At Maidstone in each of the three years 1885, 1886 and 1887, the ground-water rose with the greatest regularity and steadiness to its highest pointtowards the end of the first quarter of the year, and fell with equal steadiness to its lowest point in the autumn. During two of the years there was little diphtheria, and in one of them none. But, in the next two years, 1888 and 1889, “the levels of the ground-water oscillated to and fro with unwonted frequence,” having several maxima in 1888, and a somewhat uniform high level all through 1889; and during those two years there was a severe outbreak of diphtheria, as well as an excessive number of deaths registered as “croup[1381].”The relationship with the ground-water, if any, will probably be found to be more than ordinarily complex; but some connexion is indicated by the remarkable selection of the Fen country of Lincolnshire in 1858. Among the 18th century observations, it was remarked in New England in 1735-36 that the throat distemper was worst near lakes or rivers, as at Newbury Falls, Hampton Falls, and the like. The ill-reputed “Kidderminster sore throat,” was associated with the low situation of weavers’ houses in the valley of the Stour, subject to inundations. Practitioners in many parts of England and Scotland have suspected an association with water, even if it were only a mill dam, in the more recent prevalence of diphtheria[1382].
At Maidstone in each of the three years 1885, 1886 and 1887, the ground-water rose with the greatest regularity and steadiness to its highest pointtowards the end of the first quarter of the year, and fell with equal steadiness to its lowest point in the autumn. During two of the years there was little diphtheria, and in one of them none. But, in the next two years, 1888 and 1889, “the levels of the ground-water oscillated to and fro with unwonted frequence,” having several maxima in 1888, and a somewhat uniform high level all through 1889; and during those two years there was a severe outbreak of diphtheria, as well as an excessive number of deaths registered as “croup[1381].”
The relationship with the ground-water, if any, will probably be found to be more than ordinarily complex; but some connexion is indicated by the remarkable selection of the Fen country of Lincolnshire in 1858. Among the 18th century observations, it was remarked in New England in 1735-36 that the throat distemper was worst near lakes or rivers, as at Newbury Falls, Hampton Falls, and the like. The ill-reputed “Kidderminster sore throat,” was associated with the low situation of weavers’ houses in the valley of the Stour, subject to inundations. Practitioners in many parts of England and Scotland have suspected an association with water, even if it were only a mill dam, in the more recent prevalence of diphtheria[1382].
Diphtheria has affinities in its pathological nature with enteric fever on the one hand and with scarlatina on the other. The process in the throat and pharynx is comparable to the typhoid process in the ileum, which is often a truly diphtheritic process in the second half of the fever[1383]. The affinities to scarlatina are shown best of all in the real ambiguity of diagnosis in some whole epidemics of the 18th century, if not also in the great epidemics ofgarrotilloin the 16th and 17th centuries. Another singular affinity both to scarlatina and to enteric fever lies in the fact that diphtheria, as well as each of these, has been distributed in milk from some particular dairy, and that contamination of the milk by the products of disease upon the cows’ teats has been found to be the relevant thing both for the scarlatina and the diphtheria[1384]. Again, whatever suspicion pertains to slaughter-houses or animal offal for the production of a scarlatinal miasm, pertains to them also for the diphtherial. With such more or less real affinities in the pathology and etiology, it may be made a question whether the recent increase of the death-rate by diphtheria in London and some other places has depended, as if in the way of correlation, upon the decrease in thedeath-rates of scarlatina and of enteric fever[1385]. Diphtheria is perhaps the most obscure and complex of all the infective diseases in its causes and favouring conditions. A certain explanation may seem to suit one outbreak and be wholly irrelevant for another. More particularly there have been innumerable cases for which insanitary surroundings cannot be alleged in any ordinary meaning of the term.
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 betweenthe 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].
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, Sydenhamremarks 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 ofInfants, 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 differedtoto caelofrom 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 of1669
Summer and Autumn of1670
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.
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
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 of1688
Summer and Autumn of1689
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.
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.
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.
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
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
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 in1837. 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]: