CHAPTER VIII.

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,