Chapter I: Typhus and Other Continued Fevers (1)

It was remarked by Dr James Lind, in 1761, that a judicious synopsis of the writings on fevers, in a chronological sense, would be a valuable book: it would bring to light, he was fain to expect, treasures of knowledge; “and perhaps the influence of a favourite opinion, or of a preconceived fancy, on the writings of some even of our best instructors, such as Sydenham and Morton, would more clearly be perceived[1].” Lind himself was the person to have delivered such a history and criticism. He was near enough to the 17th century writers on fevers to have entered correctly into their points of view; while so far as concerned the detection of theoretical bias or preconceived fancies, he had shown himself a master of the art in his famous satire upon the “scorbutic constitution,” a verbal or mythical construction which had been in great vogue for a century and a half, and was still current, at the moment when Lind destroyed it, in the writings of Boerhaave and Haller. A judicious historical view of the English writings on fevers, such as this 18th century critic desired to see, may now be thought superfluous. The theories, the indications for treatment, the medical terms, have passed away and become the mere objects of a learned curiosity. But the actual history of the old fevers, of their kinds, their epidemic prevalence, their incidence upon rich or poor, upon children or adults, their fatality, their contagiousness, their connexion with the seasons and other vicissitudes of the people--all this is something more than curious.

Unfortunately for the historian of diseases, he has to look for the realities amidst the “favourite opinions” or the “preconceived fancies” of contemporary medical writers. Statements which at first sight appear to be observations of matters of fact are found to be merely the necessary truths or verbal constructions of some doctrine. One great doctrine of the 17th and 18th centuries was that of obstructions: in this doctrine, as applied to fevers, obstructions of the mesentery were made of central importance; the obstructions of the mesentery extended to its lymphatic glands; so that we come at length, in a mere theoretical inference, to something not unlike the real morbid anatomy of enteric fever. Another great doctrine of the time, specially applied by Willis to fevers, was that of fermentations and acrimonies. “This ferment,” says a Lyons disciple of Willis in 1682, “has its seat in the glandules of the velvet coat of the stomach and intestines described by Monsieur Payer[2].” But the Lyons physician is writing all the while of the fevers that have always been common in the Dombes and Bresse, namely intermittents; the tertian, double tertian, quotidian, quartan, or double quartan paroxysm arises, he says, from the coagulation of the humours by the ferment which has its seat in the glandules described by M. Payer, even as acids cause a coagulation in milk, the paroxysm of ague continuing, “until this sharp chyle be dissipated and driven out by the sweat or insensible perspiration.” The lymphatic follicles of the intestine known by the name of Payer, or Peyer, were then the latest anatomical and physiological novelty, and were chosen, on theoretical grounds, as the seat of fermentation or febrile action in agues. On the ground of actual observation they were found about a century and a half after to be the seat of morbid action in typhoid fever.

While there are such pitfalls for the historian in identifying the several species of fevers in former times, there are other difficulties of interpretation which concern the varieties of a continued fever, or its changes of type from generation to generation. Is change of type a reality or a fiction? And, if a reality, did it depend at all upon the use or abuse of a certain regimen or treatment, such as blooding and lowering, or heating and corroborating? A pupil of Cullen, who wrote his thesis in 1782 upon the interesting topic of the change in fevers since the time of Sydenham[3], inferred that the great physician of the Restoration could not have had to treat the low, putrid or nervous fevers of the middle and latter part of the 18th century, otherwise he would not have resorted so regularly to blood-letting, a practice which was out of vogue in continued fevers at the time when the thesis was written, as well as for a good many years before and after. Fevers, it was argued, had undergone a radical change since the time of Sydenham, in correspondence with many changes in diet, beverages and creature comforts, such as the greatly increased use of tea, coffee and tobacco, and of potatoes or other vegetables in the diet, changes also in the proportion of urban to rural population, in the use of carriages, and in many other things incident to the progressive softening of manners. In due time the low, putrid, nervous type of typhus fever, which is so much in evidence in the second half of the 18th century, ceased to be recorded, an inflammatory type, or a fever of strong reaction, taking its place; so that Bateman, of London, writing in 1818, said: “The putrid pestilential fevers of the preceding age have been succeeded by the milder forms of infectious fever which we now witness”; while Armstrong, Clutterbuck, and others, who had revived the practice of blood-letting in fevers shortly before the epidemic of 1817-18, claimed the comparatively slight fatality and short duration of the common fever of the time as an effect of the treatment. After 1831, typhus again became low, depressed, spotted, not admitting of the lancet; on which occasion the doctrine of “change of type” was debated in the form that the older generation of practitioners still remember.

Thus the task of the historian, whose first duty is to ascertain, if he can, the actual matters of fact, or the realities, in their sequence or chronological order, is made especially difficult, in the chapter on continued fevers, by the contemporary influence of theoretical pathology or “a preconceived fancy,” by the ascription of modifying effects to treatment, whether cooling or heating, lowering or supporting, and, most of all, by the absence of that more exact method which distinguishes the records of fever in our own time. Nor can it be said that the work of historical research has been made easier in all respects, by the exact discrimination and perfected diagnosis to which we are accustomed in present-day fevers. In the years between 1840 and 1850, the three grand types of fever then existing in Britain, namely, spotted typhus, enteric, and relapsing fever, were at length so clearly distinguished, defined and described that no one remained in doubt or confusion. Thereupon arose the presumption that these had always been the forms of continued fever in Britain, and that the same fevers, presumably in the same relative proportions to each other, might have been left on record by the physicians of former generations, if they had used the modern exactness and minuteness in observing both clinical history and anatomical state, which were seen at their best in Sir William Jenner. It would simplify history, indeed it would make history superfluous, if that were really the case. There are many reasons for believing that it was not the case. As Sydenham looked forward to his successors having experiences that he never had, so we may credit Sydenham with having really seen things which we never see, not even those of us who saw the last epidemics of relapsing fever and typhus. It is due to him, and to his contemporaries and nearest successors, to reciprocate the spirit in which he concludes the general chapter on epidemics prefatory to his annual constitutions from 1661 to 1676:

“I am far from taking upon myself the credit of exhausting my subject
in the present observations. It is highly probable that I may fail
even in the full enumeration of the epidemics. Still less do I warrant
that the diseases which during the years in question have succeeded
each other in the sequence about to be exhibited shall remain the same
in all future years. One thing most especially do I aim at. It is my
wish to state how things have gone lately; how they have been in this
country, and how they have been in this the city which we live in. The
observations of some years form my ground-work. It is thus that I
would add my mite, such as it is, towards the foundation of a work
that, in my humble judgment, shall be beneficial to the human race.
Posterity will complete it, since to them it shall be given to take
the full view of the whole cycle of epidemics in their mutual
sequences for years yet to come[4].”

The epidemic fever of 1661, according to Willis.

On the very threshold of the period at which the history is resumed in this volume, we find a minute account by Willis of an epidemic in the year 1661, which at once raises the question whether a certain species of infectious fever did really exist at that time which exists no longer, or whether Willis described as “a fever of the brain and nervous stock” what we now call enteric fever. Willis’s fever corresponds in every respect to the worm fever, the comatose fever, the remittent fever of children, the acute fever with dumbness, the convulsive fever, which was often recorded by the medical annalists and other systematic observers as late as the beginning of the 19th century[5]. It ceased at length to be recorded or described, and it has been supposed that it was really the infantile or children’s part of enteric fever, which had occurred in former times as now[6]. The epidemic fever which Willis saw in the summer of 1661, after a clear interval of two years from the great epidemics of agues, with influenzas, in 1657-59, is called by him “a certain irregular and unaccustomed fever[7].” It was not, however, new to him altogether; for he had seen the same type, and kept notes of the cases, in a particular household at Oxford in 1655, as well as on other occasions. It was an epidemical fever “chiefly infestous to the brain and nervous stock.” It raged mostly among children and youths, and was wont to affect them with a long and, as it were, a chronical sickness. When it attacked the old or middle-aged, which was more rarely, it did sooner and more certainly kill. It ran through whole families, not only in Oxford and the neighbouring parts, “but in the countries at a great distance, as I heard from physicians dwelling in other places.” Among those other witnesses, we shall call Sydenham; but meanwhile let us hear Willis, whose account is the fullest and least warped by theory.

Its approach was insidious and scarce perceived, with no immoderate
heat or sharp thirst, but producing at length great debility and
languishing, loss of appetite and loathing. Within eight days there
were brain symptoms--heavy vertigo, tingling of the ears, often great
tumult and perturbation of the brain. Instead of phrensy, there might
be deep stupidity or insensibility; children lay sometimes a whole
month without taking any notice of the bystanders, and with an
involuntary flux of their excrements; or there might be frequent
delirium, and constantly absurd and incongruous chimaeras in their
sleep. But in men a fury, and often-times deadly phrensy, did succeed.
If, however, neither stupidity nor great distraction did fall upon
them, swimmings in the head, convulsive movements, with convulsions of
the members and leaping up of the tendons did grievously infest them.
In almost all, there were loose and stinking motions, now yellow, now
thin and serous; vomiting was unusual; the urine deep red. The
sufferers in this prolonged sickness wasted to a skeleton, with no
great heat or evacuations to account for the wasting. Some, at the end
of the disease, had a severe catarrh. In others, with little infection
of the head, soon after the beginning of the fever a cruel cough and a
stinking spittle, with a consumptive disposition, grew upon them, and
seemed to throw them suddenly into a phthisis, from which, however,
they recovered often beyond hope. In some there were swellings of the
glands near the hinder part of the neck, which ripened and broke, and
gave out a thin stinking ictor for a long time. “I have also seen
watery pustules excited in other parts of the body, which passed into
hollow ulcers, and hardly curable. Sometimes little spots and
_petechiales_ appeared here and there.” But none of the spots were
broad and livid, nor were there many malignant spots.

Willis then gives several cases clinically, in his usual manner. The
first is of a strong and lively young man, who was sick above two
months and seemed near death, but began to mend and took six weeks to
recover, sweating every night or every other night of his convalescent
period. The second case, aged twelve, was restored to health in a
month. Numbers three and four were children of a nobleman, who both
died, the convulsive type being strongly marked; one of the two was
examined after death, and found to have several sections of the small
intestine telescoped, but all the abdominal viscera free from
disease[8], the lungs engorged, the vessels of the brain full, much
water in the sub-arachnoid space, and more than half a pint in the
lateral ventricles.

In farther illustration of this type of fever, epidemic in 1661,
Willis goes back to his notes of a sporadic outbreak of what he thinks
was the same disease in a certain family at Oxford in the winter of
1653-4[9]: “yea I remember that sometime past very many laboured with
such a fever.” In the family in question, five children took the fever
one after another during a space of four months, two of the cases
proving fatal; the domestics also took it, and some strangers who came
in to help them, “the evil being propagated by contagion.” The cases
in the children are fully recorded[10], the following being some of
the symptoms:

In case 1, aged seven, the illness began at the end of December, 1653
(or 1655): there were contractions of the wrist tendons, red spots
like fleabites on his neck and other parts, drowsiness, and
involuntary passage of the excrements. At the end of a fortnight, a
flux set in and lasted for four days; next, after that, a whitish
crust or scurf, as it were chalky, began to spread over the whole
cavity of his mouth and throat, which being often in a day wiped away,
presently broke forth anew. He mended a little, but had paralysis of
his throat and pharynx, was reduced to a living skeleton, but at
length got well.

Case 2, a brother, aged nine, had frequent loose and highly putrid
motions on the eleventh day; and next day, the flux having ceased, the
most severe colic, so that he lay crying out day and night, his belly
swollen and hard as a drum, until, on the 24th day, he died in an
agony of convulsions.

Case 3, a brother, aged 11, was taken with similar symptoms on the
13th February, and died on the 13th day.

Case 4, a sister, was taken ill in March, with less marked symptoms,
and recovered slowly, having had no manifest crisis.

Case 5, a boy of the same family, and the youngest, fell ill about the
same time as No. 4, and after the like manner, “who yet, a looseness
arising naturally of itself, for many days voiding choleric and
greenish stuff, was easily cured.”

Then comes a general reference to the domestics and visitors, who fell
sick of the same and all recovered.

The prolonged series of cases in the household of this “venerable man” appears to have made a great impression upon Willis, as something new in his experience, as well as in the experience of several other physicians who gave their services. That it was malignant he considers proved “ex contagio, pernicie, macularum pulicularum apparentia, multisque aliis indiciis.” He adds that he had seen the same disease sporadically at other times; and again “I remember that formerly several laboured under such a fever.” Those cases were all previous to the general prevalence of the fever which he identifies with them in the summer of 1661, under the name of a “fever of the brain and spinal cord.”

The signs given by Willis are as nearly as may be the signs of infantile remittent fever, or worm fever, or febris synochus puerorum, or hectica infantilis, or febris lenta infantum, or an acute fever with dumbness, of which perhaps the first systematic account in this country was given by Dr William Butter of Lower Grosvenor Street, in 1782[11]. It is, he says, both a sporadical and an epidemical disease, “and when epidemical it is also contagious.” The age for it is from birth up to puberty; but “similar symptoms are often observed in the disorders of adults.” Morton, writing in 1692-94, clearly points to the same fever under the name of worm fever (febris verminosa). He adds it at the very end of his scheme of fevers, as if in an appendix, having been unable to find a place for it in any of his categories owing to its varying forms--hectic, acute, intermittent, continued, συνεχής, inflammatory, but for the most part colliquative or σύνοχος, “and malignant according to the varying degrees of the venomous miasm causing it[12].” Butter also recognizes its varying types: it has many symptoms, but they seldom all occur in the same case; there are three main varieties--the acute, lasting from eight to ten days up to two or three weeks; the slow, lasting two or three months; and the low, lasting a month or six weeks. The slow form, he says, is only sporadic; the low is only epidemic, and is never seen but when the acute is also epidemical; it is rare in comparison with the latter, and not observed at all except in certain of the epidemical seasons. Waiving the question whether the remittent fever of children, thus systematically described, was not a composite group of maladies, of which enteric fever of children was one, we can hardly doubt that Willis found a distinctive uniform type in the epidemic of 1661, in Oxford as he saw it himself, in other parts of England by report. It had symptoms which were not quite clearly those of enteric fever: spots, like fleabites, on the neck and other parts, swelling and suppuration of the glands in the hinder part of the neck, effusion of fluid on the brain and in the lateral ventricles, and the intestine free from disease[13].

Confirming Willis’s account for Oxford, is the case of Roger North, when a boy at Bury St Edmunds Free School in 1661, as related by himself in his ‘Autobiography[14].’ Being then “very young and small,” after a year at school he had “an acute fever, which endangered a consumption.” Elsewhere he attributes his bad memory with “confusion and disorder of thought,” to that “cruel fit of sickness I had when young, wherein, I am told, life was despaired of, and it was thought part of me was dead; and I can recollect that warm cloths were applied, which could be for no other reason, because I had not gripes which commonly calls for that application.” That “great violence of nature,” while it had impaired his mental faculties, had sapped his bodily vigour somewhat also, of which he gives a singular illustration.

This special prevalence of epidemic fevers in the summer and autumn of 1661 is noticed also by the London diarists.

Evelyn says that the autumn of 1661 was exceedingly sickly and wet[15]. Pepys has several entries of fever[16]. On 2 July, 1661: “Mr Saml. Crewe died of the spotted fever.” On 16 August: “At the [Navy] Office all the morning, though little to do; because all our clerks are gone to the burial of Tom Whitton, one of our Controller’s clerks, a very ingenious and a likely young man to live as any in the office. But it is such a sickly time both in the city and country everywhere (of a sort of fever) that never was heard of almost, unless it was in a plague-time. Among others the famous Tom Fuller [of the ‘Worthies of England’] is dead of it; and Dr Nichols [Nicholas], Dean of St Paul’s; and my Lord General Monk is very dangerously ill.” On 31 August: “The season very sickly everywhere of strange and fatal fevers.” On 15 January, 1662: “Hitherto summer weather, both as to warmth and every other thing, just as if it were the middle of May or June, which do threaten a plague (as all men think) to follow; for so it was almost the last winter, and the whole year after hath been a very sickly time to this day.”

The great medical authority of the time is Sydenham. His accounts of the seasons and reigning diseases of London extend from 1661 to 1686, so that they begin with the year for which Willis described the epidemic fever “chiefly infestous to the brain and nervous stock,” popularly called the new disease. But Sydenham did not describe the epidemic in the same objective way that Willis did. He records a series of “epidemic constitutions of the air,” the particular constitution of each year being named from the epidemic malady that seemed to him to dominate it most. It was, perhaps, because it had to conform to Sydenham’s “preconceived fancy,” as Lind said, that his account of the dominant type of fever in 1661 differs somewhat from that given by Willis.

Sydenham’s epidemic Constitutions.

Sydenham adopted the epidemic constitutions from Hippocrates, as he did much else in his method and practice. In the first and third books of the ‘Epidemics,’ Hippocrates describes three successive seasons and their reigning diseases in the island of Thasos, as well as a fourth plague-constitution which agrees exactly with the facts of the plague of Athens as described by Thucydides. The Greek term translated “constitution” is κατάστασις, which means literally a settling, appointing; ordaining, and in the epidemiological sense means the type of reigning disease as settled by the season. The method of Hippocrates is first to give an account of the weather--the winds, the rains, the temperature and the like,--and then to describe the diseases of the seasons[17]. Sydenham followed his model with remarkable closeness. The great plague of London has almost the same place in his series of years that the plague-constitution, the fourth in order, has in that of Hippocrates. It looks, indeed, as if Sydenham had begun with the year 1661, more for the purpose of having several constitutions preceding that of the plague than because he had any full observations of his own to record previous to 1665. He is also much influenced by the example of Hippocrates in giving prominence to the intermittent type of fevers. It was remarked by one of our best 18th century epidemiologists, Rogers of Cork, and with special reference to Sydenham’s “intermittent constitutions,” that fevers proper to the climate of Thasos were not likely to be identified in or near London excepted by a forced construction.

_Sydenham’s Constitutions._

-----------------------------------------------------------------------
| | Total | | Fever | | |
| Constitutions | deaths|Plague| and |Smallpox|Measles|
| | in | |Spotted| | |
| | London| | Fever | | |
----|-------------------------|-------|------|-------|--------|-------|
1661|“Intermittent” | 16,665| 20| 3,490 | 1,246 | 188 |
1662| constitution: with a | 13,664| 12| 2,601 | 768 | 20 |
1663| continued fever | 12,741| 9| 2,107 | 411 | 42 |
1664| throughout. | 15,453| 5| 2,258 | 1,233 | 311 |
| | | | | | |
1665|Constitution of plague | 97,306|68,596| 5,257 | 655 | 7 |
1666| and pestilential fever.| 12,738| 1,998| 741 | 38 | 3 |
| | | | | | |
1667|Constitution of smallpox,| 15,842| 35| 916 | 1,196 | 83 |
1668| with a continued | 17,278| 14| 1,247 | 1,987 | 200 |
1669| “variolous” fever. |} | | | | |
| |}19,432| 3| 1,499 | 951 | 15 |
1669|Constitution of dysentery|} | | | | |
1670| and cholera nostras, | 20,198| 0| 1,729 | 1,465 | 295 |
1671| with a continued fever.| 15,729| 5| 1,343 | 696 | 17 |
1672| Measles in 1670. | 18,230| 5| 1,615 | 1,116 | 118 |
| | | | | | |
1673|Constitution of | 17,504| 5| 1,804 | 853 | 15 |
1674| “comatose” fevers. | 21,201| 3| 2,164 | 2,507 | 795 |
1675|Influenza in 1675. | 17,244| 1| 2,154 | 997 | 1 |
1676| | 18,732| 2| 2,112 | 359 | 83 |
| | | | | | |
1677|Not recorded. | 19,067| 2| 1,749 | 1,678 | 87 |
| | | | | | |
1678|Return of the | 20,678| 5| 2,376 | 1,798 | 93 |
1679| “intermittent” | 21,730| 2| 2,763 | 1,967 | 117 |
1680| constitution, absent | 21,053| 0| 3,324 | 689 | 49 |
| since 1661-64. | | | | | |
| | | | | | |
1681|“Depuratory” fevers, | 23,951| 0| 3,174 | 2,982 | 121 |
1682| or dregs of the | 20,691| 0| 2,696 | 1,408 | 50 |
1683| intermittents. | 20,587| 0| 2,250 | 2,096 | 39 |
1684| | 23,202| 0| 2,836 | 1,560 | 6 |
| | | | | | |
1685|Constitution of a | 23,222| 0| 3,832 | 2,496 | 197 |
1686| “new” continued fever. | 22,609| 0| 4,185 | 1,062 | 25 |

--------
|Griping
| in the
| Guts
|
|-------
| 1,061
| 835
| 866
| 1,146
|
| 1,288
| 676
|
| 2,108
| 2,415
|
| 4,385
|
| 3,690
| 2,537
| 2,645
|
| 2,624
| 1,777
| 3,321
| 2,083
|
| 2,602
|
| 3,150
| 2,996
| 3,271
|
|
| 2,827
| 2,631
| 2,438
| 2,981
|
| 2,203
| 2,605

The foregoing is a Table of Sydenham’s epidemic constitutions from 1661 to 1686, compiled from his various writings, with the corresponding statistics from the London Bills of Mortality.

I give this Table both as a convenient outline and in deference to the great name of Sydenham. But we should be much at fault in interpreting the figures of the London Bills, or the history of epidemic diseases in the country at large, if we had no other sources of information than his writings. Only some of the figures in the Table concern us in this chapter; plague has been finished in the previous volume, smallpox, measles and “griping in the guts” are reserved each for a separate chapter, as well as the influenzas and epidemic agues which formed the chief part of the “strange” or “new” fevers. If this work had been the Annals of Epidemics in Britain, it would have been at once proper and easy to follow Sydenham’s constitutions exactly, and to group under each year the information collected from all sources about all epidemic maladies. But as the work is a history, it proceeds, as other histories do, in sections, observing the chronological order and the mutual relations of epidemic types as far as possible; and in this section of it we have to cull out and reduce to order the facts relating to fevers, beginning with those of 1661.

Cases of fever, says Sydenham, began to be epidemic about the beginning of July 1661, being mostly tertians of a bad type, and became so frequent day by day that in August they were raging everywhere, and in many places made a great slaughter of people, whole families being seized. This was not an ordinary tertian intermittent; indeed no one but Sydenham calls it an intermittent at all, and he qualifies the intermittence as follows:

“Autumnal intermittents do not at once assume the genuine type, but in
all respects so imitate continued fevers that unless you examine the
two respectively with the closest scrutiny, they cannot be
distinguished. But, when by degrees the impetus of the ‘constitution’
is repelled and its strength reined in, the fevers change into a
regular type; and as autumn goes out, they openly confess themselves,
by casting their slough (_larva abjecta_) to be the intermittents that
they really were from the first, whether quartans or tertians. If we
do not attend to this diligently” etc. And again, in a paragraph which
does not occur in the earlier editions, he writes as follows in the
context of the “Intermittent Fevers of the years 1661-1664:”

“It is also to be noted that in the beginning of intermittent fevers,
especially those that are epidemic in autumn, it is not altogether
easy to distinguish the type correctly within the first few days of
their accession, since they arise at first with continued fever
superadded. Nor is it always easy, unless you are intent upon it, to
detect anything else than a slight remission of the disease, which,
however, declines by degrees into a perfect intermission, with its
type (third-day or fourth-day) corresponding fitly to the season of
the year.”

The intermittent character of these fevers seems to have struck Sydenham himself in a later work as forced and unreal. Writing in 1680, when the same kind of fevers were prevalent, after the epidemic agues of 1678 and 1679, he calls them “depuratory,” and says that “doubtless those depuratory fevers which reigned in 1661-64 were as if the dregs of the intermittents which raged sometime before during a series of years,” i.e. the agues of 1657-59[18].

Theory or names apart, Sydenham’s account of the fatal epidemic fever of the summer and autumn of 1661, comes to nearly the same as Willis’s. Without saying expressly, as Willis does, that the victims were mostly children or young people, he speaks in one place of those of more mature years lying much longer in the fever, even to three months, and he specially mentions the same sequelae of the fever in children that Willis mentions, and that Roger North remembered in his own case--namely that they sometimes became hectic, with bellies distended and hard, and often acquired a cough and other consumptive symptoms, “which clearly put one in mind of rickets.” He refers also to pain and swelling of the tonsils and to difficulty of swallowing, which, if followed by hoarseness, hollow eyes, and the _facies Hippocratica_, portended speedy death. Among the numerous other _accidentia_ of the fever, was a certain kind of mania. Among the symptoms were phrensy, and coma-vigil; diarrhœa occurred in some owing, as he thought, to the omission of an emetic at the outset; hiccup and bleeding at the nose were occasional.

But, although Sydenham must have had the same phenomena of fever before him that Willis had, the epidemic being general, according to the statements of both, one would hardly guess from his way of presenting the facts, that the fever was what Willis took it to be--a slow nervous fever, with convulsive and ataxic symptoms, specially affecting children and the young. Both Willis and Sydenham recognised something new in it; the common people called it, once more, the “new disease,” and Pepys calls it a “sort of fever,” and “strange and fatal fevers.”

As Sydenham maintains that the same epidemic constitution continued until 1664 (although the fever-deaths in London are much fewer in 1662-3-4 than in the year 1661, which was the first of it), we may take in the same connexion Pepys’s account of the Queen’s attack of fever in 1663. The young princess Katharine of Portugal, married to Charles II. in 1662, had the beginning of a fever at Whitehall about the middle of October, 1663; Pepys enters on the 19th that her pulse beat twenty to eleven of the king’s, that her head was shaved, and pigeons put to her feet, that extreme unction was given her (the priests so long about it that the doctors were angry). On the 20th he hears that the queen’s sickness is a spotted fever, that she was as full of the spots as a leopard: “which is very strange that it should be no more known, but perhaps it is not so.” On the 22nd the queen is worse, 23rd she slept, 24th she is in a good way to recovery, Sir Francis Prujean’s cordial having given her rest; on the 26th “the delirium in her head continues still; she talks idle, not by fits, but always, which in some lasts a week after so high a fever, in some more, and in some for ever.” On the 27th she still raves and talks, especially about her imagined children; on the 30th she continues “light-headed, but in hopes to recover.” On 7th December, she is pretty well, and goes out of her chamber to her little chapel in the house; on the 31st “the queen after a long and sore sickness is become well again.”

Typhus fever perennial in London.

Sydenham says that a continued fever, the symptoms of which so far as he gives them suggest typhus, was mixed with the masked intermittent, (or the convulsive fever of children, as in Willis’s account), in every one of the years 1661-4; and that statement raises a question which may be dealt with here once for all. Fever in the London bills is a steady item from year to year, seldom falling below a thousand deaths and in the year 1741, during a general epidemic of typhus, rising to 7500. The fevers were a composite group, as we have seen, and shall see more clearly. But the bulk of them perennially appears to have been typhus fever. Where the name of “spotted fever” is given there can be little doubt. Every year the bills have a small number of deaths from “spotted fever,” and the number of them always rises in the weekly bills in proportion to the increase of “fever” in general, sometimes reaching twenty in the week when the other fevers reach a hundred. It would be a mistake to suppose that only the fevers called spotted were typhus, the other and larger part being something else. The more reasonable supposition is that the name of spotted was given by the searchers in cases where the spots, or vibices or petechiae of typhus were especially notable. If a score, or a dozen or half-a-dozen deaths in a week are set down to spotted fever, it probably means that a large part of the remaining hundred, or seventy, or fifty cases of “fever” not called spotted were really of the same kind, namely typhus. In the plague itself, the “tokens,” which were of the same haemorrhagic nature as the larger or more defined spots of typhus, were exceedingly variable[19]. One of the synonyms of typhus (the common name in Germany) is spotted typhus; but the spots were of at least two kinds, a dusky mottling of the skin and more definite spots, sometimes large, sometimes like fleabites.

Assuming that the cases specially called “spotted” in the London Bills were only a part of all that might have been called by the same name in the wider acceptation of the term (as in Germany), it is a significant fact that there are few of the weekly bills for a long series of years in the 17th and 18th centuries without some of the former. Such a case as that of Mr Samuel Crewe, brother of Lord Crewe, who died of the “spotted fever” on 2 July, 1661, probably means that there were more cases of the same kind in the poorer parts of the town, from which no account of the reigning sicknesses ever came unless it were the number of deaths in the bills. The conditions of endemic typhus were there long before we have authentic accounts, towards the end of the 18th century, of that disease being ever present in the homes of the lower classes. In the time of Sydenham, and even in the time of Huxham two generations after, there was no thought of the unwholesome domestic life graphically described by Willan and others, as a cause of typhus--the overcrowding, the want of ventilation, the foul bedding and the excremental effluvia.

If there had been any reason to suppose that the London of the Restoration, or of the time of Queen Anne, or of the first Georges had enjoyed better public health in its crowded liberties and out-parishes than we know it to have done from the time when the authentic accounts of Lettsom and other dispensary physicians begin, then one might err in assuming the perennial existence of typhus fever and in assigning to that cause the bulk of the deaths under the heading of “fevers” in the Parish Clerks’ bills. But the public health was undoubtedly worse in the earlier period. A writer as late as the year 1819, who is calling for that reform of the dwellings of the working classes in London which was soon after carried out, namely the construction of regular streets instead of mazes of courts and alleys, speaks of the “silent mortality” that went on in the latter[20]. It was still more silent in earlier times, when the west end of London knew nothing of what was passing in the east end[21].

In all matters of public health, after the somewhat romantic interest in plague had ceased, the poorer parts of London were for long an unexplored territory. Dr John Hunter, who had been an army physician and was afterwards in practice in Mayfair, began about the year 1780 to visit the homes of the poor in St Giles’s or other parishes near him, and was surprised to find in them a fever not unlike the hospital typhus of his military experience. I quote at this stage only a sentence or two[22].

“It may be observed, that though the fever in the confined habitations
of the poor does not rise to the same degree of violence as in jails
and hospitals, yet the destruction of the human species occasioned by
it must be much greater, from its being so widely spread among a class
of people whose number bears a large proportion to that of the whole
inhabitants. There are but few of the sick, so far as I have been able
to learn, that find their way into the great hospitals in London.” I
shall defer the subject of the dwellings of the working class in
London until a later stage.

The “constitution” in Sydenham’s series which succeeded the febrile one of 1661-64 was “pestilential fever.” It began in the end of 1664, lasted into the spring of 1665, and passed by an easy transition into the plague proper. The bills for those months have very large weekly totals of deaths from “fever,” as well as a good many deaths from “spotted fever,” before they begin to have more than an occasional death from plague. It is this particular form of typhus fever that Bateman had in mind when he wrote, in 1818, “We never see the pestilential fever of Sydenham and Huxham”; although Willan, who preceded him at the Carey Street dispensary, described in 1799 a fever of so fatal a type that it gave rise to the rumour that the plague was back in London. The term “pestilential” was technically applied to a kind of fever a degree worse than the “malignant.”

Willis, the earliest of the Restoration authorities on fevers, had three names in an ascending scale of severity--putrid, malignant and pestilential. The putrid fevers were what we might call idiopathic, engendered within the body in some way personal to the individual from “putrefaction” or fermentation of the humours; all the intermittents were included in that class, and the theory of their cure by bark was that the drug corrected putridity. In the malignant and pestilential, an altogether new element came in--the τὸ θεῖον of Hippocrates, the mysterious something which we call infection; and of these two infectious fevers, the malignant was milder than the pestilential[23].

Morton drew out the scale of fevers in an elaborate classification, of which only the last section of continued contagious fevers concerns us at present[24]:

{ {Fever mostly with sweats and
{Simple Malignant Fever {other signs of malignity, but
{ {without buboes, carbuncles,
{ {petechiae or miliary rash.
Synochus {
{ {Fever with petechiae, purple
{Pestilential Fever {spots, miliaria, morbillous rash
{ {on the chest.
{
{Plague {With buboes, carbuncles and
{ {black spots.

The order in this Table was also the order in time: the fever of 1661, which Willis calls malignant, remained as the constitution of the years following until the end of 1664; then began the pestilential, which passed definitely in the spring of 1665 into the plague proper. Willis, Sydenham and Morton, differing as they did on many points of theory and treatment, all alike taught the scale of malignity in fevers and plague, and all used the language of “constitutions.” The Great Plague of 1665 was, in their view, the climax of a succession of febrile constitutions of the air, being attended by much pestilential fever and followed by a fever which Morton places in the milder class of συνεχής.

The epidemic Constitutions following the Great Plague.

During the ten or twelve years following the Great Plague of London, the epidemic maladies which Sydenham dwelt most upon as the reigning types will appear on close scrutiny to have been on the whole proper to the earlier years of life. This cannot be shown in the simple way of figures; for the ages at death from the several maladies, although they were in the books of the Parish Clerks, were not published.

There was some continued fever every year, which we may take to have been chiefly the endemic typhus of a great city, and there were also deaths among adults due to those reigning epidemics which fell most on the young. In 1667 and 1668 the leading epidemic was smallpox, with a continued fever towards the end of the period which Sydenham called “variolous,” for no other reason, apparently, than that it was part of a variolous constitution. In the autumn of 1669, and in the three years following, the epidemic mortality was peculiarly infantile, in the form of diarrhoea or “griping in the guts,” with some dysentery of adults, and some measles in 1670. From 1673 to 1676, the constitution was a comatose fever, which chiefly affected children, with a sharp epidemic of measles in the first half of 1674, attended by a very high mortality from all causes, and a severe smallpox in the second half of 1674, attended by a much lower mortality from all causes. There was also an influenza for a few weeks in 1675. In 1678 the “intermittent” constitution returned, having been absent for thirteen years, and continued through 1779-80, until its “strength was broken.” In 1681 smallpox was unusually mortal, the deaths being more than in any previous year. Most of these constitutions fall to be dealt with fully in other chapters: but as we are here specially concerned with the succession to the plague, it is to be noted how largely the epidemic mortality in London fell upon the age of childhood for a number of years after the Great Plague of 1665. It was observed both by English and foreign writers that the next epidemic following the Black Death of 1348-49, namely, that of 1361 in England and of 1359-60 in some other parts of Europe, fell mostly upon children and upon the upper classes of adults. There is doubtless some particular application of the population principle in the earlier instance as in the later, but not the same application in both. The conditions at the beginning of the three hundred years’ reign of plague in Britain were different from those at the end of it. The increased prevalence of smallpox in the generation before the last great outburst of plague, and the infantile or puerile character of the epidemic fever of 1661, as described by Willis, show that the incidence of infectious mortality had already begun to shift towards the age of childhood. It looks as if the conditions of population, intricate and obscure as they must be confessed to be, were somehow determining what the reigning infectious maladies, with their special age-incidence, should be. Such a gradual change is the more probable for the reason that infectious mortality came in due time to be mostly an affair of childhood. The plague, which was the great infection of the later medieval and earlier modern period, was peculiarly fatal to adult lives; on the other hand, the mortality from infectious diseases in our own time falls in much the larger ratio upon infants and children. It looks as if this change, now so obvious, had begun before the end of plague in Britain, having become more marked in the generation following its extinction. The direct successor of plague, so far as concerns age-incidence and nosological affinity, was the pestilential or malignant typhus, which came into great prominence in 1685-86, in circumstances that seemed to contemporaries to forebode a return of the plague. But before we come to that, there remains a little to be said of some other fevers, especially of the comatose fever of 1673-76, which was largely an affair of childhood.

Pepys says that he went on 3 May, 1668, to Old Street (St Luke’s) to see Admiral Sir Thomas Teddiman, “who is very ill in bed of a fever,” and, in a later entry, that he “did die by a thrush in his mouth” on the 12th of May. Next year, 1669, Pepys and his wife went on tour through several parts of Europe, and had hardly returned to their house in Seething Lane when the lady fell ill of a fever; on 2nd November, it was “so severe as to render her recovery desperate,” and on 10th November she died, in her 29th year,--a surprising sequel, as her husband felt, to a “voyage so full of health and content.” These two years, for which we have a sample of the London fevers, were marked in the Netherlands by epidemics of fevers which are among the most extraordinary in the whole history. At Leyden in 1669 the fever reached such a height as to cut off 7000--a mortality which would not have been surprising if the disease had been plague; but it was not plague, it wanted the buboes, carbuncles &c., was longer in its course, and, strangest of all, affected the upper classes far more severely than the poor, so much so “that of seventy men administering the public affairs, scarcely two were left[25],” while, according to Fanois, who was the Leyden poor’s doctor, the lower classes, “protected as it were by having survived the simpler forms of fever,” suffered from this malignant epidemic far less than the rich[26]. The mortality is said to have risen as high as three-fourths of the attacks. At Haarlem the burials in a week rose to three or four hundred (which was a fair week’s average for London itself in an ordinary season), the epidemic lasting four months and leaving hardly one family untouched. Among the symptoms were extreme praecordial anxiety, weight at the pit of the stomach, constant nausea and loathing, vomiting, in part bilious but chiefly “pituitous,” thirst and restless tossing. It was attended by an affection of the throat and mouth--an angina with aphthae or thrush of the palate. The pools and other sources of water for domestic use were unusually stagnant that summer in Holland, and were commonly blamed for the epidemic; but Fanois points out that at Haarlem and Emden, where similar fevers raged, “salubriores non desunt aquae[27].”

After such an instance as the Leyden fever of 1669, nothing is incredible in the records of fever subsequent to the extinction of plague. Turning to Sydenham’s account of the continued fever which occurred in London during the same season, the latter half of 1669, as well as in the three years following, we find that it was characterized rarely by diarrhoea or sweats, commonly by pain in the head, by a moist white tongue which afterwards became covered by a dense skin, and by a greater tendency than Sydenham had ever seen to aphthae (the “thrush in the mouth” of Admiral Teddiman in 1668) when death threatened--the same being a “deposition from the blood of foul and acrid matter upon the mouth and throat.” But London in 1668 and 1669 suffered little from fevers in comparison to Leyden, Haarlem and other Dutch towns, its high mortality in the summer and autumn of 1669 being from infantile diarrhoea, cholera nostras and dysentery.

Sydenham’s continued fever from 1673 to 1676 (he was absent from his practice in 1677 owing to ill health) was a malady which affected adults as well as children, but, it would appear, the latter especially. The only characteristic case given is of a boy of nine who did not begin to mend until the thirtieth day. Many recovered in a fortnight, while others were not clear of the fever in a month. On account of the remarkable stupor which almost always attended it, Sydenham called the fever of this constitution a comatose fever. It began with sharp pains in the head and back, pains in the limbs, heats and chills, etc. His account of the comatose state is exactly like that given by Willis for the fever of children in 1661--profound stupor, sometimes for a week long, so profound in some as to pass into absolute aphonia (the “acute fever with dumbness” of later writers), while others would talk a few words in their sleep, or would seem to be angry or perturbed by something (the chimaeras mentioned by Willis) and would then become tranquil again; when roused to take physic or to drink they would open the eyes for a moment and then fall back into stupor. When they began to mend, they would crave for absurd things to eat or drink. During convalescence the head, through weakness, could not be kept straight but would incline first to one side and then to the other[28].

The years 1678-1680 witnessed remarkable epidemics of ague, such as had occurred on several occasions before, the last in the years 1657-59. They engross so much of Sydenham’s writing, especially in connexion with the Peruvian-bark controversy, that we hear little of any other fever until the great epidemic of continued fever, or typhus, in 1685-6. But he does mention briefly that the interval between the decline of the agues in 1680 and the beginning of the “new fever” of 1685, was occupied by “continued depuratory” fevers--depuratory of the dregs of the preceding intermittent constitution, and comparable in that respect to the fevers of 1661-64 which followed the agues of 1657-59[29].

Sydenham’s term “depuratory” does not help us much; but we learn something from Morton as to what fevers were prevalent, besides the epidemical intermittents, in the years preceding the epidemic of 1685-86. Morton classes them as continued συνεχής (_Synocha_), by which he means something less malignant than _Synochus_. A fever which began in the milder form would often degenerate into the more malignant, the cause assigned, in the usual recriminatory manner of the time between rival schools, being mistaken treatment. But sometimes the fever was malignant from the outset, with purple spots, petechiae, morbillous efflorescence, watery vesicles on the neck and breast, buboes, and anthraceous boils. All these fevers, says Morton, whether they were spurious forms of synocha, or malignant from the outset, were sporadic, “neque contagione, ut in pestilentiali constitutione, sese propagabant[30].” This points to their having been part of that strange aguish epidemic of which an account is given in another chapter. In Short’s abstracts of parish registers, the year 1680 seems to have been the most unhealthy of the series in country parishes, and that is borne out by one Lamport, or Lampard, an empiric who practised in Hampshire: “I will tell you somewhat concerning a malignant fever. In the year ’80 or ’81 there were great numbers of people died of such fevers, many whereby were taken with vomitings, etc., yet I had the good fortune to cure eighteen in the parish of Aldingbourn, not one dying, in that great compass, of that disease[31].” The moral is that the empiric recovered his cases, whereas the regular faculty lost theirs; which means that the fevers were of various degrees, some aguish, some typhus, as in the exactly similar circumstances a century after, 1780-85.

In the London Bills from 1681 to 1684, the deaths from fever were many, with some from “spotted fever” nearly every week, while the annual mortalities from all causes were high. It is the more remarkable, therefore, that Sydenham should have discovered, in the beginning of 1685, the outbreak of a new fever, different from any that had prevailed for seven years before. The explanation seems to be that a malignant typhus fever, such as might have been discovered in any year in the crowded parishes where the working classes lived, broke out at the Court end of the town, where Sydenham’s practice lay.

The epidemic fever of 1685-86.