Early in the summer of 1818 an epidemic of continued fever appeared in a manufacturing village seven miles from Lintrathen; it attacked at first young and plethoric subjects, and ran through whole families. In August it reached Lintrathen parish, in which one practitioner had forty cases, with no deaths. The fever was of an inflammatory nature; the bulk of the cases fell in October, and were nearly all of young women. They were bled to syncope, which then meant usually to 32 ounces. There was a prejudice against blooding among the old people, who said “they had had many fevers, and in their time no such thing was ever allowed.” But, according to the doctor, this withholding of the lancet had the effect of protracting their illnesses: “they toasted sick for six weeks, and were often confined to bed for months[328].”
The epidemic of 1817-19 brought into prominence two questions, the one theoretical, the other practical. The theoretical question (not debated at the time) was touching the place or affinities of relapsing fever in the nosology. Christison maintained that it was the inflammatory fever, or synocha of Cullen, showing a peculiar tendency to relapse. The fever of the same epidemic period in England was also undoubtedly a fever of strong or inflammatory reaction, corresponding to Cullen’s definition of synocha, but it relapsed much less frequently than in Ireland and Scotland in the same years. Even in Ireland and Scotland there were always many cases of “relapsing fever” which did not relapse. The law of its relapses was reduced to great simplicity by a physician learned in fevers, Dr John O’Brien, in the Dublin epidemic of 1827. The bulk of that epidemic was a fever of short periods—three, five, seven or nine days, most of the attacks ending on the fifth or seventh night of the fever. The attack being ended in a free perspiration, there might or might not happen, after an interval, a relapse, and again a relapse after that, or even a third. The five-days’ fever was more liable to relapse than the seven-days’ fever, the seven-days’ fever more liable than the nine-days’ fever, the fevers of the longest periods not liable at all. In other words, the sooner the patient “got the cool,” by a night’s sweating, the more liable he was to have one or more relapses[329].
The logical position of relapsing fever was completed by Dr Seaton Reid, of Belfast, when he proposed, in his account of the epidemic in 1846-7, to call it Relapsing Synocha[330]. Other fevers have shown a tendency to relapse in certain circumstances. Three fevers which have many points in common, the sweating sickness, dengue and influenza, are all subject to relapses. It was doubtless of the sweating sickness that Sir Thomas More was thinking when he wrote: “Considering there is, as physicians say, and as we also find, double the peril in the relapse that was in the first sickness.” Plague, also, might relapse, or recur in an individual once, twice, three times, or oftener in the same epidemic season. Enteric is an instance of a long-period fever which has at times a tendency to relapses[331]. None of these, however, can dispute the claim of relapsing synocha to be relapsing fever par excellence. For whatever reason, the short-period fever of times of distress and dearth or famine has shown a peculiar tendency to relapse, and has shown that tendency more in the 19th century than in the 18th, and more among the Irish and Scotch poor than among the English.
The practical question that came to the front in the epidemic fever of 1817-19 was that of isolation hospitals for the sick. It was thus stated by Dr Millar, of Glasgow, in a letter of advice to the authorities of Aberdeen:
“It is only by a universal, or nearly universal sweep of the sick into Fever Hospitals, joined to a universal or nearly universal purification of their dwellings, that anything is to be hoped for in the way of suppressing our epidemic. So far as this grand object is concerned, all the rest is folly: it is worse than folly[332].”
This was the well-meant but somewhat fanatical application of a trite and commonplace notion. It was well understood by reflective persons at that time, who were quite sound on the contagiousness of fever, that the whole question of segregating the poor in fever hospitals was beset with difficulties, not merely of expense but also of expediency. A Select Committee of the House of Commons sat upon it in 1818, and published their report, with the minutes of evidence, on the 20th May. So much had been said in Parliament by Peel and others, and said so truly, of the spreading of fever all over Ireland by whole families turned adrift in beggary, that the Select Committee were full of ideas of contagion, and of the great opportunity of suppressing fever by destroying its germs or seeds. But they had soon occasion to learn that a fever may be potentially contagious, yet not contagious in all circumstances, and that segregation in fever hospitals had a rival in dispersion through general hospitals. Half-a-dozen London physicians of position, answering respectively for Guy’s, St Thomas’s, the London, St Bartholomew’s, St George’s, the Westminster and the Middlesex Hospitals, declared that they mixed their cases of contagious fever in the ordinary wards among the other patients; and when asked by the astonished Committee whether the fever did not spread, they answered one after another with singular unanimity, “Never,” which under cross-examination, became in one or two instances, “hardly ever,” as, for example, in the evidence for St Thomas’s Hospital, where a sister and a nurse had caught fever and died. The point of this London evidence was that the great safeguard against febrile contagion was free dilution with air, and that the great provocation of a contagious principle was to “concentrate” the cases of fever[333]. The Bristol experience in the same epidemic, although it did not come before the Select Committee, was wholly in agreement with medical opinion in London. The fever-cases there were received either into St Peter’s Hospital, which was the city poor-house, or into the General Infirmary. The former was an old irregular building, badly ventilated, in which the contagion spread freely to the ordinary inmates and became very virulent. Contrasting with the apartments of the old poor’s house, the wards of the Bristol General Infirmary were spacious, lofty, well-ventilated:
“Here the patients labouring under fever were dispersed among invalids of almost every other description; so that, whatever effluvia emanated from infected bodies became immediately diluted in the mass of air free from such pollution. Here, accordingly, no instance occurred of the propagation of fever. None of the nurses were attacked, nor were patients lying in the adjacent beds in any instance infected, though cases of the worst description, some of them exhibiting all the symptoms of typhus gravior, were placed promiscuously among the other patients, scarcely two feet of space intervening between the beds[334].”
The same practice was kept up in the Edinburgh Infirmary until 1858 or longer; Christison, who gives a diagram of an ordinary ward with four fever-beds in it, declared in 1850 that there had been no spread of fever for fifteen years before, except on one occasion, when the rules of the house were neglected[335]. The bold policy of dispersing fever-patients among the healthy was begun by Pringle and Donald Monro during the campaigns of 1742-48 and 1761-63 in the Netherlands and North Germany. They found that concentration raised the contagion to high degrees of virulence and that dispersion weakened it to the point of non-existence, Monro’s success at Paderborn in 1761 having been of the most signal kind[336].
The Select Committee of 1818 were more influenced by what they were told of the good effects of the earliest Houses of Recovery, at Waterford, Manchester and other places in the end of the last century. For several years after their opening they were little needed, the epidemic which gave the immediate impulse to their establishment having subsided in due time both in the towns provided with Houses of Recovery and in the innumerable places where no such provision had been made. The recommendations of the Committee do not appear to have been carried out; for the London Fever Hospital, in Pancras Road, which had been enlarged to seventy beds when the epidemic began in 1817, remained the only special fever hospital in London until the establishment of the hospitals of the Metropolitan Asylums Board in 1870[337].