“Of enteric typhus (typhoid fever) we saw nothing then [1817-20], nor for many years afterwards. If it might have been overlooked during life, it could not have been missed after death. For our dissections were many, and, to meet the bias of the day for finding a local anatomical cause for all fevers [the doctrine of Broussais], every important organ in the body was habitually looked to. Nevertheless we were constantly met with the want of morbid appearances anywhere, unless slight signs of vascular congestion in various membranous textures be considered such[351].”
These vascular congestions were, indeed, scanned closely for traces of ulceration, after Bright’s plates of 1828, and any little irregularity on the surface of a congested Peyer’s patch was liberally construed in that sense, as in Craigie’s reports subsequently. But in the Edinburgh epidemic of 1827-29, the anatomical signs of enteric fever were wanting until the end of it. Writing in 1827, Alison said that he had dissected 26 cases dead of the epidemic fever, without finding intestinal ulceration in one of them. Christison, however, says that a very few cases of enteric fever were dissected in Edinburgh in 1829[352].
In Dublin, also, the anatomical mark of enteric fever was missed in 1826-27, in the few dissections that were made during the epidemic[353]. An opinion in a widely different sense was given on that point by Stokes twelve years after the event, to which I refer in a note[354].
Return of Spotted Typhus after 1831: “Change of Type.” Distress of the Working Class.
A fever with relapses, and a fever with sloughing of the follicles and lymph glands of the intestine, were not the only novelties in the first thirty or forty years of the 19th century. Relapsing fever and enteric or typhoid fever were each clearly separated, at a later date, from typhus fever. But what was the “typhus fever” from which they were at length separated? It was a fever which came prominently into notice after the “constitution” of 1826-29 was ended—a fever with a mottled, measly, or rubeoloid rash, and with various other spots, on account of which it was described by Dr Roupell in 1831, in a lecture before the College of Physicians of London, as a “new fever[355].” It was a new fever only in the sense in which each new febrile “constitution,” whether it were an influenza, an epidemic ague, or a malignant typhus, was apt to be called popularly “the new fever,” in the 16th and 17th centuries. There were, of course, erudite men at the College of Physicians in 1831 who knew that a fever with a mottled rash, with vibices and petechiae, and with all other symptoms of typhus gravior, had often occurred in England, Scotland and Ireland in former times. The “spotted fever” was perhaps the most familiar name of typhus in the 17th century. The mottled rash, like that of measles, was described for the fever of Cork by Rogers in the beginning of the 18th century, and for various other English and Irish epidemics by Huxham, O’Connell, Rutty and others. But undoubtedly the maculated typhus was somewhat new to the generation who saw it about 1830 and following years, the continued fevers which had prevailed in England, Scotland and Ireland since 1816 having been for the most part the simple continued, or synocha, with or without the relapsing character, and to some extent enteric fever[356].
It was from 1830 to 1834 that a change in the reigning type of fever began to be remarked in London, Dublin, Edinburgh and Glasgow, the new type becoming more and more evident as fevers became more prevalent in the ‘thirties’ and ‘forties.’ Typhus at length became so much a spotted fever that the question arose whether it should not be classed among the exanthemata. In 1840, Dr Charles West, having observed “the alteration in character which fever has undergone within the last few years,” went over the history (but more the foreign than the English) with a view “to illustrate the question whether typhus ought not to be classed among the exanthematous fevers[357]:” of course he found many old descriptions of a mottled rash or other spots, but saw no reason to make spotted typhus one of the exanthemata. Dr Kilgour, of Aberdeen, who treated more than a thousand cases in his fever-ward at the infirmary there from 1838 to 1840, wrote in 1841, “I am perfectly satisfied that this fever, call it by what name we will, is truly an exanthematous fever[358].” Previous to 1835, the spots of fever-cases in the Glasgow Infirmary had hardly been remarked; but after that date all cases were classed either as spotted or not, the spotted cases being three-fourths of the whole. Besides being spotted, the fever of the new constitution was insidious in its approach and low in its reaction, very unlike the sthenic, militant, inflammatory synocha of the generation before. The blood-letting which had been all but universally used in the fever from 1816 to 1828, and had seemed to answer well, was continued for a time in the fever of the ‘thirties.’ But it was soon found to be injurious: the patients in the new fever were apt to faint when only a few ounces of blood (four or six) had been drawn, whereas in the other fever (whether relapsing or simple continued) they had often lost thirty ounces before deliquium was reached. It was found, on the other hand, that fever-cases in the ‘thirties’ needed wine and other cordial regimen. There was nothing new in these revolutions, whether of the fevers themselves, or of the opinions as to their treatment. Sydenham’s method of taking his cue for treatment from the “constitution” of the season, which was the method of Hippocrates, appeared to be once more the best suited to the circumstances.
It is not easy to make out what were the circumstances of the time that led to the supersession of simple continued fever (or relapsing fever in Ireland and Scotland), by spotted fever or typhus gravior in all parts of the kingdom. Sydenham would have looked, among other things, to the weather and the character of seasons; but from 1830 onwards there was no season so notable as the dry and hot summer of 1826, although the end of the year 1836 was remarkably wet. The period of typhus gravior was a time of much sickness of other kinds—the Asiatic cholera of 1831-32, the influenza of 1831, 1833, and 1836-37, and the general unhealthiness of the year 1837. This was also the decade when the “condition-of-England question” was a common topic, a time of strikes and of much distress among the working classes, as shown in the reports of the Poor Law Commission.
In Glasgow there was a considerable prevalence of fevers year after year from the relapsing-fever epidemic of 1827-29, according to the following table of admissions for fever to the Royal Infirmary and the special fever-hospitals[359]:
Admissions for Fever, Glasgow.