22 | — | ||||||||||||||
| nervosa | 4 | 3 | 4 | 14 | 7 | 11 | 4 | 5 | 1 | 1 | 5 | 4 | 65 | 3 | ||||||||||||||
| putrida | 14 | 19 | 14 | 25 | 14 | 21 | 34 | 22 | 11 | 6 | 7 | 5 | 192 | 8 | ||||||||||||||
| remittens | 6 | 10 | 5 | 4 | 3 | 6 | 7 | 3 | 12 | 13 | 10 | 3 | 82 | — | ||||||||||||||
| simplex vel diarium | — | 2 | 1 | 6 | 2 | 5 | 4 | 5 | — | — | — | 4 | 29 | — | ||||||||||||||
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:
Case 1 is of a man aged forty who had occasion to visit a miserable crowded workhouse in Spitalfields. He was instantly seized with such a nausea and debility as induced him to keep his room as soon as he got home. At the end of a week Lettsom found him in “the true jail-fever, or, what is the same, a true workhouse-fever.” He had involuntary stools and leaping of the tendons, and took more wine in a week than he had done for many years.
Cases 2 to 12 were of several families in one house in a court in Long Lane, Aldersgate Street, who had been infected by a discharged prisoner from Newgate. Other cases follow, where the infection was caught from visiting the sick. In Case 17, Lettsom applied blisters “owing to the importunity of the friends,” but without advantage. Case 30, on 26th October, 1773, was of a family of six persons near Christ Church, Lambeth, father, mother, boy of seventeen, child of two (slight attack) and two maids. Other localities were courts off Whitecross Street, Jewin Street, Little Moorfields, Chiswell Street, and St Martin’s-le-Grand. Case 43 was of a woman, aged thirty, in Bunhill Row; she attended a relation who died of a putrid fever, and was herself attacked; her eyes were bloodshot, her skin marbled and interspersed with a general deep-coloured eruption, her cheeks and nose mortified. Cases 44-47 were of people in a “very helpless situation” in Gloucester Court, Whitecross Street.