The epidemic of relapsing fever in 1826-28, which made a great impression in the towns of Ireland and Scotland, has left few traces in specially English records. But it is clear that there was some increase of fever about the same time in London; and it becomes a matter of interest, as well as of no little difficulty, to ascertain the type or types of the same. It was just after this quasi-epidemic in London that Dr Burne published his essay on fevers, the preface bearing the date of 28th February, 1828[343]. The materials of this essay came from Guy’s Hospital, and they were both clinical and anatomical. The author seeks to find a common name for all varieties of continued fever, the name that he chooses being “Adynamic Fever.” “By far the greater number of cases,” he says, “are of the first or second degree only of severity, and not dangerous.” These were cases of “simple continued fever,” or fever of short duration, with flushed face, suffused eyes and other signs of the “inflammatory” type, or of synocha. Although Burne does not give the exact proportion of cases with relapse, as Bateman had done for the London epidemic of 1817-18, yet he makes it clear that relapses did occur, and he discusses the phenomenon in a manner which makes his testimony interesting: “Convalescents are more liable to a relapse after the adynamic fever than after any other disease; and this may be accounted for by the very enfeebled and exhausted state in which the powers of the system are left.” His relapses were obviously a return of the original fever, beginning again suddenly in the midst of convalescence with flushing of the face, headache, dry tongue, and scanty urine, and with a great access of febrile heat in the night, a disturbance of the system which generally continued for several days, while in some it went off sooner with a diarrhoea. He assigned three principal causes for the relapse—overloading the enfeebled but craving stomach, walking out in the open air too soon, and giving way to emotion[344].
The references to relapse apply almost certainly to fevers of the shorter periods (synocha or “inflammatory” fever), and not to those cases of enteric fever which did undoubtedly occur in the practice of Guy’s Hospital in the same seasons.
Typhoid or Enteric Fever in London, 1826.
The identification of enteric fever and relapsing fever respectively, or the separation of each from typhus, became actual in Britain at one and the same time. I have already said all that seems necessary as to the earlier appearances of relapsing fever on the stage of epidemiological history. This will be the fitting point in the chronology, the third decade of the 19th century, to bring in the question of enteric or typhoid fever. As to its identification, or recognition as a distinct species, that was not really completed, to the satisfaction of everyone, until the elaborate analysis of the symptoms respectively of typhus and enteric fevers by Sir William Jenner in 1849-51[345]. But, for ten years before that, the co-existence with maculated typhus of a different long-period fever, having abdominal symptoms and abdominal lesion, had been recognised, and the characteristic ulceration or sloughing of the lymph-follicles of the ileum, with sphacelation of the mesenteric lymph-glands, had been clearly described by several London physicians and depicted in coloured plates, in the years 1826 and 1827, during an unusual prevalence of such cases in London. The authentic history of enteric fever in Britain really begins with these writings by physicians of St George’s and Guy’s Hospitals. But, as it is improbable that the type of fever was absolutely new in the years 1825 and 1826, it may be asked whether the enteric type cannot be discovered in the old accounts of British fevers, and if so, whether we may assume in the past as much enteric fever relatively to spotted typhus, relapsing fever, or simple continued fever, as in the period after 1850.
Having adverted to this point from time to time in the preceding history as it arose, for example in connexion with Willis’s fever of 1661, Strother’s fever of 1727-29, the Rouen fever of 1750, and other instances both in children (remittent or convulsive or comatose fever of children) and in adults, I shall not recapitulate farther back than the beginning of the 19th century.
There was a certain amount of post-mortem observation in the 18th century, especially in camp sicknesses, by Pringle and others; but there is no trace of intestinal ulceration among their fatal fevers. It was found, however, in the epidemic of 1806 among the troops at Deal, and it is probable that Ferriar’s cases at Manchester about 1804, and Bateman’s cases of continued fever in London from 1804 to 1816, were in some part enteric, although the anatomical test is wanting. That was a period when there was singularly little of the old London fever in the houses of the poorer class. Then came the remarkable “constitution” of relapsing or simple continued fever, from about 1816 to 1828, the relapsing character of which was far more obvious in Ireland and Scotland, than in London, Bristol, or elsewhere in England, but was not altogether unobserved in London, whether in 1817-19 or in 1827-28. The relapsing type disappeared after that for fifteen or twenty years, and was replaced by typhus more maculated than had been seen for many years. But, before the relapsing or simple continued fever disappeared for a time, enteric fever was seen in London in company with it.
The chief season of enteric fever in London was the autumn of 1826, following a long period of great drought and heat. The remarkable weather of that season was the same in England, Ireland and Scotland, and is thus described for the last by Christison:
“The spring and summer seasons of that year were remarkable for the extraordinary drought and heat which prevailed for many continuous months. No such seasons could be recollected by anybody, and assuredly there has been nothing similar in this country since.... The fine weather set in with the beginning of March, and continued, with scarcely a check, well into the autumn.... The drought prevailed and the heat increased till the middle of June, when a thunderstorm with heavy rain cooled the air for a day or two. But the heat then became greater than ever, and there was continuous sunshine and no rain till after the middle of July, when again there was thunder and rain, after which sun, heat and drought ruled the season once more.” The shade temperature at Edinburgh was 84° Fahr., at 3 p.m. on three successive days of July[346]. The two summers preceding had also been exceptional, that of 1824 having been hot and moist, that of 1825 hot and dry, with dysentery in Dublin.
In August, 1826, Dr Cornwallis Hewett, of St George’s Hospital, published ten fatal cases of enteric fever, four of which had occurred in his own practice, six in the practice of his colleagues[347]. The first was admitted on 23 April, 1825, the latest on 3 July, 1826. While his paper was under hand, he had read in the Medico-chirurgical Review for July, 1826, some extracts from Bretonneau’s paper on “Dothiénentérite” (enteric fever), and he pronounced the London cases to be the same as those recently observed at Tours. Several other cases occurred at St George’s Hospital in the autumn of 1826, three of them reported by Dr Chambers[348]. At the very same time, there was a run of enteric cases at Guy’s Hospital. Dr Bright says: “Fever occurred with considerable frequency among the patients who presented themselves for admission into Guy’s Hospital, during the months of October, November and December, 1826. On the whole, the disease was not severe.” The more comprehensive account of these cases was given by Burne, early in 1828, from which it appears that the bulk of them were fevers of the shorter period, that there were relapsing cases among them, and that some were cases of enteric fever, verified by post-mortem examination[349]. It was the enteric cases that attracted the notice of Dr Bright, who says nothing of the relapsing cases, or of cases of simple continued fever. The fact that the intestinal mucous membrane may become diseased during fever was, he says, “long known in particular cases, but never suspected to be so general till brought into view by the French physicians, and which has lately been illustrated in this country with great beauty [this does not mean in plates] by the pens of my able and assiduous friends Dr Chambers and Dr Hewett.” He gives ten fatal cases, with coloured plates of the intestinal or mesenteric lesion in some of them, the earliest coloured plate having been made from a case admitted on 13 October, 1825, and the most typical plate of the sloughing Peyer’s follicles from a case admitted on 25 November, 1826. He gives also eleven cases of recovery, to show the benefit of treating the diarrhoea by calomel[350]. Nearly all the cases occurred in the end of the year, either of 1825 or 1826; and Burne confirms this when he says that the cases with enteric lesion were found at Guy’s Hospital only in autumn. Some two years after, in 1830, Drs Tweedie and Southwood Smith, physicians to the London Fever Hospital, described cases of fever with ulcerated intestine and sphacelated mesenteric glands. After that, the interest shifted to typhus, which reappeared in London of an unusually maculated type; so that the years 1826-30 make a somewhat distinct period in which the new fever, with enteric lesion, was an engrossing medical topic. It is tolerably certain that it was the unusual seasons of 1825 and 1826 which brought enteric fever into prominence; while, as soon as it became frequent, it could hardly have escaped the systematic apparatus of clinical case-taking and post-mortem examination, with preservation and drawing of specimens, for which Guy’s Hospital was already noted under the influence of Bright and his colleagues, and in which the staff of St George’s Hospital would appear to have been not less competent. Although Dr Hewett, in 1826, identified his cases with the dothiénentérite of Bretonneau, yet neither he nor Dr Bright took the abdominal ulcerations or sloughs as distinctive of a new kind of fever. They regarded them rather as a new complication of “idiopathic” typhus fever, a “complication” which appealed to them more on the side of treatment than of systematic nosology; hence the writings of both physicians are occupied mainly with the benefit of calomel in relieving the congestion of the bowels and in checking the diarrhoea.
It is undoubted that cases of enteric fever in 1826-27 were relatively more numerous in London than in Dublin and Edinburgh, where the epidemic fever was almost wholly of the relapsing type. In Edinburgh, at least, the comparative infrequency of enteric fever for years after it had been recognized in Paris, Tours and other French cities, and had been found in London as a common autumnal type, can be proved beyond cavil. Writing long after of the first epidemic of relapsing fever in Edinburgh, Christison said: