The epidemic which began in 1817 continued in London throughout the years 1818 and 1819, chiefly in the densely populated poorer quarters of the town. Two instances of the London slums of the time came to light before the House of Commons Committee on Mendicity and Vagrancy in 1815-16: firstly, Calmel’s Buildings, a small court near Portman Square, consisting of twenty-four houses, in which lived seven hundred Irish in distress and profligacy, neglected by the parish and shunned by everyone from dread of contagion; and, secondly, George Yard, Whitechapel, consisting of forty houses, in which lived two thousand persons in a similar state of wretchedness. The dwellings of the poorer classes in London at this period, before the alleys and courts began to disappear, were described thus generally by Dr Clutterbuck[310]:

“The houses the poor occupy are often large, and every room has its family, from the cellar to the garret. Thirty or forty individuals are thus often collected under the same roof; the different apartments must be approached by a common stair, which is rarely washed or cleansed; there are often no windows or openings of any kind backwards; and the privies are not unfrequently within the walls, and emit a loathsome stench that is diffused over the whole house. The houses are generally situated in long and narrow alleys, with lofty buildings on each side; or in a small and confined court, which has but a single opening, and that perhaps a low gateway: such a court is in fact little other than a well. These places are at the same time the receptacles of all kinds of filth, which is only removed by the scavenger at distant and uncertain intervals, and always so imperfectly as to leave the place highly offensive and disgusting.”

In England, generally, this epidemic of 1817-19 is somewhat casually reported. One writes from Witney, Oxfordshire, “on the prevailing epidemic,” which began there in July, 1818, among poor persons, in crowded, filthy and ill-ventilated situations. At first it was like the ordinary contagious fever of this country, “a disease familiar to common observation”; but afterwards it showed choleraic and pneumonic complications. Sometimes the parotid and submaxillary glands were inflamed; petechiae were absent[311]. The type of fever at Ipswich in the spring of 1817 was contagious (e.g. six cases in one family) and sthenic, or of strong reaction, admitting of bloodletting, according to the teaching which Armstrong, Clutterbuck and others had been reviving for fevers[312]. Those instances, one from Oxfordshire the other from Suffolk, must stand for many. Hancock says that the fever of 1817-19 “visited almost every town and village of the United Kingdom[313].” Prichard says that it began in Ireland, “where the distress was most urgent, and afterwards prevailed through most parts of Britain,” some of the more opulent also being involved in the calamity. As to its prevalence in the manufacturing towns of Yorkshire we have ample testimony. The Leeds House of Recovery, which had not been fully occupied at any time since its opening in 1804, received 178 cases in 1817, and 254 in the first ten months of 1818. Of the latter, 66 came from low lodging-houses, of whom upwards of 50 were strangers. Of 50 admitted in January, 1818, 20 came from four or five lodging-houses in March Lane, and from another locality equally bad—Boot and Shoe Yard; while the rest of the 50 in that month came from houses and streets in the same vicinity. March Lane was one of the worst seats of the great Leeds plague in 1645. By the month of April, 1820, the epidemic had decreased a good deal in Leeds, the cases becoming at the same time more anomalous[314].

The following is one of the Rochdale cases:

June 2, 1818, Alice Eccles, a delicate young woman living in a crowded and filthy court from which fever had not been absent for nearly a year, was bled to ten ounces, purged, and recovered. On September 20th the same woman returned, desiring to be bled again. She was labouring under her former complaint; “since her last illness she had been repeatedly exposed to contagion, or rather, she had been living in an atmosphere thoroughly saturated with infectious effluvia, the house in which she resided, and generally the room in which she slept, having had one or more cases of fever in them,” and the windows kept closed[315].

At Halifax in the summer of 1818, typhus (or relapsing fever) had increased so much that fever-wards were added to the Dispensary. It had been alarmingly fatal in a high-lying village near Settle. It was prevalent in Ripon, Huddersfield and Wakefield; and had been brought from Leeds to Atley. A Bradford physician visited 27 cases of fever in one day at a neighbouring village. Throughout Yorkshire, it was confined to the lower orders, and was not very fatal[316]. At Carlisle it began about July, 1817, and became somewhat frequent in the winter and spring following; of 457 cases treated from the Dispensary 46 died, or 1 in 10[317]. At Newcastle, a mild typhus (typhus mitior) broke out in the autumn of 1816, not in the poorer quarters, but mostly among the domestics of good houses in elevated situations. There was much privation at Newcastle, as elsewhere, at this time, among the poor. Murchison takes this fever of the autumn of 1816 at Newcastle to have been enteric or typhoid; but it is described as a simple continued fever, with vertigo, headache, and bloodshot eyes, lasting from five or six days to four or five weeks, ending usually without a marked crisis, and causing few deaths[318]. The epidemic continued in Newcastle for three years, the admissions to the Fever Hospital from 4 Sept. 1818, to 4 March, 1819, having been 160, with 12 deaths. Dr McWhirter wrote, in April, 1819, that he saw on his rounds as dispensary physician “too many of the obvious causes of fever,” including the filth and wretchedness of the poor inhabitants: “one rather wonders that so many escape it than that some are its victims[319].”

Thus far there has been little besides Bateman’s essay to indicate the nature or type of the fever in England. In Ireland it was to a large extent relapsing fever, and, as we shall see, it was so also in Scotland. Bateman found less than a tenth part of the cases at the London Fever Hospital to have relapses, which was an unusually large proportion, in his experience. Elsewhere in England the tendency to relapse was either wanting or the relapses were described or accounted for in other ways; to understand this it has to be kept in mind that the epidemic was the occasion of a great revival of blood-letting, a practice which had fallen into disuse in fevers since the last half of the 18th century, and was something of a novelty in 1817. The fever of that year was undoubtedly abrupt in its onset, strong, “inflammatory,” with full bounding pulse, beating carotids, hot and dry skin, intense headache, suffused eyes, and the like symptoms, which seemed to call for depletion. The common practice was to bleed ad deliquium, which meant to ten, or fourteen, or twenty ounces, at the outset of the fever. There was hardly one of the writers upon the epidemic, unless it were Bateman, an advocate of the cordial and supporting regimen, who did not consider the stages or duration of the fever as artificially determined by the blood-letting, and not as belonging to the natural history.

In order to show how much the treatment by blood-letting dominated the view of the fever itself, of its type, its stages, or duration, I shall take the Bristol essay of Prichard, who adopted phlebotomy, as he says, at first tentatively and with some fear and trembling, but at length practised it vigorously, having found it to answer well[320]. The epidemic of fever in Bristol began about June, 1817, and lasted fully two years. The first cases brought to St Peter’s Hospital, which was the general workhouse of the city, were of wretched vagrants found ill by the wayside or abandoned in hovels. About the same time forty-two felons in the Bristol Newgate, “one of the most loathsome dungeons in Britain, perhaps I might say in Europe,” were infected, of whom only one died, and he of a relapse. From June, 1817, to the end of 1819, there were 591 cases in the poor’s house, 647 in the General Infirmary, and 975 treated from the Dispensary, making 2213 cases, of which a record was kept. But there were also many cases in private practice among the domestics, children, and others in good houses, such as those on Redcliff Hill. The cases in the poor’s house were classified by Prichard as follows:

1817 1818 1819
Simple Fever 22 45 40
with cephalic symptoms 24 27 25
"pneumonic symptoms 7 10 16
"gastric symptoms 3 11 5
"enteric symptoms 3 4 5
"hepatic symptoms 5 3 3
exhausted and moribund 1 6 4
not characterised 30 44 2
95 150 105
Of these there died 20 16 11

The “genuine form,” or ground-type, according to Prichard, was “simple fever,” of which the cases with cephalic symptoms were merely the more protracted or more serious. “The pneumonic, hepatic, gastric, enteric and rheumatic forms may be regarded as varieties”—the gastric and hepatic being cases mostly in summer with jaundice, the enteric in autumn and winter with diarrhoea and dysentery. Nearly all these patients were bled within four or five days from the commencement of the disease: “in a very large proportion of the cases the fever was immediately cut short”; when it did not end thus abruptly, its symptoms declined gradually, and the attack was over within eight or ten days. After the blooding “sleep very frequently followed, and a partial or sometimes a complete remission of the symptoms.” Only one case of relapse is mentioned, No. 118, of the year 1818, and that was a relapse in a very prolonged case: the patient was admitted on 6 October, had a relapse on 18 November, and was discharged on 23 December. Prichard has not one word in his text to suggest relapsing fever; the bulk of his cases were simple continued fever, with or without cephalic or other local symptoms, ending in four, six, eight or ten days, while some were cases of typhus gravior. The fever was undoubtedly contagious: it spread through whole families, and in St Peter’s Hospital itself it attacked seventy of the ordinary pauper inmates, including a good many lunatics.