INFANTILE DIARRHOEA, CHOLERA NOSTRAS, AND DYSENTERY.
Infantile diarrhoea and the cholera nostras of adults are closely allied
in symptoms and pathology, but they are so unlike in their fatality that
they are best considered apart. Dysentery is sufficiently distinguished
from choleraic disorders even in nosological respects; and except in
Ireland, where its history (already given) has been somewhat special, it
might have been made the subject of a separate chapter in British
epidemiology. But, for the same reason as in the case of influenzas and
epidemic agues and of scarlatina and diphtheria, it is necessary in a
historical review to include infantile diarrhoea, cholera nostras of
adults, and dysentery in one chapter, the reason being, that they are not
clearly separated in the earlier records. So little are they separated in
the London bills of mortality that the younger Heberden, in his fragment
upon ‘The Increase and Decrease of Diseases[1386],’ has understood the
name of “griping in the guts,” under which enormous totals of deaths are
entered in the bills for many years of the earlier period, to mean
dysentery alone: having assigned that meaning to the name, and having
observed, as everyone must, the very palpable fact that “griping in the
guts” steadily declined in the bills from the end of the 17th century
until it had almost disappeared from them in his own time, he has
elaborately proved from the figures that dysentery was at one time among
the most important causes of death in London, that it declined in the most
regular way, and at length became all but extinct. This illustration of
the increase or decrease of diseases has seemed so apt, the statistical
demonstration so complete, that it has become a favourite example of those
broad contrasts between the public health of past and present times which
are not less pleasing in rhetoric than they are on the whole true in
fact[1387]. But it happens that the particular instance is wholly
fallacious and erroneous. It was not dysentery that the article “griping
in the guts” meant for the most part, it was infantile diarrhoea; which
has not only not ceased in our own time, but is commonly believed to be
distinctively a product of the industrial town life of the present age. I
shall show that it was one of the most important causes of London
mortality from the Restoration onwards, and that although it is still one
of the great causes of death in infants, yet that it had weekly
mortalities in some of the hot summers of former times which were far
higher in ratio of the numbers living than the diarrhoeal death-rates of
our own time. So far as concerns dysentery itself, it is indeed now rare
in England and Scotland, and not common in Ireland; but the real history
of its decrease has been altogether different, both in the period of it
and in the extent of it, from what Heberden supposed. There are two
reasons for the fallacy and error of that writer: the first, that he
overlooked the question of age-incidence in “griping in the guts”; the
second, that he failed to observe that enormous annual totals of deaths
under that head had been gradually transferred in the bills of the Parish
Clerks to the head of “convulsions,” until there were only a few of the
old name left[1388].
Summer Diarrhoea of Infants in London, 17th century.
In the period of twenty-five years which Sydenham’s epidemic constitutions
cover (1661-1686), the first distinctively choleraic season was the late
summer and autumn of 1669. It was the first of a series of such seasons,
in one or more of which there occurred dysentery, cholera morbus and
bilious colic. In the context of the bilious colic of the years 1670-72,
Sydenham remarks that this was a disease which attacked chiefly the young
of a hot and bilious temperament, and was most rife in the summer
season[1389]. It is in connexion with the smallpox of 1667-69 that he
speaks of diarrhoea in infants; in that malady, he says, diarrhoea is as
natural to infants as salivation to adults, and he blames the imprudent
efforts of nurses to check the diarrhoea for the deaths of “many thousands
of infants[1390].” This is perhaps all that can be found in Sydenham to
show that infants did in fact suffer from diarrhoea, and that it was fatal
to them in large numbers. Equally indirect is the testimony of Willis.
Speaking of convulsions, he says they occur at two special periods of
life,--within one month of birth (the “fits of the mother” of 18th century
writers), and during teething; and with reference to the cause he says:
“As often as the cause of the convulsive distemper seems to be in the
viscera, either worms or sharp humours, stirring up to torments of the
belly, are understood to be at fault[1391].” It may be thought singular
that Sydenham and Willis should not have enlarged upon the infantile age
at which the summer diarrhoea of London mostly proved fatal, or that
Sydenham should not have elucidated by some comment the enormous weekly
totals of deaths by “griping in the guts” in the Parish Clerks’ bills
during many of the summers and autumns that came within the period of his
epidemic constitutions.
It should be kept in mind, however, that it was from the populous
liberties and outparishes occupied by the working class,--from
Cripplegate, Shoreditch, Spitalfields, Whitechapel, St Olave’s, Southwark,
Newington and Lambeth,--that the largest totals in the bills came.
Sydenham in Pall Mall, Willis in St Martin’s Lane, and Morton in Newgate
Street, were not likely to see much of the maladies of the poorest class,
least of all the infantile part of these; and the fact that their
illustrative cases of choleraic disease are mostly of adults should not
mean that the age of infancy did not then furnish most of the deaths, as
it certainly did in later times.
Whatever may have been the reason of their saying so little of infantile
diarrhoea, its great frequency or fatality in London in the end of the
17th century rests upon the explicit testimony of Doctor Walter Harris, in
his book on the Acute Diseases of Infants, written in 1689[1392]: “From
the middle of July to the middle of September these epidemic gripes of
infants are so common (being the annual heat of the season doth entirely
exhaust their strength) that more infants, affected with these, do die in
one month than in other three that are gentle.” It was probably this
remarkable fatality of the summer diarrhoea of infants that led Sydenham
to say that the cholera morbus of August differed _toto caelo_ from the
disease with the same symptoms at any other time of the year[1393].
The summer of 1669 was excessively hot; it was a season of enormous
mortality from fevers in Holland, of a type very difficult to understand,
and in New England it was remarkable for fluxes, agues and other fevers.
In that summer, as well as in the following, Sydenham lays stress upon the
amount of choleraic and dysenteric sickness, without saying that it was
specially fatal to children. The following Tables, compiled from the
weekly bills of the Parish Clerks for each of the two summers, show the
enormous rise of the total deaths in August and September, “griping in the
guts” accounting for almost the whole of the increase.
_Weekly Mortalities supposed of Infantile Diarrhoea in London._
Summer and Autumn of 1669
Week Convulsions Griping in All
ending the guts causes
June 29 30 42 283
July 6 49 74 365
13 48 105 391
20 53 119 389
27 36 122 368
Aug. 3 28 96 340
10 22 129 437
17 43 173 510
24 31 182 482
31 42 269 665
Sept. 7 45 318 707
14 34 277 619
21 33 231 524
28 29 232 570
Oct. 5 38 185 553
12 30 172 518
19 25 156 473
26 16 146 421
Nov. 2 14 89 372
Summer and Autumn of 1670
Week Convulsions Griping in All
ending the guts causes
July 5 37 41 318
12 40 51 320
19 43 76 351
26 40 77 372
Aug. 2 49 113 470
9 38 160 485
16 44 189 555
23 47 222 629
30 42 250 629
Sept. 6 31 253 617
13 24 239 586
20 38 225 575
27 27 150 474
Oct. 4 16 130 401
11 13 104 376
18 17 78 325
25 15 75 336
Nov. 1 19 46 283
These are the characteristic London bills of a hot autumn; they recur
sometimes two or three years in succession, and on an average perhaps once
or twice in a decennium. Any year with an unusually high total of deaths
from all causes is almost certain to show a large part of its excess of
deaths in the weekly bills of summer and autumn. The proof that these
enormous weekly totals under the head of “griping in the guts” were
infantile deaths lies in the fact that they were gradually transferred to
“convulsions,” as will appear in the tables of future autumnal epidemics
showing the transference half made and wholly made. The transference to
“convulsions” was almost complete before the year 1728, when the ages at
deaths from all causes were first published in the weekly bills. After
that year it is obvious that any excessive mortality of the six or eight
hot weeks of late summer or autumn corresponds to a great increase of the
deaths under two years, which is also the increase of deaths from
convulsions. But those were the “convulsions” of a particular season,
occupying exactly the place which “griping in the guts” held in the weekly
bills of certain years in the earlier period. As most of the deaths from
infantile diarrhoea are really from convulsions, it is easy to see that
high weekly totals of deaths under that generic name must have been from
infantile diarrhoea--when they began to rise in August far above the
ordinary level of convulsions to fall to the level again in October. It is
by precisely the same reading between the lines that we discover, under
the head of “diarrhoea and dysentery” in the modern registration returns,
that there is hardly any fatal dysentery, not much fatal diarrhoea of
adults, but an enormous fatality from the diarrhoea of infants, especially
in summer.
The sickness of the latter half of 1669, and of the years following to
1672, which we know from Sydenham and Morton to have been choleraic and
dysenteric, was not special to London. The following abstracts of the
burial registers of country parishes,
_Deaths in Country Parishes of England._
Registers With excess of Baptisms Burials
Years examined burials over baptisms in these in these
1669 118 33 685 878
1670 119 53 781 1403
1671 121 36 668 1051
1672 121 28 555 741
1673 124 16 365 487
by Short, show an excessive mortality in those years, which would have
been in part caused by bowel complaints, as in the general “choleric
lasks” of the 16th century.
In the summers of 1671 and 1672 the article of “griping in the guts”
continues high in the London bills. It rises again decidedly in the summer
of 1675, reaching a maximum of 129 deaths in the week ending 24 August,
the deaths from all causes being 460. In the summer of 1676 it almost
equals the high mortality of 1669 and 1670, reaching a maximum of 238
deaths in the week ending 22 August, the deaths from all causes being 607.
In 1678 and 1679 there were epidemic agues, complicated with choleraic
flux and gripes, which undoubtedly affected many adults[1394]. The deaths
from “griping in the guts” continue high in the summers of 1680 and 1681.
But by that time the article “convulsions” had steadily increased in the
bills; and in the next great season of bowel complaint, the excessively
hot and dry summer of 1684, the high mortality of the season is divided
more equally between “griping in the guts” and “convulsions,” a sufficient
indication of the age-incidence of the former:
_London Weekly Mortalities._
1684
Griping in
Week ending the guts Convulsions All deaths
July 1 56 98 454
8 71 92 404
15 65 79 364
22 74 89 420
29 116 84 503
Aug. 5 154 180 720
12 -- -- --
19 186 100 609
26 -- -- --
Sept. 2 171 95 585
9 144 82 564
16 103 58 471
23 91 59 464
The summers and autumns of 1688 and 1689 were again characteristic seasons
of infantile diarrhoea. The deaths rose in August and September almost as
in 1669 and 1670; but now the article of convulsions has actually more of
the mortality of the season assigned to it than the original article of
“griping in the guts.”
_London Weekly Mortalities._
Summer and Autumn of 1688
Week Convulsions Griping in All
ending the guts causes
July 10 84 28 353
17 94 35 388
24 90 80 491
31 108 86 510
Aug. 7 122 119 557
14 141 136 630
21 130 113 518
28 120 90 483
Sept. 4 109 98 532
11 112 119 547
18 90 102 474
25 102 76 476
Oct. 2 71 65 380
9 67 43 362
Summer and Autumn of 1689
July 16 108 60 486
23 109 65 463
30 121 69 504
Aug. 6 147 102 576
13 121 130 631
20 140 150 662
27 150 190 726
Sept. 3 150 170 733
10 108 156 693
17 110 117 630
24 95 90 558
Oct. 1 104 89 540
9 76 78 486
The following table from the annual bills will serve to show the summers
most fatal to infants in London, and at the same time the gradual
usurpation of the place of “griping in the guts” by “convulsions.”
_Annual deaths from Infantile Diarrhoea, etc., in London._
Griping in Convulsions
the guts
1667 2108 1210
1668 2415 1417
1669 4385 1730
1670 3690 1695
1671 2537 1650
1672 2645 1965
1673 2624 1761
1674 1777 2256
1675 3231 1961
1676 2083 2363
1677 2602 2357
1678 3150 2525
1679 2996 2837
1680 3271 3055
1681 2827 3270
1682 2631 3404
1683 2438 3235
1684 2981 3772
1685 2203 3420
1686 2605 3731
1687 2542 3967
1688 2393 4438
1689 2804 4452
1690 2269 3830
1691 2511 4132
1692 1756 3942
1693 1871 4218
1694 1443 5024
1695 1115 4496
1696 1187 4480
1697 1136 4944
1698 1165 4480
1699 1225 4513
1700 1004 4631
1701 1136 5532
1702 1189 5639
1703 985 5493
1704 1134 5987
1705 1021 6248
1706 948 5961
1707 883 5948
1708 768 5902
1709 812 5892
1710 707 6046
1711 614 5516
1712 575 6156
1713 581 5779
1714 670 7161
1715 589 6818
1716 709 7114
1717 653 7147
1718 801 8055
1719 826 7690
1720 731 6787
Summer Diarrhoea of Infants, 18th century.
The first series of unhealthy summers in the 18th century is from 1717 to
1729 (the summer of 1715 having had also high “convulsions”). In the week
ending 17th September, 1717, the article of “convulsions” rises to 187,
while that of griping in the guts is only 13, the deaths from all causes
being 522. For the next two years, the highest mortalities of the autumn
were these:
_London Weekly Mortalities._
Griping in
Week ending the guts Convulsions All deaths Births
1718
Aug. 12 34 226 653 355
19 23 239 645 383
26 25 256 693 347
Sept. 2 28 265 668 350
9 27 245 725 388
16 26 221 653 336
23 27 213 639 367
30 24 182 632 361
1719
Aug. 11 32 215 688 354
18 29 243 670 342
25 28 245 755 371
Sept. 1 27 233 726 362
8 17 229 735 393
15 22 218 728 379
22 14 202 663 360
29 17 161 639 372
If these two tables be compared with the tables already given for the
summers and autumns of 1669 and 1670, it will be found that the figures
under “griping in the guts” and under “convulsions” have exactly changed
places, the hundreds of the former in 1669-70 becoming tens in 1718-19,
and the tens of the latter in 1669-70 becoming hundreds in 1718-19.
In those two years the article of fever was very high, contributing
largely to the weekly totals of deaths from all causes, especially in
the summer and autumn. In 1720 “fever” and “convulsions” again reached
a maximum in September, the deaths from all causes in the week ending
20th September being 592. The winter of 1721 (February) is the first
of a series when the weekly deaths of the cold season reach the
enormous height of the most unwholesome summers, the causes being
“fever,” “aged,” “consumption,” “dropsy,” and the like, with a due
proportion of infantile deaths. The fatal winters following are 1723
(January), 1726 (Jan.-March), 1728 (Feb.-March, the end of a great
epidemic of fever), 1729 (Nov.-Dec., still fever), 1732-33 (Dec.-Feb.)
and 1738 (November). This was the great period of spirit-drinking,
crime, and general demoralization in London. In the week ending 30th
Jan. 1733, the deaths from “dropsy” were 64: it was in the midst of an
influenza.
The next characteristic weekly bills of autumn are found in the year 1723,
when the following enormous mortalities occurred in three successive
weeks:
1723
Griping in
Week ending the guts Convulsions All deaths Births
Sept. 3 23 308 761 396
10 32 251 705 339
17 33 262 768 390
Then comes a succession of four summers and autumns, 1726-29, in which the
weekly mortalities are of the same kind--high totals from all causes and
high “convulsions,” while “fevers” are high in several seasons of the
period, perhaps from influenzas. Strother, writing in the summer of 1728,
says there was much diarrhoea in London “last autumn [1727] and this
summer,” the effects of which upon the bills of mortality are nowhere
visible except under the enormous weekly totals of “convulsions.”
I shall take one more example of a season fatal to infants, the autumn of
1734, by which time we find recorded the ages at death:
_London Weekly Mortalities, with the numbers under five years._
1734
All deaths Total of
All deaths from deaths
Week ending Convulsions under two two to five at all ages
Aug. 13 218 240 71 558
20 217 284 76 547
27 240 297 80 573
Sept. 3 260 331 59 638
10 226 283 61 593
17 209 253 43 528
24 169 225 46 515
Oct. 1 158 224 59 510
8 190 236 61 558
15 136 172 42 464
In those nine mortal weeks of 1734, it will be seen that the deaths under
two years were about 45 per cent. of the deaths at all ages; they were at
the same time considerably more than half the recorded births. That was
the characteristic mortality of an unhealthy summer and autumn. It was
chiefly caused by the same cholera infantum or summer diarrhoea which
raises the weekly bills of London in our own time, and the occasions of it
recurred in a series of hot summers, or at intervals, just as they do now.
I shall not seek to illustrate this point for the rest of the 18th
century, and down to the beginning of registration in 1837. The history
of infantile diarrhoea is a continuous and uniform one, with indications
of greatest severity in the first half of the 18th century. Sir William
Fordyce, whose general theme is what he calls the hectic fever of children
(rickets), thus reveals some reasons why that should have been the worst
period of infantile diarrhoea[1395]:
“I speak within the bounds of truth when, judging from the Bills of
Mortality and the numbers in such circumstances who have been brought
to my door since the year 1750, I assert that there must be very near
20,000 children in London, and Westminster and the suburbs (if this be
questioned, examine the public charity schools and workhouses, the
purlieus of St Giles’s and Drury Lane, and satisfy yourselves) ill at
this moment of the hectic fever, attended with tun-bellies, swelled
wrists and ancles, or crooked limbs, owing to the impure air which
they breathe, the improper food on which they live, or the improper
manner in which their fond parents or nurses rear them up: for they
live in hotbed chambers or nurseries, they are fed even on meat before
they have got their teeth, and, what is if possible still worse, on
biscuits not fermented, or buttered rolls, or tough muffins floated in
oiled butter, or calves-feet jellies, or strong broths yet more
calculated to load all their powers of digestion; or are totally
neglected.”
Mistaken regimen among the more comfortable, total neglect among the
lowest class--these general causes of infantile mortality reached their
highest point in London under George I. and George II., at the time of the
disastrous mania for spirit-drinking. But the broken constitutions of the
parents were probably a more telling thing for the poor stamina of the
children than close nurseries, injudicious food or even total
neglect[1396].
While the article “Convulsions” in the London bills gradually
swallowed up nearly all the deaths of infants under two years, and so
far extinguished the article “griping in the guts” that the latter in
the year 1739 had fallen to the merely nominal figure of 280 deaths in
the year, yet it should be borne in mind that there must have been in
the same period an excessive mortality from convulsions not specially
related to cholera infantum. For example, the kind of convulsions in
new-born infants which nurses called the “nine-day fits,” produced the
following mortalities in the Lying-in Hospital of Dublin: Of 17,650
infants born alive in the hospital from 8 Dec. 1757 to 31 Dec. 1782,
there died 2944 within a fortnight of birth, or 17 per cent. The
disease of perhaps nineteen in twenty was “general convulsions, or
what our nurses have been long in the habit of calling the nine-day
fits[1397].” Corresponding deaths in London would have been included
under “chrisoms and infants” in the earlier period; but as that
article gradually ceased, they were naturally transferred to the
article “convulsions.”
The sacrifice of infants’ lives in London by the diarrhoea of summer
having been so enormous as the preceding tables show, the question arises
whether the same disease was a chief factor in the mortality of provincial
cities and towns. There is little positive evidence for, and there is a
good deal of probability against, its having been so important anywhere as
in London. In the second quarter of the 18th century, when London had
700,000 inhabitants, the larger provincial towns such as Edinburgh,
Glasgow, Manchester, Newcastle had not more than 30,000 to 40,000. A
Liverpool writer in 1784, by which time the population had grown much,
does indeed say that young children in large towns during the hot summer
months are apt to be fretful and peevish, and that they should have a
change to the air of the country[1398]. But it is inconceivable that
Manchester, with such vital statistics as are shown at p. 644 could have
had the same death-rates from convulsions in general or from the
summer-diarrhoea kind of them in particular, that London then had. Still
it had at least a local predisposition, then as now, to epidemic
diarrhoea. Thus Ferriar, having described certain flagrant nuisances in
the town, goes on to say that the burning summer of 1794 was followed by
wet warm weather, that a bilious colic raged among all ranks of the
people, and that thereafter “the usual epidemic fever” became very
prevalent among the poor[1399].
The bills of mortality for occasional years at Chester, Warrington,
Northampton, Carlisle and Edinburgh, which have been cited before in
various contexts, throw hardly any light upon this question of infantile
diarrhoea. The records of the Newcastle dispensary in the end of the 18th
century do show a good many cases of diarrhoea to have been attended, with
a proportion of fatalities which suggests that some, at least, were in
infants. Newcastle, as will appear in the sequel, was certainly much
subject to dysentery and the diarrhoea of adults in the 18th century, and
was as likely a place as any in England for cholera infantum. In the
records of two towns of Scotland it seems probable that a good deal of
infantile diarrhoea had been entered in the burial registers under the
name of “bowel-hive.” At Kilmarnock, from 1728 to 1764, and at Glasgow
from 1783 to 1800, the principal causes of death in infancy had the
following annual average ratios per cent. of the deaths from all causes:
Kilmarnock Glasgow
1728-64 1783-1800
Smallpox 16 per cent. 18·8 per cent.
Bowel-hive 7·0 " 6·5 "
Chincough 3·0 " 5·0 "
Closing 2·8 " 2·7 "
Measles 2·4 " 1·3 "
Teething 1·4 " 3·5 "
The article “bowel-hive” has a somewhat higher ratio of the deaths from
all causes at Kilmarnock, with about 4000 population, than at Glasgow with
some 80,000, and was probably a very comprehensive term[1400].
So far as concerns systematic medical description, an article by Dr
Benjamin Rush, of Philadelphia, written in 1773, is the first expressly on
the theme of cholera infantum or the summer diarrhoea of children; but, as
Hirsch correctly remarks, the popular names of the disease then current in
American towns, such as “disease of the season,” “summer complaint,” or
“April-and-May disease” (Southern States), indicate that it was well known
before the profession began to write upon it[1401]. So far as concerns
London, I am disposed to infer that it was more common, relatively to the
population, in the end of the 17th century and throughout the 18th than in
our own time. I shall come back to that after giving the modern statistics
of the malady for the capital and other English towns.
Modern Statistics of Infantile Diarrhoea.
The first six months of registration of the causes of death in England and
Wales, July-December, 1837, brought to light the following highest
mortalities from diarrhoea, which are mostly in manufacturing towns, and
especially in those of Lancashire and Yorkshire:
1837
Deaths by Diarrhoea
3rd qr. 4th qr.
{Manchester 164 47
{Salford 26 15
{Chorlton 63 14
{Liverpool 142 49
{West Derby 53 15
Leeds 52 37
Nottingham 43 4
(besides dysentery 25 2)
Dudley 45 52
Wolverhampton 37 32
Bolton 40 27
Newcastle 35 25
Sheffield 30 23
Stockport 28 23
Preston 21 20
Wakefield 22 10
Cockermouth 12 14
The returns were incomplete at first; and, for London, the figures of only
three parishes are given:
3rd qr. 4th qr.
Shoreditch 73 15
Greenwich 43 19
Kensington 35 13
Apart from the imperfect machinery of registration in the first years, the
figures of mortality by infantile diarrhoea are incorrect owing to many
such deaths having been certified as from “convulsions,” according to the
old tradition of the Parish Clerks’ bills. Doubtless this goes on still to
a considerable extent; but it will appear from the following comparative
table for London that it masked the real amount of infantile diarrhoea to
a much greater extent at the beginning of registration than afterwards.
_London Mortalities from the beginning of Registration._
Gastritis and
Years Diarrhoea Dysentery Cholera Enteritis Convulsions
1838 393 105 15 881 3419
1839 376 79 36 843 2961
1840 452 70 60 977 2983
1841 465 78 28 957 2778
1842 704 151 118 996 2773
1843 834 271 85 874 2701
1844 705 125 65 818 2736
1845 841 99 43 707 2395
1846 2152 156 228 648 2086
1847 1976 -- -- -- 2258
There is a progressive decline under “convulsions” and a progressive
increase under diarrhoea. The year 1846 was undoubtedly marked by an
unusual amount of choleraic disease; but the high level of the diarrhoeal
deaths was maintained from that year, so that it is probable that some
radical change had been made in the mode of entry. The nearly equal
proportion of deaths from diarrhoea and from convulsions in London has
continued since that time to the present, the former falling mostly in the
third quarter of the year, the latter not unequally on all the quarters.
In all England and Wales during the first five and a half years of
registration the deaths from diarrhoea were few compared with the numbers
relative to population in later periods:
England and Wales
Years 1837 (6 mo.) 1838 1839 1840 1841 1842
Deaths from Diarrhoea 2755 2482 2562 3469 3240 5241
There is a break in the annual tabulations of the returns for four years
from 1843 to 1846; when they are resumed in 1847, the diarrhoeal
death-rate per million living is found to have apparently risen to an
enormous height, at which it remained somewhat steady for a whole
generation.
_Annual average Mortalities per million living from Diarrhoea (and
Dysentery)._
England and Wales
1838-42 254
1847-50 900
1851-60 918
1861-70 968
1871-80 917
1881-90 662
London
1838-40 274
1841-50 782
1851-60 1030
1861-70 1040
1871-80 949
1881-90 749
From year to year the mortality has fluctuated enormously, as in the
following list, the rise or fall depending for the most part on the kind
of summer: e.g. that of 1893 was hot, and had an excessive mortality from
infantile diarrhoea.
1866 18266
1867 20813
1868 30929
1869 20775
1870 26126
1871 24937
1872 23034
1873 22514
1874 21888
1875 24729
1876 22417
1877 15282
1878 25103
1879 11463
1880 30185
1881 14536
1882 17185
1883 15983
1884 26412
1885 13398
1886 24748
1887 20242
1888 12839
1889 18434
1890 17429
1891 13962
1892 15336
1893 28755
These large annual totals stand almost wholly for deaths of infants,
according to the following table of rates per million living at the
respective ages:
_Mortality from Diarrhoeal diseases per million living at the
age-periods._
All ages 0-5 5-10
1851-60 1080 5263 229
1861-70 1076 5985 160
1871-80 935 5728 69
Three-fourths of the deaths are of infants in their first year. The middle
period of life is comparatively free from this cause of death, but at
fifty-five the ratio begins to rise again, and at seventy-five and upwards
is almost as high, among the comparatively small number living in extreme
age, as it was in infancy. Male infants die of it in excess of females,
according to a very general rule of sex mortality. It is also according to
rule that the ratio of female deaths approximates to that of males in
middle life and old age.
The deaths from infantile diarrhoea fall in great excess upon the towns,
and most of all upon the manufacturing towns and certain seaports. London,
which almost certainly had a great pre-eminence in the 18th century in the
matter of infantile deaths by summer diarrhoea, has lost it to a number of
provincial towns, of which the following is a list in the order of the
percentage ratios of their diarrhoeal death-rate per 1000 living under
five years to their death-rates from all causes under five years
(Decennial Period, 1871-80):
_Percentages of Diarrhoeal death-rate in the death-rates from all causes
under five years._
Yarmouth 19·4
Leicester 19·2
Preston 16
Worcester 16
{Sculcoates 16
{Hull 14
Northampton 15
Coventry 15
Goole 14
Leeds 13·7
Birmingham 13·5
Manchester 13
Salford 13
Norwich 13
Wigan 12·7
Hartlepool 12·5
Nottingham 12·4
Sheffield 12
Hunslet 12
Bolton 11·6
Holbeck 11·6
Stoke-on-Trent 11·3
Stockport 11·2
Liverpool 11
Blackburn 10
London, St Giles’s 10
London, Whitechapel 9·6
The reasons for placing the towns in the above order will be found in the
Table that follows, the significance of which will be pointed out after
some other matters have been disposed of. Meanwhile it may be said that
all these have diarrhoeal death-rates under five years greatly in excess
of all England and of all London.
_Table of English Towns with highest death-rates from Infantile
Diarrhoea._
Death-rate Death-rate
from from
all causes diarrhoea
under five under five Deaths of
per 1000 per 1000 infants Birth- Death-
living living under one rate rate
at the at the to 1000 per per
age-period age-period births 1000 1000
Liverpool 119·29 14·13 217 35·08 33·57
Manchester
(1871-73
incl. Prestwick) 103·82 18·84 207 38·97 31·46
Manchester (1874-80) 103·52 11·23 190 40·78 32·16
Preston 97·85 15·61 212 37·86 28·05
Salford 95·96 12·44 184 42·39 27·65
London,
Whitechapel 95·83 19·24 181 36·42 33·03
Holbeck 94·00 10·93 196 42·63 26·64
London, St Giles’s 92·69 9·42 176 34·05 23·42
Leicester 92·52 17·81 214 41·44 24·46
Sheffield 91·22 10·96 183 42·50 27·41
Blackburn 90·33 9·02 191 39·30 25·29
Hunslet 88·35 10·75 192 44·52 25·49
Leeds 87·47 12·02 188 39·33 26·04
Wigan 87·28 11·13 172 45·70 25·77
Stoke-on-Trent 86·76 9·91 189 43·29 25·80
Birmingham 86·10 11·78 179 39·89 25·82
Stockport 80·33 9·05 182 35·79 24·73
Nottingham 79·30 9·86 184 32·58 22·55
Bolton 78·54 9·13 167 39·20 24·34
Yarmouth 75·37 14·38 199 32·45 22·94
Hartlepool 75·26 9·43 166 43·36 22·49
{Hull 77·89 11·02 178 37·88 24·52
{Sculcoates 71·53 11·64 170 39·46 21·66
Norwich 72·29 9·78 188 32·86 23·32
Northampton 71·41 10·85 173 37·48 22·65
Worcester 68·24 11·10 176 32·00 22·13
Coventry 68·09 10·06 164 35·17 21·59
Goole 64·58 9·20 166 36·47 21·39
The deaths by infantile diarrhoea have a seasonal rise more marked than
that of any other malady. In the curves formed by Buchan and Mitchell of
the rise and fall of the deaths by various diseases in London throughout
the year, that of diarrhoea was the sharpest, rising to a high peak in the
third quarter of the year (July-Sept.). “Speaking generally,” says Dr
Ogle, “it appears from the returns of mortality in London that the
diarrhoeal mortality becomes high when the mean weekly temperature rises
to about 63°F.[1402]” The season is practically the same throughout the
British Isles. But in warmer countries, such as the more southern of the
United States of America, infantile diarrhoea is “the April and May
disease.” It is not the fatalities only, but the cases as a whole, that
fall decidedly upon the third quarter of the year[1403].
Causes of the high death-rates from Infantile Diarrhoea.
Sydenham said that the diarrhoea or bilious colic of London in the month
of August differed _toto coelo_ from that of other seasons of the year;
and Harris, writing in the year of Sydenham’s death (1689), said that more
infants, affected with the epidemic gripes, died in one month of the hot
season, from mid-July to mid-September, than in other three that are
gentle. If this were taken to mean that the infantile mortality from all
causes was trebled by the prevalence of diarrhoea during the eight warmest
weeks of the year, it would be nearly borne out by the weekly bills of
mortality, according to the examples given of them from the more fatal
years. So far from the deaths of infants in London by summer diarrhoea
having increased in the present century, they would appear to have
diminished greatly. The two worst weeks of an unhealthy summer or autumn
raised the London deaths in former times relatively as much as the whole
diarrhoeal season would do now. If this great change for the better be
admitted as correct, it may throw some light upon the causes of excessive
infantile diarrhoeal mortality in London in former times, and in some
other English towns at the present time.
The London populace in the 17th and 18th centuries were not only the
single great urban community in the kingdom, but they were far more
“urban” than now, in Milton’s sense of being
“long in populous city pent,
Where houses thick and sewers annoy the air.”
The houses stood closer together, many of them back to back in courts and
alleys. The streets were narrower. The inhabited area had few or no open
spaces besides the bed of the Thames. Not only the City and Liberties, but
also the out-parishes were compact, as if within a ring fence, joining on
to the open country abruptly, and not as now in straggling suburbs. It was
hardly possible to take children out for an airing, except in the west
end. When Lettsom about 1770 applied the fresh-air treatment to
convalescent cases of typhus, he had to send the patients to loiter on the
bridges spanning the Thames. As Cobbett said, London was a “great wen,” in
the correct sense of a shut sac which grew by distension. The soil was
full of organic impurities, including the decompositions of many
generations of the dead. A hot summer in former times raised effluvia from
the ground such as the modern residents have no experience of. The life
indoors was equally adverse to infants. Fustiness was favoured by the
window-tax; a tenement-house was apt to be pervaded by the excremental
effluvia from the “vault” at the bottom of the stair. The worst time of
all in London was the great drunken period from about 1720 onwards.
Doubtless drink was then used, as it is sometimes now, to drug the fretful
infants into torpor; but it told also upon them indirectly, inasmuch as
dissolute parents would have bred children with _mala stamina
vitae_[1404]. In all these respects there has been so great an improvement
in London that, although its population now exceeds four millions, its
death-rate from infantile diarrhoea, a distinctively urban disease,
exceeds only by a little the mean of all England and Wales.
While the mortality from infantile diarrhoea in London has undoubtedly
decreased since the 17th and 18th centuries per head of the population, it
is equally certain that there has been within the present century a great
relative increase of the deaths from that cause in the country generally.
The reason is that there has been an enormous increase of population and
that the increase has been almost wholly urban. The rise of new
manufacturing towns, with the great extension of the borders of old towns,
as in Lancashire and Yorkshire, has inevitably brought to the front this
distinctive fatality of town-bred infants. If the additional millions had
been dispersed in village communities over the face of the country, as in
Bengal, the mere density of population per square mile would have had its
effect on the public health, but not the same effect. There are now two
or three provincial cities comparable in size to 18th century London, and
there are some twenty more large enough to be in the same group. In most
of these the mortality from infantile diarrhoea has held its ground, for
all the improvements in sanitation and in well-being whereby the
death-rate from all causes has been considerably reduced. It is mainly
owing to that disease, and to whooping-cough, that the death-rate in the
first year of life, although it has ranged widely from year to year, has
fallen but little in the successive decennial periods. The bad eminence of
some towns in the list already given is probably due to a composition of
causes, among which the situation, soil, depth of ground-water, and the
like, would count. It is remarkable, however, that there are only a few of
them, such as Liverpool and Hull, that have been the chosen seats of great
epidemics of Asiatic cholera. On the other hand, Leicester and Birmingham
never had an epidemic of that disease, while Preston and the
cotton-weaving towns of Lancashire generally have had but slight outbreaks
of it. Again, the deaths from diarrhoea have been more purely infantile in
the group of towns which have had little or no Asiatic cholera[1405].
That which distinguishes the Lancashire and West Riding towns with highest
proportions of diarrhoeal death-rates in their infantile death-rates
generally, as well as such towns as Leicester, Worcester, Northampton,
Coventry and Norwich, Birmingham, Nottingham and Stoke-on-Trent, is the
extensive employment of women in factory work and other labour of the
factory kind. The Census returns do not adequately show this for married
women, who may be returned simply as of the married rank whether they be
wage-earners or not; but it is well known that the female labour of
industrial towns is to a large extent the labour of child-bearing women.
Among the towns that stand highest for infantile diarrhoea, Preston, in
the Census of 1881, had 32 per cent. of its adult female population
occupied in the cotton mills; Leicester had 20 per cent. of all its women
occupied in various industries, of which the chief are the hosiery and
boot-making; Northampton only 13 per cent., all at boot-making; Worcester,
a percentage, unknown for the city, occupied mostly at glove-making;
Norwich about 10 per cent. of its women returned as employed at
boot-making, silk manufacture, and various smaller industries.
One obvious result of married women engaging in factory labour, or piece
labour of the same kind at home, is that they do not suckle their infants;
and it has long been known that infants brought up with milk from a
feeding-bottle are much more liable to diarrhoea than infants brought up
at the breast. But the feeding-bottle is now too universal an appurtenance
of infancy among all classes and in all places to be a sufficient
explanation without something else, although there is no doubt that
feeding-bottles which are not kept very carefully clean are a real danger
in the particular way. Again, young children above the age for suckling or
feeding by the bottle are attacked by summer diarrhoea in about the same
proportions (e.g. at Leicester) as infants under one year, although they
do not contribute an equal quota to the death-roll.
In the discussions upon this question it has been commonly assumed that
the fault lies with the mother after the birth of her child, and all the
remedial measures, such as crèches for the infants of workwomen, have that
assumption underlying them[1406]. I believe that this is a very inadequate
account of the cause of this great modern evil, and that the remedies
proposed are mere palliatives which are destined to fail. The importance
of the matter may justify me for once in making an excursus into
physiology and pathology.
The problem of infantile diarrhoea is in great part the same as the
problem of rickets. The peculiar summer disease of town-bred infants
is especially apt to assail the rickety: probably a very large number
of the infants under one who are cut off by it would have become
obviously rickety if they had lived a few months longer. But even if
there were not this well-known correspondence between the subjects of
infantile diarrhoea and of rickets, we should find analogies in the
pathology of each. Rickets is an exquisitely congenital disease, or a
disease acquired by the child in the womb from the kind of
intra-uterine nutrition that it receives. In recent times it has been
usual to restrict the term congenital in rickets to the very few cases
that have rickets developed at birth. This is a typical instance of
the peculiar narrowness of view in modern pathology. All rickets is
congenital, although it is rare to find the symptoms made manifest
until the infant is nearly a year old. Cullen’s reasoning on this
point a century ago has never been answered nor superseded. The
theories of that day to explain rickets by injudicious feeding or
regimen after birth seemed to him beside the mark: “Upon the whole I
am of opinion that hired nurses seldom occasion this disease unless
when a predisposition to it has proceeded from the parents.... I am
very much persuaded that the circumstances in the rearing of children
have less effect in producing rickets than has been imagined.... I
doubt if any of the former [dietetic errors and the like] would
produce it where there was no predisposition in the child’s original
constitution.... So far as I can refer the disease of the children to
the state of the parents, it has appeared to me most commonly to arise
from some weakness, and pretty frequently from a scrofulous habit, in
the mother,” (Cullen, _First Lines_, Part III. Bk. II. chapter 4). The
chief exponent of the diathetic views on rickets in our time has been
Sir William Jenner (_Med. Times and Gaz._, 1860, I. 466); but I
remember at the Pathological Society on 7 Dec., 1880, how
unacceptable, or perhaps unintelligible, that part of his exposition
was to a younger generation who appeared to have forgotten the meaning
of _mala stamina vitae_.
The congenital nature of rickets is not only an empirical fact, based
upon experience, but it is a doctrine of rational pathology. The
latter aspect of it rests upon the correct physiology of intra-uterine
nutrition, for which I refer to my investigations on the structure and
function of the placenta (_Journal of Anatomy and Physiology_, July,
1878, and January, 1879). The detailed application of the
physiological facts to rickets I have attempted deductively in section
5 of the article “Pathology” in the _Encyclopaedia Britannica_, vol.
XVIII., 1884. The building up of the placenta by the mother, and the
due performance of function by that great and wonderful extemporised
organ, require certain favouring conditions, which have been never
unperceived by the common sense of mankind. Those conditions are
certainly not to be found in factory labour. A woman who has to be
thinking of the time-keeper at the gate and the foreman in the mill,
who has ever in her ears the din of belts and wheels and mill-stones,
who has dust in her lungs and weariness in her back, can hardly do
justice to the child in her womb. The rearing of the child after it is
born is of small consequence beside the rearing of it before it is
born. The opportunity comes once (heredity apart) of giving it good
stamina or bad; and in the circumstances of factory labour the wonder
is that breeding women provide so well as they do for their unborn
offspring. It is undoubted that they often tax themselves beyond
measure to do so, in tacit obedience to the great law of maternity.
While the connexion of rickets in the child with the laborious or anxious
preoccupations of the mother during gestation can be followed out in
physiological or pathological detail, the connexion with the same of a
disposition to summer diarrhoea remains empirical, except in so far as it
is a part of the rickety constitution itself. Some congenital weakness, we
may suppose, attends the functions of digestion and assimilation, and,
under the relaxing influence of continued high temperature, leads to
vomiting and purging, to which many infants succumb through the eventual
implication of the cerebral functions.
Ballard gives a table to show that of 332 infants (in a total of 340)
who died of diarrhoea at Leicester in 1881 and 1882, 141, or 42·5 per
cent. were “healthy,” and 191, or 57·5 per cent. were “weakly,” and
other tables to show that “our experience of these Leicester epidemics
by no means supports an opinion commonly held that a summer diarrhoeal
epidemic makes its first fatal swoop upon the weakliest
children[1407].” If “weakly” and “healthy” were as determinate as
bushels of wheat or barley, there would be some fitness in this resort
to numerical precision. But, in the circumstances, common experience
will come as near the truth as the statistical method can, and will
assign poor stamina to a much larger proportion of the infants that
die. The poor stamina may be more a matter of inference than of direct
observation. Thus, the last case of a death from infantile summer
diarrhoea that came under my notice was in a big-boned and well-grown
infant in the country. But it was the twelfth child of an equally
large-built country woman, then big with her thirteenth, whose
husband, a farm labourer, earned on an average not more than ten
shillings a week. The rate of fecundity has, of course, a direct
influence upon the stamina of the children. Its bearing upon the
death-rate from infantile diarrhoea is shown in one of the columns of
the table at p. 762.
Cholera Nostras.
Thus far I have considered diarrhoea as the “disease of the season” for
the age of infancy or early childhood; and undoubtedly the large totals of
deaths from it in the London bills, whether under the name of “griping in
the guts” or afterwards under the generic name of “convulsions” were
nearly all infantile deaths, both in earlier and later times. If we had
regard only to the statistics of mortality and the effects upon
population, we might now pass from the subject of epidemic diarrhoea,
having said all that has to be said of it in those respects. But the
deaths from epidemic diarrhoea, mostly of the summer and autumn, are far
from being a correct measure of its prevalence, whether in our own time or
in earlier times. Adults suffered from it in a fair proportion of the
numbers living at the higher ages, although few of them died of it, except
among the elderly and aged. It is only for modern times that we have any
figures of the number of persons attacked at the respective periods of
life; and these I shall take first in order, as illustrating the
probabilities or generalities that may be collected from earlier writers
such as Willis and Sydenham.
The following Table of the ages attacked at Leicester during a recent
series of years shows a smaller proportion of attacks in infancy than some
other modern tables do; but it is not misleading for general experience,
and it will serve emphatically to correct the illusion that infants,
because they contribute the bulk of the deaths, are most obnoxious to the
attacks[1408]:
_44,678 cases of Summer Diarrhoea at Leicester in seven epidemic seasons,
1881-87._
Age Cases Per cent.
Under one year 2,284 5·2
One year and under five 8,956 20·0
Five years and upwards 33,438 74·8
------ -----
44,678 100·0
On the other hand, the fatalities from diarrhoea in all England during the
same seven years had the following very different incidence upon the
periods of life:
Under One year and
one year under five Five years and upwards
1881 9408 2476 2852 = 19·3 per cent.
1882 10680 3555 3050 = 17·6 "
1883 9962 2843 3128 = 19·6 "
1884 17854 4794 3764 = 14·2 "
1885 8821 2023 2524 = 17·9 "
1886 16514 4936 3298 = 13·3 "
1887 14101 2936 3205 = 15·8 "
----
Annual average per cent. above five 16·8
Thus, while (at Leicester) the attacks above the age of five years were
74·8 per cent. the fatalities above that age (in all England) were only
16·8 per cent. and the greater part of the deaths in that small fraction
were of elderly or aged persons. This means that persons attacked by
diarrhoea between the ages of five and (say) fifty nearly all recover; on
the other hand a large proportion of infants in their first year succumb
to the attack, and a considerable proportion of elderly or aged persons
succumb to it.
If we were to judge from the direct testimony of Sydenham and Willis, we
should say that the cholera nostras of London in the 17th century was
chiefly a malady of the higher ages; there is little in their writings to
suggest the enormous mortality of infants from that cause, which can be
deduced from a close study of the bills. One reason for this, as already
said, was that the ailments of infants and young children in former times
came little under the notice of physicians, being left to the
“mulierculae” or nurses, and that among the working class, from which most
of the deaths in the bills came, there was in those times an almost total
lack of the medical experiences now gained through dispensaries, hospitals
and other charities or public institutions. With this proviso we may take
the accounts of the older writers as giving a correct picture of the
epidemic cholera nostras of a hot and close summer or autumn in former
times.
The great seasons of choleraic disease in the 16th century were the years
1539-40, (which were remarkable all over Europe for dysentery as well),
1557-58, 1580-82, and probably 1596[1409]. The term commonly used in that
period was a choleric lask, which meant _profluvium_. In some, if not in
all, of those seasons there was unusual heat and drought. It is clear that
these were only the years when cholera nostras of the summer season was
exceptionally common and severe. According to a medical work of the year
1610, dealing with the indications for the use of tobacco by individuals,
including the seasons of the year when it was most admissible, midsummer
is characterized in general terms, and perhaps in the stock language of
foreign medical treatises, as the season for “continuall and burning
fevers, bleareyedness, tertian agues, vomiting of yellow choler,
cholericke fluxes of the belly, paines of the eares and ulcerations of the
mouth, putrefactions of the lower parts: especially when the summer,
besides his heat, is enclined to overmuch moisture, and that no windes
blow, and the weather bee darke, foule, close and rainie.... So that in
this season, and for these remembered griefes, no man, I trust, will grant
tobacco to be verie holesome[1410].” Consistently with this Sydenham says
that, while the cholera morbus of August, 1669, was more general than he
had ever known it, yet in every year, at the end of summer and beginning
of autumn, there was some of it; and he compares its regularity to the
coming of the swallow in spring or of the cuckoo in early summer. It was
marked by enormous vomiting, purging, vehement pain in the bowels,
inflation and distension, cardialgia, thirst, a quick pulse, sometimes
small and unequal, heat and anxiety, nausea, sweats, spasms of the arms
and legs, faintings, coldness of the extremities, and other symptoms,
alarming to the attendants and sometimes causing death within twenty-four
hours[1411]. Next year, 1670, in the corresponding season, he describes
under the name of a bilious colic, a prevalent malady which, he says,
should count rather among chronic diseases[1412]. It was marked by
intolerable pain, the abdomen being now bound as if in a tight bandage,
now bored through as if by a gimlet. These pains would remit for a time,
and the paroxysm come back, the patient shrinking from the mere idea of it
with misery expressed in his face and voice. This was evidently somewhat
different from the cholera morbus of the summer of 1669; it was apt to end
in inverted peristaltic action, with vomiting of the matters of enemata,
or in iliac passion[1413]. There was also dysentery in both years, as we
shall see.
Morton gives the first choleraic and dysenteric season under the year
1666, and says of its recurrence in the following autumn, that hardly any
other disease was to be seen, that the whole town was seized, and that
300, 400 or 500 died of it in a week. This is obviously antedated by two
years, just as Morton is two years earlier than Sydenham with the great
fatality of measles (1672 instead of 1674). Willis, again, who wrote some
twenty years nearer to the events than Morton did, places the great
choleraic seasons in 1670 and 1671, instead of 1669 and 1670. Sydenham’s
dates are undoubtedly correct, both as borne out by the bills of
mortality, and as occurring in consecutive order in the annals which he
kept for a period of twenty-five years. The correctness of his dates
apart, Willis may be cited for the symptoms of the London cholera[1414].
The onset was sudden, with vomiting and watery purging, accompanied by
prostration: “I knew a great many that, though the day before they
were well enough and very hearty, yet within twelve hours were so
miserably cast down by the tyranny of this disease that they seemed
ready to expire, in that their pulse was weak and slender, a cold
sweat came upon them and their breath was short and gasping; and
indeed many of them, that wanted either fit remedies or the help of
physicians, died quickly of it. This distemper raged for a whole
month, but began to decrease about the middle of October, and before
the first of November was almost quite gone.” The vomitings and
purgings were copious, watery, almost limpid, not bilious. The
sickness was peculiar to London or the country within three miles of
it. It did not seem to be infectious, but to attack only those
predisposed to it; for it would seize those who kept out of the way of
the sick and spare those who attended them. Morton, however, declares
that he was infected in two successive seasons, “dum, mense Augusto,
sedes dysentericorum minus cauté inspicerem.”
These illustrations from the highly choleraic summers of 1669 and 1670
will serve to show the prevalence of cholera nostras among adults in
London in former times. Its great seasons were the same as those of
cholera infantum, of which numerous instances have been given from the
London weekly bills of mortality. The years 1727-29 were specially noted
for cholera by the annalists, such as Wintringham, of York. Hillary, of
Ripon, having entered in his annals a “cholera morbus” in 1731, adds:
“which disease I have observed to appear almost every year towards the
latter end of summer[1415].” A letter from Darlington, 29 July, 1751,
having mentioned the death of the earl of Derby by “the cholera morbus,”
adds that the disease usually rages at the close of summer and towards the
beginning of autumn[1416]. Newcastle was much subject to it, as well as to
dysentery, Wilson, of that town, devoting an essay to dysentery in 1761
and to cholera in 1765. Lind, who went to Haslar Hospital in the very
unwholesome period about 1756-58, found much aguish and choleraic
sickness: “Obstinate agues, and what is called the bilious cholic, from
being accompanied with vomitings and a purging of supposed bile, but
especially the flux, are often at Portsmouth and Gosport in the autumnal
season highly epidemical. Since I resided here, I have observed those
distempers to rage among the inhabitants, strangers and troops with an
uncommon degree of mortality; while, during this period of universal
distress at land, ten thousand men in the ships at Spithead remained
unaffected with them[1417].” At Manchester, in the burning summer of 1794,
a bilious colic, says Ferriar, “raged among all ranks of people[1418].”
Clarke, of Nottingham, writing in 1807 of the great prevalence of cholera
nostras, calls it “the usual attendant on autumn[1419].”
The appearance of Asiatic cholera in England in the end of 1831 gave rise
to much controversial writing for a few months, as to whether the epidemic
were really the foreign pestilence. Every effort was made by a certain
school to find native precedents for a disease equally malignant; which,
if they did not prove the point in question, gave more exact particulars
of cholera nostras than we might otherwise have received. The only one of
these accounts that need concern us here is Thackrah’s for Leeds and its
vicinity in 1825[1420].
The weather had been exceptional. In May, three-eighths more rain fell
than usual, the wind being in the east the whole month. June was
showery and sultry, the thermometer on the 12th marking 87°. July was
sultry, with drought for several weeks to the 3rd of August, when
showers fell. There had been a few cases of cholera in May, June and
July, but it was not until August that the disease became rife in
Leeds and still more in certain villages near it. The symptoms were
purging, vomiting, cramps, prostration, coldness of the extremities,
shrinking of the features, &c. At Moor Allerton, a parish three or
four miles north of Leeds, with a poor scattered population occupied
on the farms, there were found in 60 houses, containing 299 persons,
no fewer than 114 cases of sickness in July, August and September, 81
of these from cholera, with 3 deaths. Dysentery was common, both as a
sequel of the cholera and as a primary malady. At Halton, three or
four miles east of Leeds, with a population better off than in the
former, there were found in 60 houses, with 298 persons, 74 cases of
sickness, of which 63 were choleraic. At Grawthorpe, four miles west
of Wakefield, with a weaving population not poor but of filthy habits,
there had been for two months before the visit of inspection more
sickness than any one remembered. Twenty of all ages had died of the
epidemic, there having been 7 corpses in the village on one morning.
Of 70 houses inspected, only 7 had been exempt from cholera and
dysentery. In one house of 9 persons 7 were ill, 2 with cholera,
others with dysentery and typhus. This was one of the most unhealthy
villages, supplied with water from ponds only. In Leeds the choleraic
epidemic was less than in the adjoining country, and the few deaths
that occurred from it were all among the poor and debilitated. The hot
summer of 1825 was unusual for the amount of cholera nostras. It
prevailed at South Shields that season with unusual severity, the
cramps and spasms being peculiarly manifest[1421].
Dysentery in the 17th and 18th centuries.
The younger Heberden remarks, “There is scarcely any fact to be collected
from the bills of mortality more worthy the attention of physicians than
the gradual decline of dysentery.” I have shown the fallacy of Heberden’s
proof in the first part of this chapter on Infantile Diarrhoea. It is true
that dysentery did decline in London, but not on the evidence adduced by
Heberden, nor within the noteworthy limits that he supposed. It was at no
time one of the greater causes of death in London, and it had already by
the middle of the 18th century reached as low a point as it stood at when
Heberden wrote. As it is one of the diseases that have become rare in this
country, there is a scientific interest in establishing the fact of its
decrease, even although its prevalence had been at no time more than
occasional.
Hirsch groups the outbreaks of dysentery as of four degrees of extent: (1)
localized in a single town or village, or even a single house, or barrack,
or prison, or ship; (2) dispersed over a few neighbouring localities; (3)
dispersed over a large tract of country in the same season; (4)
simultaneous in many countries, or extending over a great part of the
globe, and continuing as a pandemic for several years[1422]. The last are
the most curious; and of these there are at least two in which Britain had
a share, the dysenteries of 1539-40 and of 1780-85. Of the next degree,
there have been several in Ireland and Scotland, including those of the
great Irish famines of the 18th and 19th centuries, and the “wame-ill” of
Scotland in 1439. Of the two minor degrees of extent, there have been, of
course, many instances in the towns, counties or provinces of Britain.
A considerable decline of dysentery in London before the end of the 17th
century is made probable by various facts that can be gathered from the
bills of mortality. When these began to be printed in 1629, dysentery
appeared in them under the unambiguous name of bloody flux; there were 449
deaths from that cause in 1629, they had decreased to 165 in 1669 (a year
remarkable for dysentery and other forms of bowel-complaint), and to 20 in
the year 1690, soon after which the article of bloody flux ceased in the
bills. But we are not to judge of the amount of dysentery from the
entries under the name of bloody flux alone. In 1650 there began the
article of “griping in the guts”; as I have shown, it was mostly infantile
diarrhoea of the summer and autumn, but, so long as it lasted, it had
probably included some dysentery. Besides the articles of bloody flux and
griping in the guts, there was a third article for a time in the bills,
namely “surfeit,” a term which came at length to mean dysentery[1423].
Thus the great plague of 1625 is said to have been preceded by a surfeit
in Whitechapel; and it is clear from other uses of that word, for example
as applied to slaves shipped on the West Coast of Africa for transport to
the West Indies, that it meant dysentery more than any other form of
bowel-complaint[1424]. Accordingly when we find in the weekly bills of
mortality for London that a series of weeks in the dysenteric summer and
autumn of 1669 had deaths from “surfeit” to the numbers of 9, 11, 10, 12,
9, 15, &c., we may take it that these were dysenteric rather than
choleraic, the more so as the other name “bloody flux” has fewer deaths to
it than we might have expected from Sydenham’s general language. These
various items in the London bills cannot be used for an exact statistical
purpose, but only as indications. Perhaps the most trustworthy indication
is the total of 449 deaths from bloody flux in the year 1629, being a
twentieth part of the mortality from all causes (8771 deaths). That was a
prevalence of fatal dysentery in London far in excess of anything that is
known in the 18th century, for example in the dysenteric seasons of 1762
and 1781. So long as plague lasted, dysentery seems to have been somewhat
common, and probably most so in the plague years; for, besides the surfeit
in Whitechapel with which the plague of 1625 is said to have begun, we
find many deaths from bloody flux in the year of the Great Plague itself,
1665. As Sydenham and Willis have left good accounts of the London
dysentery of 1669-72, it will be convenient to take from these sources our
impressions of the disease in the 17th century.
Referring to the dysentery of 1669, Sydenham says that there had been
comparatively little of it for ten years before, not including, doubtless,
the plague-year of 1665, when Sydenham was out of town[1425]. Both he and
Willis are clear that there was a certain amount of it every year,
although it was seldom fatal in ordinary seasons. The ordinary London
dysentery, says Willis, though it be horrid or dreadful by reason of its
bloody stools, and is most commonly of a long continuance, yet it is not
very contagious nor often mortal[1426]. Sydenham says that it was fatal
more particularly to aged persons, but highly benign in children, who
might be subject to it for months _sine quovis incommodo_. However, in
certain seasons it became malignant and caused a good many deaths.
It began usually with chills and shiverings, to which succeeded heat
of the whole body, and shortly after tormina with dejections; but
sometimes the griping and stools were the first symptoms. Always there
was intense suffering and “depression of the intestines,” with
frequent straining at stool. The stools were mucous, not
stercoraceous, and with traces of blood. The tongue might be whitish,
or dry and black; the strength was prostrated and the spirits faint.
After a time the streaks of blood in the motions would be replaced by
pure blood, without even mucus, a change which threatened a fatal end.
Sometimes the bowel became gangrenous, while aphthae would appear in
the mouth and fauces. If the patient were about to recover, the
symptoms would gradually be restricted to the rectum, in the form of
tenesmus. Willis says that the dysentery of the autumn of 1671 was
really a bloody one, and extraordinarily sharp and severe, hurrying
many to their graves. At the outset blood was voided plentifully, with
griping pains; there might be twenty stools in a day. Some were able
to rise after a week; but the malady would go on for several weeks or
even months. It was protracted also in fatal cases, the end being
marked by watchfulness, roughness of the tongue, thirst and thrush in
the mouth. He gives a case of a strong young man who recovered after
having had not only terrible bloody stools, but also bloody vomit,
which, Willis thought, might have come from ulceration of the stomach.
But with good diet and treatment most of those attacked escaped death.
Sometimes it became virulent and, as it were, pestilential, destroying
many and diffusing its infection very largely by contagion.
It was most common, says Willis, in camps and in prisons, by reason of the
stench of the places and the evil diet. From what Sydenham was told by Dr
Butler, who accompanied Lord Henry Howard in his embassy to Morocco, the
dysentery of North Africa was the same as that which prevailed in London,
as an occasional epidemic, in 1669-70.
The dysentery of the siege of Londonderry and of the camp at Dundalk, both
in the year 1689, have been described elsewhere. During the same reign,
Dr William Cockburn got fame and wealth by a secret remedy for dysentery,
which was tried first on board the king’s ships at Portsmouth[1427]. In
1693-99, there was dysentery in Scotland and in Wales. Of Scotland in
1698, the climax of the “seven ill years,” Fletcher of Saltoun says: “From
unwholesome food diseases are so multiplied among poor people that, if
some course be not taken, this famine may very probably be followed by a
plague[1428].” A Welsh practitioner, who graduated at Dublin in 1697 said,
in his thesis, that dysentery had raged for the space of three years in
several maritime regions of South Wales so severely and had made such
havock that in not a few houses there were hardly one or two left to bury
the dead[1429]. Writing before the seven ill years, Sir Robert Sibbald
mentions dysentery as one of the _dira morborum cohors_ that everywhere
affected the Scots peasantry in the end of the 17th century, the causes of
which were coarse food and excesses in spirit-drinking. In the century
following we hear of dysentery in Scotland in particular years, which
correspond on the whole to the unwholesome seasons in England. Thus in
1717, special mention is made of a fatal bloody flux in Lorn, Argyllshire.
In 1731 there were dysenteries in Edinburgh in autumn, often tedious,
rarely mortal. In 1733, during the harvest months, dysenteries were
frequent and mortal in Fife, especially along the shores of the Firth of
Forth. In the following autumn (1734) many in Edinburgh were seized with a
dysentery, which continued more or less epidemic all the winter: “It had
the ordinary symptoms of slight fever, frequent stools, for the most part
bloody and mucous, violent gripes and an almost constant tenesmus”--being
fatal to some and very tedious to others[1430]. This was a well-marked
dysenteric period in Scotland, but just as much a rare or occasional
experience as the corresponding epidemic a century after in 1827-30. It
appears to have lasted in various parts of Scotland until the end of 1737.
A regimental surgeon, who was stationed at Glasgow in the end of 1735 and
afterwards at Edinburgh, had 190 dysenteric patients (civil and military)
from December, 1735, to February, 1738[1431]. The summer and autumn of
1736 appear to have been its more severe seasons; it is heard of at St
Andrews and in the country near it, at Kingsbarns and Crail (where “many
of the boys” were seized), at Dalkeith, and in Glasgow and the
neighbourhood, where one practitioner claims to have treated “some
hundreds” with cerate of antimony[1432]. In the great period of epidemic
fever shortly after, the years 1740 and 1741, flux in the Edinburgh bills
of mortality has respectively 3 and 36 deaths, which would probably have
meant thirty to fifty times as many cases[1433].
The English epidemiographists, Wintringham, Hillary and Huxham, mention
dysentery in certain years, which were the seasons of high general
mortality. Wintringham’s first entry for York is under the year 1717, his
second in 1723 (autumnal), a third in 1724 (some fluxus alvi with blood),
in 1726 diarrhoeas and dysenteries “called morbus cholera,” and the same
for two or three weeks of September, 1727. Wintringham was one of the
first in England to emphasize the seasonal connexion between dysenteries
and agues. There was undoubtedly dysentery among the many forms of
sickness in the disastrous years 1727-29. Huxham includes it among the
fluxes which were common at Plymouth in 1734-36. A still greater
dysenteric period followed the influenza epidemic of 1743, Huxham being
again the chief chronicler of it[1434].
In the second half of the 18th century, two periods were specially noted
for dysentery, the years about 1758-62 and 1780-82. The first of these
called forth perhaps the only medical piece written by Dr Mark Akenside,
physician to St Thomas’s Hospital and author of the ‘Pleasures of the
Imagination[1435],’ as well as accounts by Sir G. Baker[1436] and Sir W.
Watson[1437]. All three writers agree that the true epidemic prevalence
occurred in London in the autumn of 1762. It is clear, however, that
Akenside had been treating in St Thomas’s Hospital since 1759 many cases
of true dysentery (which he defines as a bowel complaint with gripes,
tenesmus and bloody or mucous evacuations). He had more than one hundred
and thirty cases of it described in his ward-books in the five or six
years previous to his writing (1764); he had proved the good effects of
ipecacuanha on many in 1759; and he had remarked that the autumnal
dysenteries of 1760, 1761 and 1762 in each case lasted the whole winter,
not abating until the spring. Perhaps this may have been a special
experience of the Surrey side of the Thames; for both Watson and Baker are
clear that dysentery was something of a novelty to them in the early
autumn of 1762. Says the former, writing to Huxham on 9 Dec. 1762: “We
have had here this autumn a disease which has not been in my remembrance
epidemic at London. Very few of our physicians have seen this disorder as
it has appeared of late. You mention it as frequent at Plymouth in the
year 1743....” And Baker begins his essay by saying that there became
epidemic in London in the end of July, 1762, the disease of
dysentery--“morbi genus hac in civitate novum feré, aut nuperis saltem
annis inauditum[1438].”
The three observers agree that it attacked the poorer classes,
children more than adults, convalescents, lying-in women and the like.
Akenside says that it was mostly a slow non-febrile disease (in the
autumnal outburst of 1762, the subjects of it were more fevered), and
that some patients came to him who had been labouring under it for two
or three months. His account agrees on the whole with Sydenham’s for
the years 1669-72: some had vomiting, some had a painless flux
following the dysentery, some had dropsy as a sequel. In cases about
to end fatally there was a remission of the griping before the end; in
some there were aphthae of the mouth, stupor, and somnolence, with
cold sweats. Watson saw three children (of four or five years) die
from debility a week or more after the gripings and discharges had
ceased; they could keep down no food, and were greatly emaciated. In
another case, a young child, the motions were pure blood, and death
followed on the third day. Baker gives Hewson’s notes of the anatomy
in a case that was clearly one of follicular dysentery, as well as
Charlton Wollaston’s account of two other anatomies (mixed catarrhal
and follicular), with plates of the dysenteric bowel.
Watson, physician to the Foundling Hospital, says that the dysentery, or
dysenteric fever, was very prevalent among the children in 1762, the year
of its most general prevalence[1439]. It may have been part of that
dysenteric “constitution” which caused the following outbreak among the
foundlings at the hospital at Westerham, Kent, a branch of the Guilford
Street charity: “26 January, 1765. The apothecary visited the children at
the hospital at Westerham, January 12th, 1765, and found twenty ill with
dysenteries, many of whom had the whooping-cough complicated with it. Two
of them are since dead, which, with six that died before he went down,
make eight dead of that disease.” Two cases of dysentery were in the
infirmary of the Foundling Hospital in London on the 2nd of March,
1765[1440]. These accounts of dysentery in London in the middle third of
the 18th century show it to have been then a very occasional malady and a
very small contributor to the bills of mortality.
Next to the capital, the town that seems to have had most dysentery in the
18th century was Newcastle, which had been also the seat of frequent and
severe plagues. There was much dysentery in it and in the neighbouring
places on Tyneside during the autumns of 1758 and 1759, but the disease
was not epidemic in 1762, the season of the malady in London[1441]. It was
prevalent among the same classes in Newcastle as in London--the poorer
households, children, weakly persons. It recurred in the harvest quarter,
in fine clear weather, when the days were almost as hot as at midsummer,
but the evenings and mornings remarkably cold and the nights frequently
foggy. The reason why the lower class of people were most liable to it
seemed to be their “negligence in the article of cooling after heats by
labour, exercise, &c.” But there may have been something also in the soil
and situation of Newcastle which made these common risks to be followed by
so special an effect.
The Newcastle dysentery of 1758-59, two or three years earlier than the
London epidemic, was the occasion of the essay by Dr Andrew Wilson, a work
which compares favourably with the writings of the metropolitan
physicians. Among the symptoms of true autumnal dysentery he gives the
following:
“Constant fever, drought, parchedness of the mouth and throat,
dejection of the spirits, prostration of the strength, frequent
viscid, acid or bilious vomiting, flatulency in the belly, wringing
pain in the lower part of it, and often in the same region of the
back; these pains sometimes constant, but always preceding stools; an
almost constant pressing to stool, with great pain and irresistible
tendency to it at the same time, called a tenesmus; the stools
generally bloody, always slimy, and full of glary stuff, sometimes
mixed with a whitish matter of less tenacity, which appears in
separate little curdled-like parcels, often with blackish
corrupted-like bile; the stools always odiously fetid; they are seldom
natural without the assistance of purgatives, and then they are often
discharged in hard, dry little lumps; dryness of the skin, except when
clammy unbenign sweats are raised by the intenseness of the gripings
and tenesmus; great watchfulness, their sleep, when accidentally they
drop into any, being short and broken, with recurring pains which
awake them unrefreshed. These are the principal symptoms which attend
a true febrile dysentery. When such a disease is epidemic there are
many slight appearances of it which happily do not extend to all these
complaints, and which easily yield to proper applications.
The signs of danger in this disease are the violence with which all
the above symptoms appear. But the signs of immediate danger are,
decrease of pain, great sinking of the spirits, lowness of the pulse,
beginning coldness of the extremities, parchedness and blackness of
the tongue, aphthae; white scurf or ulceration of the throat and
fauces, and constant hiccup. When there is a cessation of pain,
intolerably fetid and involuntary stools, shiverings, with sometimes a
sense of coldness in the belly, a slight delirium, and often
unaccountable fits of agony, or rather anxiety; then the case is
beyond remedy, and the patient hastens to dissolution. This stage of
the disease is generally attended with a small obscure pulse and cold
extremities, but I have seen it in some particular cases otherwise.
... When dysentery is epidemic, it is not uncommon for people who
escape the dysentery itself to have their stools altered from their
natural colour to sometimes a greenish hue, as if they had eaten much
herbs, sometimes of a clay colour, and sometimes quite blackish, as if
they had eaten a quantity of blood.... In 1759 particularly, it was
very common for numbers of people who escaped the dysentery to be
troubled with flatulencies, slight gripings and twitchings in the
belly, which was generally attended with blackish stools. Stranguaries
were likewise pretty frequent, and icteric complaints, or the
jaundice. The stranguary was a very common symptom in many fevers
which occurred during the prevalency of the dysentery. Another
complaint which frequently occurred during the last dysenteric season
was dry gripes.
The dysentery this last season [1759] differed in many respects from
its appearance in the former season. In the latter season greater
numbers had it in that slight degree which was attended with little
fever and no danger. In many who were seized with seemingly great
violence, it was unexpectedly checked when there appeared all reason
to apprehend it would have run to a much greater length. It was not
uncommon to find it complicated with agues, rheumatisms, &c., into the
latter of which it frequently degenerated. In the former season the
griping pains attending it were confined to the lower belly. In the
latter they were very ordinarily felt also in the back, along, as
might be supposed, the windings of the rectum and colon; yet, after
the dysenteric stools were in a great measure gone, and the disease
over, these pains often remained, or assumed the appearance of a
lumbago or sciatic, with pains striking down the thighs.... The more
the season advances, and the later in the year it is when persons are
seized with this epidemic, the more chronical do the symptoms of it
grow.”
The last sentence is probably the explanation of Akenside’s original
point, that dysentery was as much a winter as an autumnal malady, not
really abating until the spring. Wilson himself claims originality in the
following point relating to the sluggishness of the bowels in dysentery,
his treatment having been largely determined by that view of the
pathology:
“During the increase and height of this distemper, it is very
improperly called a flux. A proper flux, or diarrhoea, is a constant
flow of immoderately liquid but otherwise natural stools, dissolved by
too great an irritation upon, or too great a relaxation of, the
vessels destined for mollifying the faeces and lubricating the
passages by their humours; by which means they are disposed to dismiss
a superfluous quantity of them. But in the dysentery the passage of
the natural discharges is resisted, and their consistence is often
increased to such a degree that, when they are urged along by the
assistance of purgatives, they are excluded in unnaturally hard and
dry little lumps or balls” (p. 3). The question whether scybala were
an essential character of dysentery was often referred to in later
writings.
Nothing more is heard of dysentery at Newcastle until the date of the
opening of the dispensary there, 1 October, 1777. From that date to 1
September, 1779, when the disease was not epidemic there, 72 cases were
treated from the dispensary.
Some importance, as regards priority, attaches to one of Dr Andrew
Wilson’s observations of the Newcastle dysentery of 1759: “It was not
uncommon to find it complicated with agues, rheumatisms, &c., into the
latter of which it frequently degenerated.” The pains, he says, were
not confined to the lower belly, but were felt also in the back; or,
after the dysentery was gone, the muscular pains remained as a lumbago
or sciatica, striking down the thighs. This curious relationship of
dysentery to rheumatism, shadowed forth in the Newcastle essay of 1761
[1760], was formally stated by Akenside in his essay of 1764, being
perhaps the best of his various attempted originalities. It was
afterwards taken up in Germany by Stoll, Richter, Zimmermann and
others in the 18th century, and was illustrated from the Dublin
epidemics of the 19th century by O’Brien[1442] and Harty[1443]. The
doctrine of a relationship between dysentery and acute rheumatism has
been discovered in the 7th century writer, Alexander of Tralles, but
erroneously. The Byzantine writer does indeed introduce into two
paragraphs on bowel-complaint the word ῥευματισμός--one of them
relating to the alvine profluvium attending fevers or following
fevers, the other relating to “dysenteria rheumatica[1444].” But it is
clear that he is merely ascribing to the diarrhoea in the one case and
to the dysentery in the other a rheumy nature, on certain theoretical
grounds of humoral pathology; there is no reference to joint pains or
muscular pains, or to anything else connoted in the later use of the
word rheumatism. The idea is originally an English one, from the
middle of the 18th century, and belongs most properly to Akenside,
although Wilson, a not less trained and capable observer, had recorded
the empirical fact three or four years earlier. Akenside was led to
regard dysentery “as a rheumatism of the intestines,” and to maintain
that “the cause and the _materies_ of each disease were
similar[1445].” Stoll adopted these phrases, adding that dysentery
differed from rheumatism of the joints “merely in form and situation.”
But for a few empirical facts, the relationship would be thought
fanciful. These, however, may be finger-post instances, pointing to
the true pathology of a somewhat mysterious malady. They are simple
enough: e.g. cases of dysentery have “degenerated,” as Wilson said,
into rheumatism; or cases of acute rheumatism, treated by purging,
have developed the gripings, tenesmus and stools of dysentery; or, in
a time of dysentery, cases have occurred in which the symptoms of the
latter were joined to those of acute rheumatism, or cases in which the
symptoms of the one disease obtained, say for twenty-four hours, to
give place to the symptoms of the other. Again there are countries
such as Lower Egypt where the frequency of dysentery is not more
remarkable than the frequency of rheumatic fever. Harty points out
that the rheumatic complications of dysentery seem to have arisen only
when the latter malady was improperly treated by opium and
astringents; but, howsoever the signs of affinity were called forth,
they may prove to be true indications for the pathology. The
circumstances of taking dysentery are those of taking rheumatic
fever--exposure to chill after being heated with labour[1446]. In
rheumatism the effect of the chill falls upon the great groups of
voluntary muscles, pain being manifested at the surfaces where the
muscular work is applied, namely the joints; while the redness, heat
and swelling are as if restricted to the tissues by which the muscles
become effective, namely the tendons, aponeuroses, ligaments and
synovial membranes[1447]. In dysentery, it may be said, the effect of
the chill falls upon the great involuntary muscle, that of the
intestine, or upon a section of it, a muscle which serves, so to
speak, as its own tendons and insertions, and is the seat of its own
pains, while the tissues next to the muscular, the submucosa and
mucosa with the lymph-follicles, become the seats of congestion,
inflammation and suppuration. In acute rheumatism, the muscles
generate heat without doing any work; in dysentery there is often
febrile heat (although not invariably), and the work of the
involuntary muscle is paroxysmal and ineffective. In some such way the
parallel suggested by Akenside might be followed out.
After 1762, the next period of epidemic dysentery in England was from
about 1779 to 1785, a period when agues also were epidemic, as well as
workhouse fevers and typhus under its various names. In London it was
prevalent in the autumns of 1779, 1780 and 1781, a strictly autumnal
disease like the diarrhoea of children or the cholera nostras of adults.
From the list of symptoms, the latter disease must have formed part of the
dysenteric epidemic:--“profuse watery evacuations, mucous evacuations
mixed with blood, gripings, tenesmus, pain in the back and loins, fever.”
Some had tormina without flux. Some few old and infirm died; but usually
the malady yielded to treatment[1448]. It is heard of also at Liverpool
about 1784[1449], and its prevalence at Plymouth called forth an
essay[1450]. It must have been a considerable disease in the dockyard
towns; for a body of troops, originally numbering 2800, which arrived at
Kingston, Jamaica, in the beginning of August, had been put on board the
transports in March with much dysentery and putrid fever among them, so
that the diseases with which they put to sea became more violent during
the five months’ voyage, and caused many deaths. Arriving at Jamaica, four
hundred were sent on shore sick, exhausted with flux and fever, of whom
scarce the half recovered in the military hospitals[1451]. Here we have
the singular fact of transports from England bringing dysentery to
Jamaica. On the other hand, Clark, of Newcastle, who had seen much of
tropical maladies, says that the dysentery which became epidemic there in
1781 was introduced first into a dockyard by some sailors returned from
abroad ill of the complaint, and that it soon spread among the workmen, of
whom several died. But it was epidemic in London the same year; and in
Newcastle itself there were extensive epidemics in 1783 and 1785, for
which no foreign source was sought or found. In those years it “attacked
great numbers of the poor,” as well as some of the richer class, to which
Clark’s eleven cases from the epidemic of 1785 mostly belong. In the
Tables of diseases treated at the Dispensary, the epidemic dysentery of
1783 and 1785 is credited with 329 cases, of which 17 were fatal; but
these, of course, were but a fraction of all that occurred in Newcastle
and neighbourhood. Every year until 1805 there are a few cases of
dysentery in the Dispensary books; but they become fewer to that year
(except in 1801 when there were 23 cases), and at length disappear from
the list altogether. A remarkable outbreak of dysentery, within narrow
limits, occurred in a fishing village or “town” in the neighbourhood of
Aberdeen during some months of the spring and summer of 1789: “It has
proved fatal to numbers. As such a disease could not be admitted into our
hospital, a temporary one has been fitted up for those that are worst, and
the faculty here have given their attendance by rotation[1452].”
Dysentery in the 19th century.
Willan, who was practising in London as early as 1785-6, says that
dysentery had not been epidemic there from the autumn of 1780, until the
autumn of 1800, his position at the Public Dispensary in Carey Street
enabling him to know the prevalent diseases. In the autumn of 1800 the
epidemic was extensive. There were, he says, some sporadic cases every
autumn, but he never saw a fatal case of it[1453]. In Bateman’s
continuation of the same records from 1804, dysentery first appears in
1805 and remains sporadic every autumn. It was “very prevalent” in the
autumn and winter of 1808, but not fatal; and it was not unusual among the
dispensary patients every year until these records end in 1816[1454]. The
years 1800-02 form one of the more distinct dysenteric periods also for
Ireland and Scotland. Old Glasgow practitioners in the severe epidemic of
1827-28 recalled the fact that they had last seen the disease about 1802,
and the books of the Glasgow Infirmary bore witness to its prevalence from
1800 to 1803 or 1804. In 1801-2 there was a good deal of it also at
Hamilton, among a regiment of dragoons as well as among the people at
large[1455]. The troops in various parts of Ireland suffered from it in
the same years[1456]. In 1808, during a somewhat unwholesome season in
which agues also were met with, some cases of dysentery were admitted to
the General Infirmary of Nottingham[1457]. An altogether exceptional
outbreak of a dysenteric nature occurred in 1823 among the prisoners in
Milbank Penitentiary[1458].
The great dysenteric period of the 19th century coincided with, or
followed, the two hot summers of 1825 and 1826, the latter of which was
probably the hottest and driest summer of the century. Of its prevalence
in and near Leeds in 1825, Thackrah says it was “before almost unknown as
an epidemic to the present practitioners of this district.” In the same
summer it was unusually common in Dublin, and was epidemic the next year
in other parts of Ireland as well (_supra_, p. 271). In Glasgow it began
about the end of July, 1827, in the flat district to the south of the
Clyde, and in the course of the autumn became prevalent in all parts of
the city. An outbreak of plague itself could hardly have caused more
surprise, so strange was dysentery to that generation. A few deaths by it
in one crowded street of the Gorbals were mentioned in a newspaper before
the disease had become general, and “gave rise to that groundless fear
which pervaded and distracted the public mind during the whole course of
the epidemic[1459].”
The symptoms were severe and alarming, but the fatalities were few,
perhaps not more than one in fifty attacks. The proper dysenteric
symptoms usually lasted from ten to fourteen days, and were followed
by diarrhoea, it might be, for many weeks. The morbid anatomy showed
in the mucous membrane of the great intestine the three degrees of
congestion, follicular ulceration and sloughing of the whole mucous
coat (in the sigmoid flexure and rectum). The cases were nearly all
above the age of puberty, and among the poorer classes. September and
October were the worst months. The weather was remarkably close, damp
and relaxing. One practitioner saw two cases of genuine ague in
natives of Glasgow, having never seen a case of ague before. The
ordinary cholera nostras of summer and autumn was much less frequent
than for several years before, and it was the general remark that it
had given place to the dysentery.
Having declined in the winter of 1827-28, it revived in May, and again
reached a great height in the autumn of 1828, while cases of it (probably
chronic, or renewals of old attacks) continued to the summer of 1830. The
following table shows the number of cases treated by the poor’s surgeons
in the several seasons, 1827-30; the 435 cases in the autumn of 1827 were
nearly a third part of all the cases so treated (1462):
_Cases of Dysentery in Glasgow treated by the Surgeons to the Poor._
Quarter 1827 1828 1829 1830
Feb.-April -- 28 29 26
May-July -- 62 35 26
Aug.-Oct. 435 261 50 --
Nov.-Jan. 143 68 22 --
It extended to the villages and country districts all round Glasgow. It
was believed to be somewhat general in Scotland in 1827-28, but the only
answers to a circular of queries sent out by the editors of the ‘Glasgow
Medical Journal’ came from Hamilton (and Bothwell), Ayr and Callander
(including the flooded valley of the Teith and the Braes of
Balquhiddar)[1460].
In Edinburgh the outbreak of dysentery began about the end of July, 1828,
a year later than in Glasgow, just as the epidemic in that city was a year
or more later than in Dublin. Attacks of it were numerous among the
patients admitted to the Edinburgh Infirmary for other diseases; but it
occurred at the same time throughout the city generally and in the country
around; “nor has it been confined entirely to the lower orders.” In the
imperfectly kept register of the Infirmary there were 42 admissions, with
11 deaths, from August to October. Christison, who treated some of these,
had never seen dysentery before[1461]. The morbid anatomy was the same as
at Glasgow--congestions, numerous small ulcerations especially of the
transverse colon, or sloughing of considerable portions of the mucous
membrane.
In the same years 1827-28 there was much dysentery in the Lunatic
Asylum at Wakefield. It is well known that aged paupers in workhouses
or asylums are peculiarly subject to the epidemic influences that
produce diarrhoeal or choleraic sickness; and there had been much of
that disease in the West Riding Asylum from its opening in 1819. Some
cases of dysentery had also occurred, but it was not until after the
exceptional summer of 1826 that they became common. In 1828 there were
55 cases among 375 inmates, mostly in old and incurable lunatics, the
fatalities being at the very high rate of one in four. The morbid
anatomy was that of true dysentery--follicular ulceration in the
transverse colon, with occasional sloughing of large pieces of the
mucous membrane. The whole sewage of the asylum collected in cesspools
or “tanks of ordure” within a few feet of the wards[1462].
The causes of the rare and surprising outbreak of dysentery in 1827-28
were much debated. In Glasgow it was remarked that the choleraic
complaints of the summer and autumn were much less frequent than usual;
also that the first season of it, the year 1827, was remarkable for rain
every day for some months, and for a close, oppressive, relaxing
atmosphere. Brown, of Glasgow, thought the weather might account for it,
the labouring class being thereby made peculiarly subject to heats and
chills, which, grafted upon the usual bowel-complaints of the season,
easily turned them to dysentery. Dr Andrew Buchanan was of opinion that
exhalations from the soil were the chief, if not the sole, exciting cause
of dysentery, reserving the question of contagiousness. Other forms of
miasmatic febrile disease, formerly rare, had, he said, made their
appearance of late years and become epidemic. Christison had already
spoken in the same sense for the Edinburgh outbreak. For five or six
weeks, he said, before the dysentery appeared there in the end of July,
1828, the tendency to bowel affections during the epidemic fever (which
was chiefly of the relapsing type) was increased in a very marked degree.
The same tendency continued throughout the whole progress of the
dysentery; “nay in some instances true acute dysentery was formed during
the height or towards the termination of continued fever; and now that the
dysentery has in great measure disappeared, or assumed a mild form, the
tendency of low gastro-enteric inflammation to accompany continued fever
is very strongly marked, perhaps is more frequent than ever.” This may
relate to a remarkable outbreak of fever among the richer classes in the
New Town of Edinburgh, more talked about than written on, which seems to
have been enteric or typhoid, according to the clinical history of a case
of it that came from Edinburgh to Hamilton and was recorded by a physician
of the latter place[1463]. It was more especially that strange epidemic in
Edinburgh that Dr Andrew Buchanan had in mind when he wrote that the
dysentery of 1827-28 was not the only disease due to exhalations from the
soil with which Scotland had of late been visited[1464]. This is an
instructive line to take in seeking an explanation of the dysentery of
1827-28, even if we keep something of the old doctrine of heats and chills
as affecting those who labour in a damp atmosphere. The ground-water
theory of miasmatic infective diseases was not then formulated; but there
has rarely been in our latitudes so signal an instance of extreme drought
and heat followed by excessive dampness as in the two years 1825 and 1826,
and the year 1827. The second dry year, 1826, was certainly the season
when enteric fever was described and figured for the first time in London.
It was said, also, that enteric cases occurred among the relapsing fever
and dysentery of Dublin in the same year; and enteric cases are known to
have occurred in Edinburgh towards the end of the epidemic of relapsing
fever and dysentery, which was one or two years later in that city than in
Dublin. In Glasgow, where the dysentery was probably a more extensive
outbreak than elsewhere, there appears to have been at that time no
enteric fever; in London, on the other hand, where there was a good deal
of the latter, there does not appear to have been any notable prevalence
of dysentery.
Along with the cholera nostras which was unusually common in the autumn of
1831, just before the outbreak of Asiatic cholera, there was some
dysentery, notably an epidemic at Bolton[1465]. At the end of the Asiatic
cholera of 1832 a succession of cases of dysentery occurred in the
Edinburgh Charity Workhouse[1466].
The next occasion of dysentery was the autumn of 1836, which was, like
that of 1827, a wet season. The outbreak at Glasgow on this occasion is
recorded only in a few figures (the medical journal of the city having
ceased to appear for a time), according to which there were 144 cases
throughout the year treated by the surgeons to the poor, of which 8 were
fatal, and 15 cases sent to the Infirmary, of which 4 were fatal[1467]. At
Dundee also, from October to December, 1836, bowel-complaints were not
unusual among the cases of typhus, which occurred in hundreds. “Many of
the cases of diarrhoea and dysentery,” said Arrott, “occurred in
December, and were accompanied by catarrhal and rheumatic symptoms,
implying an origin distinct from the bilious diarrhoea and bilious
vomiting of summer.” Of 22 cases of dysentery at the Infirmary, 2 were
fatal[1468].
Next year, 1837, there occurred in Somersetshire a remarkable epidemic
which was for the most part dysenteric. It was seen first at Bridgewater,
and in July it caused two deaths at Taunton, where it afterwards prevailed
with high malignancy. Of 223 deaths, 206 were set down to dysentery, 16 to
diarrhoea and 1 to cholera; the high ratio of children’s deaths in the
following table of ages is in accordance with other recent experiences to
be given in the sequel:
Over
Ages 0-5 -10 -15 -20 -30 -40 -50 -60 -70 -80 -90 90
Deaths 93 17 11 7 6 3 7 16 26 24 11 2
The monthly mortalities were, 75 in August, 105 in September, 29 in
October, 10 in November, 2 in December. The epidemic spread partially
amongst the unions around Taunton[1469].
In London from the beginning of registration (1837) until 1846, the deaths
set down to dysentery averaged fully a hundred in the year--a statistical
fact to which there is nothing corresponding in contemporary writings:
Watson said it was hardly ever seen in practice except in the chronic form
among sailors and soldiers who had contracted it abroad. During the
prevalence of the “Irish fever” of 1846-48, the disease was truly epidemic
and a cause of many deaths along with typhus itself, especially in
Liverpool and mostly among destitute Irish. In 1846 it was in Milbank
Penitentiary[1470]. A most instructive instance of its connexion with the
Irish emigration occurred at Penzance in the summer and autumn of 1848.
The brig ‘Sandwich’ sailed from Cork for Boston, U. S., in the end of
May, carrying a number of Irish farmers and their families. Having met
with rough weather and head winds she put in leaky to Penzance on 7
June, sixteen days out from Cork. The provisions had been bad and
there was sickness in the ship, with a very filthy state of things.
Three of the women passengers died on shore of dysentery. The ship
sailed again on 10 July, two more of the emigrants dying of dysentery
before she reached Boston, while two of the crew survived the attack.
On 16 July, two cases of the same disease occurred among the lower
class in Penzance, and thereafter the epidemic spread widely through
most parts of the town and the three adjoining parishes of Madron,
Galval and Paul, causing a great mortality, as in the following table:
_Deaths from Dysentery in Penzance and three adjoining parishes._
1848
Deaths from all
Deaths from Deaths from Total causes in
Dysentery in Dysentery in deaths from Penzance and 3
Penzance town 3 other parishes Dysentery other parishes
July 5 0 5 31
August 37 1 38 71
Sept. 26 12 38 67
Oct. 13 9 22 48
Nov. 1 1 2 31
-- -- --- ---
82 23 105 248
As many as five hundred cases were under medical treatment in the
town. No death occurred there or in the three parishes within the
registration district after 10 November, “but very many in the country
beyond its limits.” Of the 105 deaths in the table, 46 were of young
children, 35 of aged persons, and 24 between the ages of five and
sixty years[1471]. There was no resisting the evidence that an
infection had been introduced by the weather-bound Irish emigrants;
instances were also known of new foci in the country districts having
been created by domestics or others suffering from dysentery who had
been sent from Penzance to their homes. At the same time the summer
had been exceptionally wet, the rainfall having been as follows:
Inches of rain
May 0·777
June 3·287
July 3·277
Aug. 4·972
Sept. 3·042
Oct. 4·425
Nov. 3·981
A singular epidemic of dysentery occurred between the 14th and 26th
September, 1853, among the thirty-six inmates of a row of nine
cottages near the village of Hermiston, five miles west of Edinburgh.
Seven children were attacked, of whom six died, and six adults, who
all recovered. Besides these there were three cases among the four
inmates of a cottage about a hundred yards away, and one case in each
of two houses in the adjacent village of Hermiston. Christison found
that a drain which received the sewage or slops of the hamlet was in a
most offensive state, having been choked probably for years, and that
the water of a well near it was foetid. These are the conditions that
have often caused village epidemics of enteric fever in recent times;
but there was no doubt that the disease in this case was
dysentery[1472]. Another asylum outbreak of dysentery occurred in 1865
in the Cumberland and Westmoreland Asylum[1473].
Perhaps the last general prevalence of dysentery was during the Asiatic
cholera of 1849, when the house-to-house visitations in Leeds and some
other towns brought to light a somewhat surprising number of cases mixed
with the more ordinary bowel-complaints of the season.
It is impossible to trace the subsequent history of dysentery in England
by the usual statistical means of the Registrar-General’s tables of the
causes of death, for the reason that dysentery, a rare and curious disease
of all ages in this country, is merged with diarrhoea, one of the
commonest causes of infantile mortality. However, it is not likely that
any such epidemic outbursts, local or general, as those described for
certain years of the 18th and 19th centuries could have occurred without
their being otherwise known. It may be safely said that there has been
little of it in this country for the last thirty or forty years, except
among a few soldiers, sailors or others returned from abroad; in Ireland
itself, the immemorial “country disease” has now only a small annual total
of deaths.
One of the last experiences of dysentery in an English port was
instructive for the relation of the disease to typhus fever.
On 16 February, 1861, an Egyptian frigate, the ‘Scheah Gehaed,’ sent
from Alexandria to be fitted with new engines, arrived in the Mersey.
The only European on the ship was her commander, an Austrian. She
carried 476 men, mostly Arabs, with a small proportion of Nubians and
Abyssinians. Some two hundred were convicts, who had been brought on
board in chained gangs. The passage had been long and stormy, and
attended with much sickness, dysenteric and diarrhoeal; one man died
and was thrown overboard two or three days before the ship reached
Liverpool. The pilot who boarded her was at once struck by the
horrible state of filth of the ’tween decks; he remained two days on
board, and on returning home said to his wife, “This frigate will be
heard of yet.” He sickened in about a week of malignant typhus and
died. Two others who boarded the ship took typhus, of whom one
recovered. There had been no fever on board during the voyage.
Thirty-two of the Arabs or Nubians were admitted to the Southern
Hospital suffering, most of them, from dysentery or diarrhoea. Typhus
fever attacked 17 of the ordinary patients, 2 nurses, 2 porters, 2
house-surgeons and 2 others in the hospital, of whom several died. The
Arabs &c. to the number of 340 were taken in batches of 80 a day to a
public bath, in which they remained three hours. Typhus broke out
among the bath attendants. The whole number of cases of typhus traced
to the ship was 31, of which 8 were fatal. The ship was sunk in the
graving dock in order to clean her[1474].
This is a classical instance of the breeding of typhus from the effluvia
of dysentery, of which other instances, on a greater scale, have been
given in connexion with the Jamaica expedition of 1655 (in the former
volume), the siege of Londonderry and the camp of Dundalk in 1689, the
hospitals after the battle of Dettingen in 1743, and the Irish famine of
1846-48.