sore-throat,” on 19 May, “putrid fever,” and on 26 May, “fever and
ulcerated sore-throat[1291].”

Whether or not we agree with Willan in taking the Foundling epidemic of
1763 (and perhaps with it the general epidemic in London) for one of
scarlatina, it can hardly be doubted that the Foundling epidemic of 1770
was the latter disease, the names of “measles with ulcerated sore-throat,”
“putrid fever,” and “fever and ulcerated sore-throat” clearly indicating
scarlatina anginosa. Grant also records the prevalence of epidemic
sore-throat in London in 1770[1292], and Dr William Fordyce, writing in
1773, dealt with the “ulcerated and malignant sore-throat” as a question
of the day[1293].

    It was not until forty years ago, he says, that they had become
    acquainted in England with ulcerated and malignant sore-throat, while
    “both kinds” are now very common. His aim is to separate the ulcerated
    from the malignant, and he instances an outbreak in a gentleman’s
    house at Islington, where the worst symptoms of the malignant occurred
    in the children, while only the ulcerous prevailed among the servant
    maids. In 1769 it was reported to be seldom fatal in London and
    Westminster, and in the villages around; but within these last twelve
    months (1773) it had appeared of a bad type in high situations such as
    Harrow, in the months of June and July. In a later note, he adds that
    “it still continues to make a havock so considerable as to keep up the
    alarm about it both in the metropolis and all over England,” his own
    last experience of it having been two fatal cases in a noble family a
    few miles to the west of London. Fordyce identified this disease with
    Fothergill’s sore-throat, and described the eruption as “the general
    erysipelatous colour that comes about the second day on the face,
    neck, breast and hands to the finger ends, which last are tinged in so
    remarkable a manner that the seeing of them only is sufficiently
    pathognomonic of the malady [this is a repetition of Huxham and
    Fothergill]; and finally a great number of small pimples, of a colour
    more intense than that which surrounds them, appearing in the arms and
    other parts of the body.” He gives the following as a case of the
    malignant sore-throat in a young gentleman five or six years old:
    “Every part of the body that bore its own weight was gangrened, as
    well as the orifices where he had been blooded twice before I saw him
    (which was three days after the seizure); the parotid glands were very
    much swelled, the whole body was more or less oedematous, and the skin
    throughout of an erysipelatous purple; he died the third day after I
    saw him.”

Although Fordyce, and probably most others, still adhered to Fothergill’s
view of the sore-throat with ulcers as a disease apart, yet there appear
to have been at this date some who followed the line taken with regard to
it by Dr Cotton in 1749. Sometime about the end of 1771 or beginning of
1772, a physician at Ipswich sent to a London physician, who sent it to
the _Gentleman’s Magazine_, an account of a “Successful Method of treating
the Ulcerated Sore Throat and Scarlet Fever,” by tartar emetic, calomel
&c.[1294] He begins: “The ulcerated sore-throat and scarlet fever has been
very rife in this place and the neighbourhood for some months past, and
has been in a considerable number of instances fatal. It has in every
respect answered the description given of it by Dr Fothergill”--so much so
that he does not give the symptoms, but only the treatment, which, in his
own hands, had been singularly successful: “I have had considerably more
than one hundred patients, and have not buried one,” his cases, between
the writing and printing of the paper (3 June) having “increased to near
three hundred with the same success.” This must have been an interval of
mild scarlatina, during which the prevalence of the malady, however
extensive, had attracted little notice. The outburst in 1777-78, from
which the diagnosis and naming of scarlatina anginosa properly date, was
obviously an interruption of a quiet time of the disease.

Scarlatina anginosa in its modern form, 1777-78.

Dr Levison[1295], who was physician to a London charity called the General
Medical Asylum located at No. 4, Tottenham Court-road (afterwards in
Welbeck Street), observed the outbreak, on 15 July, 1777, of a malignant
sore-throat, “nearly such as described by Dr Fothergill and Dr Huxham
(only without the efflorescence and attended with costiveness),” among
children from three to seven years, by which many were cut off in the
space of six to eight days, some by suffocation and others by vomiting of
blood. It became more general in August, and in some was very malignant,
being joined with an erysipelatous inflammation and a diarrhoea. It raged
with great fury in Kentish Town, and at Enfield Chase it swept away many
in twenty-four hours. But on the high ground about London, as at Hampstead
and Highgate, it was of a benign type. It was worse in the villages round
than in the capital itself.

    In the milder form, there was only a superficial whiteness of the
    uvula, tonsils and velum; in the more severe, the same parts were
    beset with thick ulcerations, running very deep in the fauces. Both in
    the milder and in the more severe cases the neck became swollen on the
    second or third day. The commencement was usually with shivering and
    nausea, followed by heat, and an efflorescence over the breast, the
    limbs, and often the whole body, of a crimson red. “Some were spread
    over with a kind of little millets, similar to that in the miliary
    fevers, and which scaled off the skin the sixth or seventh day; in
    which cases the ulcerations were very slight, as also all other
    symptoms of malignancy.” The mouth was apt to be full of sloughs, the
    teeth covered with black crusts. The urine was scanty, high-coloured,
    with a thin suspended cloud. Some bled from the nose. The nostrils
    were apt to be stuffed with greenish sanies, which dropped out
    continually. The efflorescence and sore-throat were often met with
    separately. Most had cough throughout, great dejection of spirits, and
    oppressed breathing. The disease had no regular progress and no
    crisis; the whole of the symptoms would often cease suddenly about the
    eighth or ninth day. In one case there was recovery after three weeks’
    illness. Several cases had suppuration of the glands of the neck. In
    one fatal case, a tumour behind the right tonsil was found to contain
    three ounces of fœtid pus.

Oedema was frequent after recovery--the lips, nose and face bloated,
sallow, shining and greasy; the belly also might be swollen. This, says
Levison, was a peculiar kind of dropsy; and as he adds that it had not
been remarked by Huxham he intends to distinguish it from the bloated
greasy appearance which Huxham did remark. Some died of it a month after
the fever; many recovered from it by the aid of calomel, rhubarb and
diuretics--the treatment for the scarlatinal dropsy--and full doses of
bark. In the acute disease blisters were sometimes tried, in compliance
with custom; but they did no good, and occasioned a great discharge of
thick matter. Bleeding and antiphlogistics were seldom called for. This
outbreak, which began in July 1777, abated in November. Next year it came
back about the middle of March, but in a benign form, and unattended with
either the efflorescence or the diarrhoea, and so continued until the date
of writing, the 11th May, 1778. Levison distinguishes two or three
types--a malignant sore-throat at the outset early in summer, 1777, to
which in autumn two other epidemics were joined, namely, on the one hand,
scarlet fever (or miliary fever), and on the other hand, a purging like
autumnal dysentery.

The second season of the epidemic in London[1296], the spring and summer
of 1778, saw the outbreak of malignant sore-throat, with rash, in the
Midlands. It appeared in Birmingham about the middle of May, and in June
it was frequent in many of the towns and villages in the neighbourhood. It
continued to the end of October, and revived a little during mild weather
after the middle of November. It seems to have reached Worcestershire in
the autumn, cases having been seen first at Stourbridge and afterwards at
Kidderminster and Cleobury. According to Johnstone, the younger, it broke
out first in schools, and spread very rapidly among children, attacking
adults sometimes. The summer of 1778 was remarkable for heat, which is
described as West Indian in its intensity.

The account of this epidemic which has attracted most attention (and
deservedly) is that of Withering, of Birmingham, who had written his
thesis at Edinburgh twelve years before (1766) on _angina gangraenosa_. He
calls it definitely by the name of “scarlet fever and sore-throat, or
_scarlatina anginosa_,” explaining that it was “preceded by some cases of
the true ulcerated sore-throat,” by which he meant the disease described
by Fothergill in 1748. The elder Johnstone, then of Worcester, who had
described the Kidderminster sore-throat of 1750-51, declared that the
scarlet eruption was a more common symptom of this 1778 disease than it
used to be when he first became acquainted with it near thirty years
before; and dealing with the same epidemic as Withering, he makes out
three varieties:--namely, first the scarlatina simplex of Sydenham, with
no sore-throat, second, the scarlatina anginosa, and third, the ulcerated
sore-throat[1297]. His son, who also wrote upon the epidemic of 1778 as he
saw it at Worcester, having written his Edinburgh thesis upon malignant
sore-throat several years before, says: “The disease which now prevails is
the ulcerous malignant sore-throat, combined with the scarlet fever of
Sydenham[1298].” Saunders, a retired East Indian surgeon, described the
corresponding epidemic in the north of Scotland as one of sore-throat and
fever[1299].

Withering’s account of the symptoms differs little from that given by
Levison the year before, and is chiefly noteworthy for confirming that
writer as to the occurrence of scanty urine and oedema[1300]:

    The rash came out on the third day, continued scarlet, the colour of a
    boiled lobster, for two or three days, then turned to brown colour,
    and desquamated in small branny scales. He had been told of three
    instances in which the desquamation was so complete that even the
    nails separated from the fingers. In the colder weather of October the
    scarlet colour was less frequent and less permanent. Many had no
    appearance of it at all; while others, especially adults, had on
    tender parts of the skin a very few minute red pimples crowned with
    white pellucid heads. The worst cases fell into delirium at the
    outset, had the scarlet rash on the first or second day, and might die
    as early as the second day; if they survived, the rash turned to
    brown, and they would lie prostrate for several days, nothing seeming
    to afford them any relief. “At length a clear amber-coloured matter
    discharges in great quantities from the nostrils, or the ears, or
    both, and continues so to discharge for many days. Sometimes this
    discharge has more the appearance of pus mixed with mucus. Under these
    circumstances, when the patients do recover, it is very slowly; but
    they generally linger for a month or six weeks from the first attack,
    and die at length of extreme debility.” These discharges, compared by
    a writer a generation before to glandered secretions, are not to be
    confused, says Withering, with the matter from abscesses on both sides
    of the neck, under the ears, which “heal in a few days without much
    trouble.” The submaxillary glands were generally enlarged. Adults
    usually had a ferretty look of the eyes, and sometimes small circular
    livid spots about the breast, knees and elbows. Some had a succession
    of boils. One man had “lock-jaw.” Most patients had the fauces,
    particularly the tonsils, covered with sloughs, which separated and
    left the parts raw, as if divested of their outer membrane. The most
    troublesome symptom was exulcerations at the sides and towards the
    root of the tongue; these were painful and made it impossible to
    swallow solid food. Some threw out several white ash-coloured sloughs,
    though no such sloughs were visible upon inspecting the throat.

With reference to the diagnosis between scarlatina anginosa and angina
gangraenosa (of Fothergill) Withering says: “They are both epidemic, they
are both contagious; the mode of seizure, the first appearances in the
throat, are nearly the same in both; a red efflorescence upon the skin, a
great tendency to delirium and a frequent small unsteady pulse are
likewise common to both. With features so strikingly alike, and these,
too, of the most obvious kind, is it to be wondered that many
practitioners considered them the same disease?” And again: “But perhaps
he will never be able precisely to draw the line where the light begins
and where the penumbra ends[1301].”

The extent of the epidemic of scarlatinal sore-throat, of which we have
particulars from Middlesex, Warwickshire and Worcestershire in 1778,
cannot be ascertained. It is heard of, as we saw, in the north of Scotland
in 1777. According to Barker, of Coleshill, the scarlet fever which “in a
manner raged in the neighbouring town of Birmingham,” occurred in only a
few cases in his own parish, and these mild[1302]. It appears to have been
in Carlisle the year after, 1779, under which date Heysham says that “two
epidemics swept off a great number of children--smallpox and a species of
scarlet fever[1303].” Nothing more is heard of it in Carlisle for the next
eight years, during which Heysham kept an account of the diseases. The
epidemic of 1778-9 fell also upon Newcastle:

    From the month of June, 1778, until the 1st September, 1779, there
    were treated 146 cases of “ulcerated sore-throat,” of which 18 were
    fatal. The epidemic was at its height in September and October. The
    ages were: under ten years, 98, ten to twenty, 25, twenty to thirty,
    18, above thirty, 5. Dropsy followed in 23; 75 were mild scarlatina
    and sore-throat, 33 were angina maligna. During the ten years
    following, until 1789, only 57 more cases were treated from the
    Newcastle Dispensary, of which 8 were fatal[1304].

History of Scarlatina after the Epidemic of 1778.

In London, according to Dr James Sims, scarlatina with sore-throat
occasioned a great mortality in the latter half of 1786. The bills of
mortality assign only 19 deaths to sore-throat, while they give 793 for
the year to measles. But Sims says that “measles were not present in
London during the whole year; at least I saw none, and I saw about two
thousand cases in private and at the General Dispensary.”

The deaths from scarlet fever, he thinks, had been given under measles and
also under “fevers,” which were a large total for the year. The epidemic
was very virulent, going through families; many lost two children, some a
larger number; many adults fell victims to it who were supposed to die of
common fever.

    Sims’ first case was of a youth at Camberwell, in March, with scarlet
    rash and sloughs of the throat. He saw no more cases for several
    weeks, and then, on 1 May, he was called to a case of sore-throat in a
    school at Hampstead; the illness was slight, and there was no
    efflorescence; but in June there occurred in the same school an
    explosion of scarlatina, twenty of the girls being seized within a
    short time. It was in other suburban villages in the summer, but did
    not enter London until August, after which Sims saw three hundred
    cases of it; of some two hundred treated by him in a certain way, only
    two died. The symptoms of the epidemic were the usual ones of scarlet
    fever with ulcerated or sloughing throat. In November and December,
    swelling attacked the face and extremities, which were painful but not
    oedematous. The parotids were swollen. Several had the angina without
    the rash; others the rash without the angina[1305].

The same epidemic in London was one of the early medical experiences of Dr
Robert Willan, who gave some account of it in the volume ‘On Cutaneous
Diseases’ which he published in 1808, shortly before his death[1306]. It
began in the autumn of 1785, was superseded by measles for a time, and
revived again in 1786, to last into 1787. It was most malignant in the
narrow courts, alleys and close crowded streets of London, but existed
also in the villages near. While admitting the existence of measles in the
winter of 1785-86, he confirms Sims in saying that it was not measles (as
in the Bills) but scarlatina that caused the high mortality in 1786: “The
cases of scarlatina during the year 1786 exceeded in number the sum of all
other febrile diseases within the same period.” The deaths were mostly
between the seventh and eighteenth day of the fever. The following is his
classification of over two hundred cases seen by himself:

    1786

                 Scarlatina   Scarlatina   Scarlatina    Sore-throat
                  simplex      anginosa      maligna    without eruption

        April       --            3            --            --
        May          6           10             2            --
        June         4           12             1             4
        July         2           11             1             3
        August       1           17             4             4
        Sept.        2           29             9            12
        Oct.         3           24             5             7
        Nov.         0           38            12            10
        Dec.         0            8             5             2
                    --          ---            --            --
                    18          152            39            42

    The infirmary book of the Foundling Hospital has long lists of
    patients sick of “scarlet fever with sore-throat” in August and
    September, 1787, as many as 76 being under treatment in one week, the
    next week 39 sick of scarlet fever, besides 45 recovering from it.
    This is the first unambiguous entry of an epidemic of scarlet fever in
    the Foundling Hospital records[1307]. Under the same year, 1787,
    Barker, of Coleshill, records “scarlet fever, smallpox, and chincough”
    in a neighbouring city, as well as pestilential sore-throats
    “epidemical everywhere in the terrible foul weather of winter.” His
    next entry of “scarlet fever and sore-throat” is under the year
    1791[1308].

    An account by Dr Denman, of London, dated 28 November, 1790, of “a
    disease lately observed in infants,” but otherwise unnamed, appears to
    relate to diphtheria. Eight cases in young infants were seen, one per
    month from April to October, of which six proved fatal. The signs were
    “thrush in the nose,” fulness of the throat and neck, the tonsils red,
    swelled, and covered by ash-coloured sloughs or extensive ulcerations.
    The skin sloughed at places where blisters were applied. Nothing is
    said of a scarlet rash[1309].

Scarlatina (1788) and Diphtheria (1793-94) described by the same observer.

One good observer at the end of the 18th century, Rumsey, a surgeon at
Chesham, in Bucks, has left full accounts of two epidemics in his
district, one in 1788, which he calls “epidemic sore-throat[1310]” and the
other in 1793-94, which he calls “the croup[1311].” The one corresponds to
scarlet fever, the other to diphtheria. The author does not think it
necessary to enlarge on the distinction between the “epidemic sore-throat”
and “the croup” as it was so obvious; yet the former was “Fothergill’s
sore-throat,” which some English writers of the present time assume to
have been diphtheria; while the disease which Rumsey calls “the croup”
corresponds with laryngeal and tracheal diphtheria, not unmixed with
diphtheritis of the tonsils, uvula and velum. There is hardly anything in
the history of scarlatina and diphtheria more instructive than the
juxtaposition of those two excellent descriptions by Rumsey, who grudged
the name of scarlatina to the former epidemic because the rash was not
invariable, and called the latter by the name of croup although it was not
confined to the larynx and trachea, and was epidemic in the summer months.

The epidemic of “sore-throat” in 1788 began in April and lasted until
November, attacking those of every age except the very old, but especially
children, and mostly women among adults.

    The throat was slightly sore for twelve or twenty-four hours; it then
    became fiery red, the uvula and tonsils being much swelled. About the
    second or third day there were whitish or yellowish sloughs on the
    tonsils and uvula, which in many cases left deep, ragged ulcers. It
    was many days before the sloughs were all exfoliated. Some spat up an
    astonishing quantity of mucus; in young children there was apt to be a
    discharge of mucus from the nostrils, and in a few cases from the
    eyes. The parotid and submaxillary glands were often enlarged,
    sometimes suppurating or sloughing. A white crust separated from the
    tongue on the third or fourth day, leaving it raw and red. In some
    cases there was sickness with vomiting, in some diarrhoea. In many
    cases there was a scarlet eruption over the whole body, usually on the
    second or third day. The fatal cases had all a very red eruption, and
    the skin burning to the touch. In some the eruption was so rough as to
    be plainly felt. In a few cases, after the efflorescence broke out, a
    number of little pustules made their appearance about the breast,
    arms, &c., of about the size of millet seeds, which died away in
    twenty-four or thirty-six hours. This was not common; but in one
    family the mother and three of the four ailing children had pustules.
    One young man had large white vesicles on the sixth day; another young
    man, in November, had vesicles on the arms, thighs and legs as large
    as a half-crown piece, filled with yellow serous fluid, or gelatinous
    substance, with a good deal of erysipelas round them. The red
    efflorescence was always followed by peeling. Many had the
    throat-disease without rash, but none had the efflorescence without
    the sore-throat.

Rumsey decides against two distinct types of disease; it was the same
contagion acting on different constitutions; yet he could not help
thinking that scarlatina anginosa was an improper term for it, inasmuch as
the rash was not constant. It was a less putrid disease than that
described by Fordyce in 1773 (_supra_, p. 707), and carried off but few
considering the great numbers who were affected by it. Two of the
fatalities in children were from the anasarca of the whole body, with
scanty urine, which came on a week or two after. He bled only once,
applied leeches to the temples in several, and saw many recoveries with no
treatment but topical applications.

The epidemic five or six years after in the same town in a valley of
Buckinghamshire and on the hills for some six miles round was something
unusual. Rumsey had about forty cases of “the croup” from March, 1793,
until January, 1794; whereas his father, who had practised there above
forty years, could not recall more than eight or ten cases of “croup” in
all his experience. The cases were all in children from one to fourteen
years; there were sometimes three attacked in one family; most of the
fatal cases occurred in summer; the epidemic was distributed impartially
in the valley where Chesham stands and upon the hills enclosing it. Rumsey
gives full details of seventeen cases, eight that died and nine that
recovered, with post-mortem notes for some.

    His first case was in March, 1793; then came a succession of cases
    about June and July, of which four that proved fatal were in children
    just recovered from measles. All those earlier cases had the disease
    coming on insidiously, then the peculiar cough and tone of voice, if
    any voice remained, paroxysms of choking, expectoration of shreds of
    membrane, giving relief to the distress, and the trachea found after
    death lined with a coagulated matter[1312]. Among these summer cases
    were three children in one family, of whom two died, both being just
    out of the measles. The later series of cases in the winter of 1793-94
    were less often fatal; the epidemic constitution, he says, became less
    severe towards the end; he also used mercurials freely on the later
    cases; but it is farther noteworthy that “most of the cases which
    occurred in November and afterwards, were attended with inflammation
    and swelling of the tonsils, uvula and velum pendulum palati, and
    frequently large films of a whitish substance were found on the
    tonsils”--so that the disease was in its extension more than cynanche
    trachealis, or croup, even if it had not been also an epidemic
    infection.

In only one case, the eighth recorded, does he seem to have hesitated
between “the croup” and sore-throat: “ulcerated sore-throats being at this
time [6 Sept. 1793] somewhat prevalent, induced me to inspect the fauces,
and I observed a swelling and no inconsiderable ulcer on the left tonsil.”
It was in the autumn and winter that these throat complications of “the
croup” mostly appeared; and it was because he found “so much disease about
the tonsils” in the tracheal and laryngeal cases that he forebore to
bleed, and used mercurials. Also in the same season when “the croup” was
joined to disease of the tonsils, uvula and velum, there was a certain
epidemic constitution prevalent: “In the autumn, likewise, and winter,
many children suffered by erysipelatous inflammation behind the ears, in
the groins, on the labia of girls, or wherever the skin folded, attended
with a very acrid discharge”--precisely the complication of the
“throat-distemper” of America described by Douglass and Colden as well as
by Bard, also of the Irish throat-epidemic in 1743 mentioned by Rutty, of
the morbus strangulatorius in Cornwall described by Starr, and of the
sore-throat described by Fothergill. In systematic nosology, do the
corrosive pustules behind the ears, in the groins, labia, &c., belong to
scarlatina or to diphtheria?

It is perhaps the same juxtaposition, or intermixture of scarlatina
anginosa and diphtheria, that we find in the north of Scotland about the
same time of the 18th century. Various parish ministers who contributed to
the first edition of the _Statistical Account_ make mention of “the putrid
sore-throat” about 1790 and 1791, without any reference to fever or
scarlet rash. The following relates to three localities in Aberdeenshire:

    New Deer: “In the autumn of 1791, a putrid kind of sore-throat, which
    first made its appearance about the coast side, found its way into
    this parish. Since that, it has continued to rage in different places
    with great virulence and little intermission, and is peculiarly fatal
    to the young and people of a full constitution[1313].” Crimond, a
    coast parish: “The putrid sore-throat raged with great violence two or
    three years ago [1790 or 1791] in most parishes in the neighbourhood,
    and carried off great numbers: but though a few were seized with it in
    Crimond, none died of that disorder[1314].” Fyvie, an upland
    parish:--“There has been no prevalent distemper for some time except
    the putrid sore-throat, which raged about two years ago [probably
    1791] and proved fatal to several people. It has appeared this winter,
    but is not so violent as formerly[1315].”

From Aberdeen the epidemic is reported in a letter by one of the
physicians, in May, 1790, in such terms as not to imply that it was
scarlatina: “The malignant sore-throat has been most prevalent and very
fatal, no period of life being exempted.” In children from six months to
three years there was observed a livid appearance behind the ears which,
in seven or eight cases, spread over the external ear, causing the latter
on one or both sides to drop off by sloughing before death[1316].

The scarlet fever, with sore-throat, which reappeared in London about
1786-87 (and at Chesham in 1788) is said to have been somewhat steady
until 1794. Willan, who began his exact records in 1796, says
retrospectively that the scarlet fever with an ulcerated sore-throat had
been prevalent every autumn from the year 1785 to 1794, “and proved
extremely fatal[1317].” Lettsom gave a particular account of it in the
spring of 1793[1318]; it was seen first in the higher villages about
London, gradually descended into lower situations, and visited the
metropolis pretty generally about the end of February. “It has been
remarked for many years that this disease appears in the vicinity of
London before it visits the metropolis,” beginning often among the
numerous boarding-schools in the suburbs, to be carried thence by the
dispersion of pupils to their homes. In some villages private families
suffered greatly; in a few Lettsom heard of half the children dying, as
well as of deaths among the domestics and other adults. The same epidemic
of 1793 also called forth one of the numerous essays of Dr Rowley, who had
written on the “malignant ulcerated sore-throat” in 1788[1319].

Scarlatinal Epidemics, 1796-1805.

The history of scarlatina in London, as of most epidemic maladies, is
enriched for a few years by Willan’s monthly or quarterly accounts of the
cases treated at the Carey Street Dispensary. From the beginning of 1796
to the end of 1800, scarlet fever is hardly ever wanting, and is
occasionally the principal epidemic. It is only now and then, however,
that a death from it appears in the Parish Clerks’ bills of mortality.
Willan remarks that they gave only one death from that cause between the
8th and 29th November, 1796, “a period during which there occurred many
fatal cases of that disease.” The bills have only three deaths from it in
the quarter 27 Sept.-27 Dec. 1796. The Parish Clerks did not adopt scarlet
fever fully into their classification until 1830; long after it had become
an important factor in the mortality, they placed the deaths from it under
“fevers” or under “measles.” According to Willan’s experience, it must
have been as common as measles from 1796 to 1801. It was, he says, always
most virulent and dangerous in the month of October and November, but
generally ceased on the first appearance of frost. He records a spring
epidemic as an exceptional thing in 1797: “Since the beginning of May, the
scarlatina anginosa has become more frequent than any other contagious
disease, both in town and in many parts of the country; the disease has
generally occurred in its malignant and fatal form, which, at this season
of the year, is very unusual.” The bills give only one death from 18th
April to 18th May. Willan says that it was rife again in the autumn of
1797 and of 1798. Dr James Sims, who had described the scarlatina of
London in 1786, found the epidemic in the end of 1798 so different from
the former, and attended with so great fatality, that he made it the
subject of a second paper[1320]. It was preceded in the winter and spring
of 1797-98 by a remarkable epidemic among the cats of London (an angina,
with sanious discharge from the nostrils and running at the eyes), which
killed “myriads” of them[1321]. In Sept.-Oct. 1798, he heard that a
scarlet fever had been fatal to some adults about South Lambeth, and
afterwards to several children there, five dying in one family and three
in another. The swellings on each side under the jaw were so great as to
force the chin up into the horizontal; there was much acrid foetid
discharge from the nostrils, the pulse sank about the seventh day, and the
scarlet eruption remained out until near death, which took place usually
about the ninth or tenth day. Along with this malignant type, a mild or
simple scarlatina was also prevalent. Sims wrote when the epidemic seemed
to be “in its infancy,” and so it proved; for Willan describes it as
prevailing to the end of 1798 and rising still higher in the first months
of 1799, his report for February and March being: “Scarlatina anginosa in
its malignant form has been very prevalent, and has proved in many
instances fatal; and in those who recovered, it produced after the
cessation of the fever, anasarca, swelling of the abdomen, swelling of the
lips and parotid glands, strumous ophthalmia, with an eruption of the
favus, and hectical symptoms of long duration. The disease spread from
London to the adjacent villages, and was almost universal in Somers Town
during the month of February.” It continued throughout the year, and into
1800, being second in importance among the epidemic maladies only to
typhus, which, in that time of distress, was the grand trouble of the
poorer classes in London. Willan’s reports cease with the year 1800; but
it appears from other sources that a very malignant scarlet fever and
sore-throat prevailed in London in the summers and autumns of 1801 and
1802, becoming milder in 1803[1322], and in various parts of England
during the same three years. The provincial accounts for those years give
the impression that this was the first general outbreak for some time,
perhaps since the one described by Withering and others in 1778; and that
is also suggested by the statistics of the Newcastle Dispensary: in the
two first years of its practice, from 1 October, 1777, it treated 146
cases, with 18 deaths; in the next ten years 1779-1789, it treated only 57
cases, with 8 deaths; and from 1790 to 1802, it treated 152 cases, with 7
deaths[1323]. Accounts of very general scarlatina come from various
parts of England. In the summer and autumn of 1801 it ran through many
parishes of Cornwall, sparing others. In the parish of Manaccan, twelve
out of the twenty-five burials in the year 1801 were from scarlatina--the
malignant or putrid form, which was often fatal before the third day. In
many other cases, the first untoward symptom was the dropsical swelling
which came on as the fever went off. Three years after, in 1804, there was
much scarlatina in and around Falmouth[1324]. In 1805 it caused 12 in a
total of 20 deaths in Revelstoke parish, South Devon.

In Northamptonshire in 1801 it was observed “in a form similar to the
epidemic described by Dr Withering[1325].” At Cheltenham in 1802 it was
also compared to the epidemic described by Withering: “in consequence of
the number of persons who have gone through the disease, it has for this
month past (20th December) been gradually on the decline[1326].” At Derby,
in 1802, it had been the prevailing complaint in the last eight months of
the year[1327]. In the district of Framlingham, Suffolk, in 1802-3, it had
proved very malignant and fatal in many families[1328]. It is heard of
also from Lancaster[1329], and from various other parts of England, being
casually mentioned in reports on the influenza of 1803.

To this period also belong several incidents of a kind that had attended
scarlatina from its first appearance, namely, school epidemics of it. One
of these was an outbreak in the Quaker boarding-school for boys and girls
at Ackworth, in Yorkshire, in 1803. Although many of the children
dispersed, yet no fewer than 171, in a total of 298 on the roll, were
attacked with scarlatina in the course of four months, of whom seven
died[1330]. In the same year Dr Blackburne published a treatise on the
preventive aspect of the disease, with directions for checking the spread
of it “in schools and families[1331].” It broke out in 1804 among the boys
in Heriot’s Hospital, Edinburgh, and in the city generally in 1805[1332].
Ferriar makes mention of a “destructive epidemic of scarlet fever” in
Manchester in 1805, which he supposed to have been introduced from
Liverpool[1333].

The general prevalence of malignant scarlet fever in the first years of
the 19th century is farther shown by the accounts from Ireland, which were
recalled by Graves in a clinical lecture of the session 1834-35, during
the prevalence of a scarlet fever as malignant as that of thirty years
before[1334].

    “In the year 1801,” he says, “in the months of September, October,
    November and December, scarlet fever committed great ravages in
    Dublin, and continued its destructive progress during the spring of
    1802. It ceased in summer, but returned at intervals during the years
    1803-4, when the disease changed its character; and although
    scarlatina epidemics recurred very frequently during the next
    twenty-seven years, yet it was always in the simple or mild form, so
    that I have known an instance where not a single death occurred among
    eighty boys attacked in a public institution. The epidemic of
    1801-2-3-4, on the contrary, was extremely fatal, sometimes
    terminating in death (as appears by the notes of Dr Percival kindly
    communicated to me) so early as the second day. It thinned many
    families in the middle and upper classes of society, and even left not
    a few parents childless. Its characters seem to have answered to the
    definition of the scarlatina maligna of authors.”

The long immunity from malignant scarlatina which Graves asserts for
Ireland after 1804, is made probable also for England and Scotland after
1805, by the fewness of the references to it in medical writings. Bateman
in 1804 resumed the regular reports on the prevalent diseases of London,
which Willan had left off at the end of 1800, and continued them until
1816[1335]; but he makes very few references to scarlatina compared with
his predecessor. The two occasions when it is said to have been somewhat
common were in 1807-8, during the severe epidemic of measles (and then it
was “generally mild, presenting the eruption with a slight sore-throat”),
and in 1814 when it was “very prevalent” along with measles. In Scotland
during the same epidemic of malignant measles, in 1808, scarlatina was
only occasional, and mild. It is heard of in its old malignant form from
two localities of England, during the time of distress and typhus fever in
1810-11. At Nottingham it was “very prevalent, passing through whole
families,” in September, 1810, and in October became more violent and
often fatal[1336]. In the district around Debenham, in Suffolk, where it
was last reported by the same observer in 1803, it made its appearance in
February, 1810, in its very worst forms, causing deaths of children and
adults in many houses, and destroying some children within forty-eight
hours from the first attack. “All the surgeons for ten miles round have
had to attend to scarlatina maligna in a variety of cases in all ages,
from infants to fifty and sixty years.” It was still raging in October,
1810, and was breaking out “in different spots around this country, that
appear to have had no communication with the afflicted[1337].”

It is not until 1831 that we begin to hear much of malignant scarlatina
again. But it is clear that scarlet fever was common enough all through
that interval, probably in its milder form. It was now the usual epidemic
trouble of schools. In September and October, 1814, there were fifty-five
cases, mostly mild, in children and two in adults in the Asylum for Female
Orphans at Westminster[1338]. In 1812 it was among the cadets in the Royal
Military College at Marlow, having been followed by anasarca in only one
instance[1339]. Heysham, whose exact records of epidemics at Carlisle were
made twenty or thirty years earlier, mentions casually in 1814 that
scarlet fever had been “more frequent of late,” but that it did not spread
as formerly[1340]. Other references to it in this interval are to show how
seldom fatal it was under the cold water treatment or the lowering
regimen[1341]. At the Newcastle Dispensary fully twice as many cases of
scarlatina were attended in the twenty-five years 1803-27 (795 cases) as
in the twenty-five years 1777-1802 (355 cases); but in the larger total,
which an increasing population might account for, there were actually
fewer fatalities (30) than in the smaller (33); the highest number in any
one year was 71 in 1824, of which every one is entered as having
recovered. This is the impression derived from various sources--that the
scarlatina from about 1803 until about 1830 may have been frequent, but
that it was mild, or easily treated, or not often fatal. Macmichael,
writing in 1822, not only testified that the “scarlatina of last summer
was very mild,” but argued that the malady in general was taken by many in
those years in so mild a form that it was not recognized as scarlatina, “a
name that sounds so fearfully in the ears of mothers,” and a rare disease
in families compared with measles or even with smallpox. His point is that
scarlet fever was in fact as nearly universal as measles, but that, as it
was often extremely slight, it passed for rose rash or the like; at the
same time he identified these slighter forms with true scarlatina by
simply pointing to the oedema which might follow them[1342].

The testimony of Graves, of Dublin, who occupies many pages of his
‘Clinical Medicine’ with the disastrous scarlatina in various parts of
Ireland about 1834, is conclusive that the severe type was new in the
experience of that generation:

    “I have already mentioned that the disease called scarlet fever
    assumed a very benign type in Dublin soon after the year 1804, and
    continued to be seldom attended with danger until the year 1831, when
    we began to perceive a notable alteration in its character, and
    remarked that the usual undisguised and inflammatory nature of the
    attack was replaced by a concealed and insidious form of fever,
    attended with great debility. We now began occasionally to hear of
    cases which proved unexpectedly fatal, and of families in which
    several children were carried off; still, it was not until the year
    1834 that the disease spread far and wide, assuming the form of a
    destructive epidemic[1343].... Many parents lost three of their
    children, some four, and in one instance which came to my knowledge,
    five very fine children were carried off.” The severe cases were mixed
    with others of scarlatina simplex. The violence of the attack lay in
    the throat-affection, the congestion of the brain, or the irritability
    of the stomach and bowels, nausea, vomiting and diarrhoea being early
    symptoms, as in the malignant sore-throat with rash a century before.

Graves proceeds, with much candour, to show how mistaken had been the
reasons assigned equally for the mild type of scarlatina between 1804 and
1831 and for the severe type of it previous to 1804:

    “The long continuance of the period during which the character of
    scarlet fever was either so mild as to require little care, or so
    purely inflammatory as to yield readily to the judicious employment of
    antiphlogistic treatment, led many to believe that the fatality of the
    former epidemic was chiefly, if not altogether, owing to the erroneous
    method of cure then resorted to by the physicians of Dublin, who
    counted among their numbers not a few disciples of the Brunonian
    school; indeed, this opinion was so prevalent, that all those whose
    medical education commenced at a much later period, were taught to
    believe that the diminished mortality of scarlet fever was entirely
    attributable to the cooling regimen and to the timely use of the
    lancet and aperients, remedies interdicted by our predecessors. This
    was taught in the schools, and scarlet fever was every day quoted as
    exhibiting one of the most triumphant examples of the efficacy of the
    new doctrines. This I myself learned--this I taught: how erroneously
    will appear from the sequel. It was argued, that had the cases which
    proved fatal in 1801-2 been treated by copious depletion in their very
    commencement, the fatal debility would never have set in, for we all
    regarded this debility as a mere consequence of previous excessive
    reaction. The experience derived from the present [1834-35] epidemic
    has completely refuted this reasoning, and has proved that, in spite
    of our boasted improvements, we have not been more successful in
    1834-5 than were our predecessors in 1801-2.”

From 1829 to 1833 there are numerous references to the scarlatina maligna
in England and Scotland: at Plymouth[1344] in 1829, Bridlington[1345] in
1831, Baddeley Green, Brown Edge, and other places in Staffordshire[1346]
in the summer of 1831, Beaconsfield, Bucks[1347], in 1832, Edinburgh[1348]
in 1832-1833. It is in 1830 that scarlet fever begins to have a line to
itself in the old and inadequate bills of the Parish Clerks of London, the
deaths that year being 94; in the next seven years they are 143, 388, 481,
523, 445, 261 and 189. In 1835 we begin to have statistics of the deaths
from it in Glasgow[1349] for five years, during which they fell much below
the deaths from either measles or smallpox.

_Deaths from Scarlatina in Glasgow._

        Under one  1-2  2-5  5-10 10-20  20-30  30-40  40 and up.  Total

  1835      27      50   89   73    23     7      2        2        273
  1836      34      57  136   86    25     9      5        3        355
  1837       4       9   34   22     5     3      1        1         79
  1838       3      15   42   17     7     1      1        1         87
  1839      29      45  104   74    10    --     --       --        262

The two first years of this period, which had the most scarlatina deaths,
correspond to the years of the Dublin epidemic, and were also the years
when it was common in Edinburgh[1350]. Probably the smaller mortality of
Glasgow in 1837 and 1838 was general; for, when registration of the causes
of death began in England and Wales in the latter half of 1837, it found
the scarlatina mortality at a much lower figure than it reached in 1839
and continued to keep thereafter.

Scarlatina since the beginning of Registration, 1837.

The first returns of the causes of death under the new Registration Act
happened to correspond with a great epidemic of typhus fever, and with an
equally great epidemic of smallpox which took its victims in largest part
among infants and young children. The deaths from scarlatina were also
considerable during those two years and a half; but in 1840 scarlatina
nearly doubled its mortality, and continued year after year for a whole
generation to be the leading cause of death among the infectious maladies
of childhood. The figures for England and Wales are given in a table at p.
614, in comparison with the annual deaths by smallpox, measles, and
diphtheria. The enormous number of deaths from scarlatina during some
thirty or forty years in the middle of the 19th century will appear in the
history as one of the most remarkable things in our epidemiology. There
can be no reasonable doubt that this scarlatinal period was preceded by a
whole generation with moderate or small mortality from that disease, just
as it is now being followed by annual death-rates which are less than a
half, perhaps not more than a third, of the average during forty years
before 1880.

The first great epidemic all over England was in 1840 (it had reached a
maximum in London the year before), another came in 1844, a third in 1848
(in which the London death-rate was 2·12 per thousand living). In the next
decennial period, 1851-60, the worst years for scarlatina were 1858-59,
which were also the years of the return of diphtheria; in the period
1861-70, the great scarlatinal years were 1863-64 and 1868-70; in the
period 1871-80, the year 1874 was the epidemic year. The annual average
death-rates per million inhabitants in all England and Wales were as
follows in four decennial periods:

  1851-60      832
  1861-70      972
  1871-80      716
  1881-90      338

In the greatest epidemic years since 1863 the death-rates per million for
the whole country have been:

  1863      1498
  1864      1443
  1868      1020
  1869      1275
  1870      1461
  1874      1062

In those years scarlatina made from four to six and a half per cent. of
the deaths from all causes.

While no county of England has been free from this infection, the bulk of
the deaths have fallen upon the capital, the great Lancashire and West
Riding towns, the Black Country of Staffordshire with Warwickshire, the
mining districts of Durham and South Wales, and, in the earlier part of
the period, upon the south-western counties.

_Highest Mortalities by Scarlatina in three Epidemics._

                      /-----------\     /-----------------\
                       1863   1864       1868   1869   1870      1874

  England and Wales   30475  29700      21912  27641  32543     24922
  -------------------------------------------------------------------
  London               4955   3244       2916   5841   6040      2648
  Lancashire           4580   4854       4445   4890   3702      6404
  West Riding          2218   3135       1676   2870   3718      3779
  Durham               1216    403       2678   1512    983      1941
  South Wales           501   1990        285    804   1370      1388
  Staffordshire        1147   1134        943   1198   1064      1270
  Devonshire            778   1054         60    155    646        72
  Cornwall              995    572        254    161    587        50
  Somerset              773   1013         55    154    584       173

In Lancashire and South Staffordshire there has been less fluctuation of
the mortality from year to year than elsewhere. The stress of an epidemic
has not fallen equally on all the principal centres in the same year or
years: thus Durham has had the epidemic in advance of other centres, while
South Wales has had it in arrear. The decline of the south-western
counties from their leading position in 1863-64 has been remarkable.
Plymouth, Devonport and Stonehouse, which had contributed most to the high
scarlatinal death-rate of Devonshire in 1863-64, were found on the average
of the next decennial period to have low rates from scarlatina, but
death-rates from measles which were unapproached in any other region of
England. In the following table four Devonshire towns are compared with
certain Staffordshire registration districts in which the scarlatinal
death-rate has remained high.

_Annual average Death-rates per 1000 living, 1871-80._

                 All causes   Scarlatina   Measles

  {Plymouth         22·63        ·25        1·13
  {E. Stonehouse    28·23        ·33        1·79
  {Stoke Damerel    20·42        ·37        1·19
  {Exeter           24·99        ·50         ·82

  {Stoke-on-Trent   25·80       1·22         ·49
  {Wolverhampton    22·78       1·05         ·35
  {Walsall          22·82       1·21         ·30
  {Dudley           24·24       1·18         ·59

This looks like a correlation between measles and scarlatina. The
excessive death-rate from measles in Plymouth, Stonehouse and Devonport
was due to a disastrous epidemic in the last two years of the decennium,
1879 and 1880 (338 deaths at Plymouth, 121 at Stonehouse, and 235 at
Devonport). Measles remained high in Plymouth all through the next
decennium, scarlatina still continuing low until the very end of it, when
in 1889 there was a mortality of 270, equal to a death-rate of 3·39 per
1000 living. In like manner Stoke-on-Trent had its great epidemic of
measles in 1888, causing 342 deaths, or a rate of 2·8. The high Plymouth
death-rate, after nearly twenty years with extremely little scarlet fever,
was surpassed in 1882 by an epidemic of 346 deaths in the colliery
townships of Aberystruth and Tredegar, Monmouthshire, equal to a
death-rate of 6·1 per 1000. Other high death-rates for single years were
at Wakefield and Swansea in 1889 and at Neath in 1890. The highest
death-rates from scarlatina on an average of ten years, 1871-80, were at
Durham 1·70, Todmorden 1·64, Auckland 1·63, Gateshead 1·60, Sheffield
1·49, Leigh 1·41, Wigan 1·30, Newcastle 1·28. The purely agricultural
counties have the lowest death-rates[1351].

As to age-incidence, the proportion of deaths under five has been almost
exactly two-thirds steadily for the last four decennial periods (supra p.
625). The following table by Dr Ogle, the Superintendent of Statistics,
shows both age and sex of the scarlatina mortality[1352]:

_Mean annual Mortality from Scarlet Fever per million living at successive
age-periods 1859-85. England and Wales._

  Age            Males    Females

  0-1            1664      1384
  1-2            4170      3874
  2-3            4676      4491
  3-4            4484      4332
  4-5            3642      3556
  0-5            3681      3482
  5-10           1667      1613
  10-15           346       381
  15-20           111       113
  20-25            59        77
  25-35            36        58
  35 and upwards   13        15
  All ages        778       717

From certain hospital statistics on a large scale, and some figures of
cases and deaths at Christiania, it was also found that the attacks of
scarlatina were much more fatal in the first years of life, the fatality
decreasing rapidly after five. This was only to be expected. But it was
somewhat surprising to find that more girls were attacked than boys, while
the fatalities among boys were more than among an equal number of girls at
all ages until womanhood, when the few females attacked by scarlatina had
more fatalities among them than the somewhat fewer males of the same ages.
A slight excess of fatality in the female sex over the male between the
ages of ten and twenty years, is shown also for smallpox by the table at
p. 618. Recent notifications of infectious diseases to medical officers of
health have enabled a comparison to be made between the number of cases of
scarlatina notified, with age and sex, and the number of deaths certified
in the corresponding time and place to the Registrar-General; from which
the above generalities as to the proportions of fatal cases in the several
age-periods of either sex have been confirmed[1353].

The enormous mortalities of some years may be taken to have depended in
part upon an increased prevalence of the disease, but still more upon an
increased fatality among the subjects of it. Since the establishment of
the Metropolitan Fever Hospitals in 1870 the percentage of deaths to cases
has ranged from 15·3 in 1879 to 6·6 in 1873 and 6·7 in 1891. Among the
smaller totals of the London Fever Hospital the percentage of deaths has
ranged even more widely from year to year[1354]. What is thus
statistically proved is also a matter of common experience; there have
been whole epidemics, extending perhaps over two or three years, marked by
high malignancy, and epidemics just as uniformly marked by mildness of
type. The severe type has usually been made by the sloughing in the neck
or throat; but there has also been a class of cases tending to a fatal
issue early in the attack by a sunken pulse and with few external
manifestations. The cause of these variations in the severity of
scarlatina is the old problem of epidemic constitutions: sometimes the
constitution is “putrid” or “pestilential” or malignant, sometimes it is
mild or benign.

Graves, in the passage above cited, has sufficiently exposed the fallacy
of attributing changes of type to modes of treatment. On the other hand
there is reason to think that the percentage of deaths (by which the
“type” is usually judged) is higher in children carried off to hospitals
than in those treated at home. As the same fact has been uniformly
observed in epidemics of Asiatic cholera, when the ambulances have been
almost as busy as those of the Metropolitan Asylums Board during an
ordinary autumnal rise of scarlatina, it is probable that the reasons
which used to be given in the former case hold good also in the latter.

_Scarlet Fever in London, 1890 and 1891._

         All Cases   Treated    Treated in   Fatalities   Fatalities in
  Year    Notified   at Home     Hospital      at Home      Hospital

  1890    15330       8793        6537          348           510
                                                or 3·95%      or 7·8%

  1891    11398       6136        5267          232           357
                                                or 3·8%       or 6·8%

This is a comparison of two parts of the same epidemic, which had a very
moderate fatality in any case. The real problem of malignity or severity
of type arises over such epidemics as those of 1840, 1848, 1858-59,
1868-70 and 1874, in which the doubling of the deaths, for one year, or
for two or even three consecutive years, had depended less upon an
increased number of seizures than upon a higher ratio of fatalities. An
explanation for each occasion will have to be sought either in the
condition of the patients, or in the inherent properties or external
favouring circumstances of the virus. As to the former, the most fatal
epidemic years of scarlet fever have not been marked in any such uniform
way as the great seasons of typhus or relapsing fever; nor is scarlatina
an infection that keeps mainly within the poorer classes. Among factors of
the external kind, a rainfall below the average has been thought a
relevant thing: thus in the three years 1862-64, the annual average
rainfall at Greenwich was only 20·6 inches, the scarlatina death-rate in
London for the same years reaching the high figure of 1·33 per 1000
inhabitants; in the next three years, 1865-67, the death-rate fell to ·56
(it would have fallen in any case), while the rainfall reached the very
high average of 29 inches; in the three years following, 1868-70, the
death-rate reached the excessive annual average of 1·5 per 1000 in London,
the rainfall of the same period averaging only 22·3 inches. Thereafter for
a number of years the rainfall was moderate and the scarlatina death-rate
low; but in the years 1883-87, they were both low together, the scarlatina
death-rate of ·26 being lower than it had ever been since registration
began[1355].

Although an empirical correspondence between the great scarlatina periods
and a series of dry years has not been made out without important
exceptions, hitherto unexplained, yet there is a very obvious
correspondence between the great rise of scarlatina deaths in London every
year and the season of late autumn, which is the season when the
ground-water touches its lowest level or begins to rise therefrom to the
high water-mark of spring. Of all the curves of seasonal rise and fall
constructed by Buchan and Mitchell from the weekly bills of mortality in
London from 1845 to 1874, that of scarlatina is the most decided next to
that of infantile diarrhoea, the deaths rising in October and November far
above the mean line of the year, and falling farthest below the mean in
spring and early summer[1356]. This was an old observation--by Sydenham
for the scarlatina simplex of that age, by Willan in the end of the 18th
century (one or two spring epidemics being remarked upon as exceptional).
It is a very curious fact, and one that is as certain (for London at
least) as it is curious. Sydenham explained it by the doctrine of his
time, that the favouring things were in the human body, namely, some
susceptibility of the humours owing to the heat of the preceding summer;
but, according to modern views, it should bring scarlatina into the same
class with the soil-poisons of enteric fever, yellow fever and cholera,
which are believed to become more rife owing to the greater activity of
their respective miasmatic viruses when the pores of the ground are
occupied to the greatest depth with air in place of water.

It would be singular indeed if, after all, we should have to include
scarlatina among the miasmatic diseases; for it is an exquisite instance
of an infection which is passed from person to person, or by the agency of
volatile contagion, or by fomites in clothes, bed-linen, house-furnishings
and the like. The controversy which has raged so keenly in the past
between contagionists and non-contagionists over the instances of plague,
yellow fever and Asiatic cholera, would become still more keen over
scarlatina--and be still more confused if it were not stated in more
correct terms at the outset. What we all find so hard to learn is, that
the one way of infection does not exclude the other. Plague was for the
most part a miasmatic infection in the air of a plague-stricken town; but
it could be conveyed in clothes or bales, while it was prudent to remain
not too long in the company of a plague-patient. In like manner contagion
from the person was, as Rush said and Blane confirmed, a “contingency” in
yellow fever; and there are some authentic cases of Asiatic cholera which
cannot well be explained except on the hypothesis of contact with the
persons of those sick or dead of the disease. Scarlatina is more
contagious than any of these, because it shows so much on the surface of
the body and scatters its infective matter into the atmosphere of a room
with the fine scales or dust of desquamation. Still, there are conditions
for the contagiousness of scarlatina, just as there are for the rarer
event of contagion from the persons of the sick in the plague, yellow
fever and cholera. It is a remarkable fact that scarlet fever should ever
be sporadic, or that a single case should appear in the midst of a crowded
population (as I have seen in a coast town filled with strangers during
the herring fishery to the extent of one-half more than its usual
numbers), and no other cases follow for months after, although there had
been not the smallest attempt at isolation. Every medical practitioner
knows, if some laymen and legislators do not, that scarlatina is sometimes
highly contagious, and sometimes hardly contagious at all; and who can say
whether the mechanical routine of “stamping out” contagion, which certain
persons pursue with more zeal than knowledge, may not be the means of
turning a mere potency into an actuality? The tact of individuals rather
than the grinding machinery of an Act of Parliament is needed in dealing
with vagaries such as Willan thus describes:

    “I have seen in numerous families one child have scarlatina without
    communicating it to any of the rest; yet, perhaps, in the succeeding
    autumn, several of them were infected by only passing near a patient
    recovering from the disease, or by touching those who had a little
    time before visited some persons affected with it[1357].”

There are two special forms of epidemic scarlatina which may prove to be
finger-post instances for the general pathology. It happens from time to
time in the surgical wards of hospitals for children, where many cases of
suppurating diseases (especially of the bones or joints) are aggregated
and kept together perhaps for months, that groups of the patients acquire
a scarlet rash, or an erysipelatous rash, or a hybrid form of rash, along
with the constitutional symptoms of scarlatina. Whether it be from the
suppuration, or from the blood of operations, this disease must be
reckoned a product of so-called “hospitalism.” It is not without
significance that there may be an element of erysipelas in such cases.
They are probably cases of “blood poisoning,” in a double meaning of the
term--poisoning of the living blood by dead blood or by pus which is
closely allied to blood[1358].

The other special kind of epidemic scarlatina is that which has broken out
among the inmates of houses supplied with milk from a common source. There
have been many such outbreaks, including one most remarkable instance in
which a large number of guests at an evening party, who had partaken of
cream with strawberries, were shortly thereafter attacked by scarlet fever
at their widely scattered homes. There can be no question that milk, or
cream, has been the vehicle of scarlatinal infection. The first hypothesis
tried was that of scarlatina on the dairyman’s premises; the effluvia of a
scarlatinal patient might have become mixed with the milk. In some
instances, it was actually shown that there had been a case or cases of
scarlet fever among the dairyman’s children; but there were other
instances in which that could not be shown, and it was, of course,
possible to refer the cases, where they did occur, to a common cause in
the milk used at the dairy and in the milk distributed from it. As more
and more outbreaks of the kind came to be investigated, it was indeed made
probable that the infection had got into the milk from the cow[1359].
Someone threw out the suggestion that the cow suffered from scarlet fever,
the sign of it being soreness of the paps. Without taking seriously so
random a hypothesis as that, we find much agreement as to the fact that
the cows, to which the contaminated milk has been traced, were affected,
one or more of them, with sore paps. In some cases the disease of the
teats had been admitted to be the same as cowpox; in other cases that has
been denied; in a third variety, a cow has had cowpox on one teat and
something else on another. It matters little what name be given to the
affection of the cow’s paps. All soreness of the skin of the teats has the
same effect so far as concerns the purity of the milk. Unless the milk be
drawn off by a catheter (according to a German practice), the paps are
necessarily made to bleed by being “stripped”; it has been admitted by
milkers that the blood, pus, and scabs are apt to become mixed with the
milk; and the discharges from the sore paps have actually been seen, by a
scientific witness, to trickle over the fingers of the milkers into the
milk-pail[1360]. The contamination of the milk which produces scarlatina
in those who use it is neither more nor less specific than that. The
disease is blood poisoning in the double sense of the term--poisoning of
the living blood by dead blood. Blood is a peculiar fluid, and so is milk.
When the two come together the result is peculiar. Both are animal fluids
that curdle by some peculiar ferment-change in their constituents. Again,
milk is peculiar in its property of taking up organic effluvia; thus the
milk standing in shallow vessels has been known to acquire the taste and
odour of tar from a tarpaulin in the adjoining farmyard. With such
properties of the milk, a small quantity of blood or pus in it will go a
long way.

The one thing that connects the scarlatina of surgical wards in children’s
hospitals and the scarlatina of the milk-pail is putrefying blood or pus:
the disease is a septic effect of blood, just as a scarlet rash is known
to be a toxic effect of very various drugs in peculiarly susceptible
subjects. The obviously septic varieties of scarlatina make but an
insignificant part of the whole; but they may be finger-post instances.
Thus, if we assume that the infection may be miasmatic from the ground as
well as contagious from the person, there are certain facts, or
suspicions, that will fit the hypothesis of putrefying blood. A theory of
scarlatina was put forward in 1871, on the basis of observations near
Croydon, that its virus came from the blood and offal of slaughter-houses
collected at particular spots to be used as manure[1361]. The first death
in a recent small epidemic within the writer’s knowledge was of a
school-girl who lived just across the road from a slaughter-house. The
septic hypothesis of scarlatina might be made to include other corrupting
animal matters. Some practitioners have a suspicion that scarlet fever is
bred in the atmosphere of a horse-mews. On the greater scale, others have
traced a connexion between the more signal outbreaks of angina maligna and
preceding murrains of cattle[1362]. The animal matters which may become
toxic to man, in miasmatic or other form, are indeed many. If scarlatinal
drug-eruptions are any clue to the mystery of scarlet fever, we need not
be surprised to find a somewhat uniform disease-effect produced by a
variety of septic agents[1363]. But, in that hypothesis, the refuse of the
shambles will merit most attention. This was thought the one great
nuisance of London in the sanitary ordinances of Edward III., Richard II.
and Henry VII.; it was then considered a danger to health in the measure
of its offensiveness to sight and smell, but there may still be dangers
from it which are subtle and unperceived.

Reappearance of Diphtheria in 1856-59.

The memorable outburst of epidemic throat-disease in Britain about the
years 1858-59 was part of a sudden uprising of the malady all over the
globe--in Europe, America, North Africa, India, China, and the
Pacific[1364]. It was only in some parts of France, and of Norway and
Denmark, that “diphtheria” had been epidemic in the generation before. Of
its novelty to nearly the whole British profession in 1858, familiar as
they were with the angina of scarlet fever, there can be no question. Its
appearance among diseases coincided with the publication of Darwin’s
hypothesis of the origin of species by natural selection; and it was in
the terms of that hypothesis that Farr, of the Registration Department,
spoke of the phenomenon of diphtheria. New diseases, he said, “are only
recognized as distinct species when they have existed for some time.
Diphtheria is an example. It obtains a distinct line in the Tables of this
year [1859] for the first time”--with a total of 9587 deaths. For four
years before that, it had been in a “provisional table” under the names of
“diphtheria” and “cynanche maligna”; but in the general table, the deaths
under these names had been merged with the scarlatinal deaths. This
inclusion for a time of diphtheria under scarlatina could not have been
because practitioners had any difficulty in diagnosing the one from the
other, but probably because scarlatina anginosa seemed the nearest
affinity in the nosological system. Diphtheria in 1858 had no scarlet
rash, and yet it was supposed to be the same disease that had made so much
commotion in England about the middle of the 18th century: “In
Fothergill’s account,” says Farr, “the symptoms are confused by the
introduction of the eruption of scarlatina into his description”--as if
his description had been a patchwork of his fancy, with some characters
taken from “diphtheria” and some from scarlet fever. The greatest of our
nosologists, Cullen, had long before that separated “cynanche maligna”
from “scarlatina anginosa,” but the separation was not made on the ground
of absent or present rash. Both had the rash, the cynanche having, besides
a general exanthem, very distinctively the peculiar scarlet redness, with
swelling and stiffness, of the fingers which Fothergill described, while
the scarlatina rash was “commonly more considerable and universal.” Both
also might have a discharge from the nose; but when the coryza did occur
in scarlatina, “it is less acrid, and has not the foetid smell which it
has in the other disease.” It was really on the ground of malignancy or
fatality that Cullen separated them. In forty years he had seen scarlatina
anginosa six or seven times prevailing as an epidemic in Scotland, and he
had seen two or three epidemics of cynanche maligna. He had seen mild
cases in the latter, as well as in the former; but whereas there would be
only one or two malignant cases in a hundred of scarlatina anginosa, the
malignant or putrid cases in an epidemic of cynanche were four-fifths of
the whole[1365]. On the other hand Willan, writing just fifty years before
the modern diphtheria made its appearance, maintained that “no British
author has yet described any epidemical and contagious sore-throat except
that which attends the scarlet fever,” not even Starr, whose “morbus
strangulatorius” he held to be “the most virulent form of
scarlatina[1366].”

The name diphtheria, which appeared for the first time among the
classified causes of death in England in the report for the year 1855
(published two years after), had been given originally in 1826, with the
termination _itis_ according to the then Broussaisian fashion, by
Bretonneau in his account of epidemics at Tours in 1818-21 and at La
Ferrière in 1824-25[1367]. It was in January, 1855, or just before the
disease became general in Europe, that he changed the termination to
_diphtherie_[1368]. This name was taken from διφθέρα, a prepared skin or
hide, suggesting in strict correctness, a certain toughness and texture
which were actually found in only a small proportion of all the
diphtheritic deposits or exudations or sloughing infiltrations in the
first great epidemic and subsequently.

The interval between 1793-94, the date of Rumsey’s diphtheria or “croup”
at Chesham, and the outbreak of diphtheria in England in 1856-59, affords
several instances of the disease, some of which were contemporaneous with
Bretonneau’s in France, but were still called “croup” in this country.
These I shall merely enumerate in a note, passing at once to the
beginnings of the great outbreak[1369].

The first public notice of the reappearance of a fatal throat epidemic in
England appears to have been in the Registrar-General’s third quarterly
report of the year 1857, when attention was drawn to the remarks by
various local registrars (Thame, Billericay, Maldon, Liskeard, Truro and
Chesterfield) as to fatalities from “inflammation of the throat,” “putrid
sore throat,” “malignant sore throat,” “disease in the throat,” and
“throat-fever.” About this time it was also called the “Boulogne sore
throat.” There had been an epidemic at Launceston from 30 September, 1855,
which had come to a height in August, 1856; several deaths had occurred
near Spalding, in Lincolnshire, in July, 1856, and the disease had been
seen at Ash, in Kent, in November, 1856. When the registered causes of
death during the year 1855 were classified (in 1857), “diphtheria” was
credited with 186 deaths, in the Supplementary Table then first
introduced, “cynanche maligna” having 199 deaths. The following shows the
progress of the epidemic during the four first years, and the mode of
entry:

                                Scarlatina (inclusive
        Cynanche                of columns 1 and 2 in
  Year   maligna   Diphtheria   the general table)

  1855    199         186            17,314
  1856    374         229            14,160
  1857   1273         310            14,229
  1858   1770        4836            30,317

In 1857 and 1858 the deaths from croup were above the average, and
probably included some of the new disease.

Accounts of the epidemic began to come into the medical journals[1370]
from various localities in the course of 1858,--from Lincolnshire, Essex,
Kent, Sussex, etc. A systematic inquiry, conducted by Greenhow and
Sanderson for the Medical Department, under the direction of Simon, gave
an exact picture of the several degrees of throat-distemper that
constituted the epidemic in the year 1858, in certain of the more severely
visited centres of Lincolnshire, South Staffordshire, Cornwall, Kent, and
other counties[1371]. The numerous cases of throat disease occurred often
in the midst of scarlatina, but sometimes also where there was no
scarlatina. One of the worst centres was in and around Spalding, a market
town situated in a flat grazing country within the fen district of
Lincolnshire. A thousand cases were counted in and near Spalding, many of
them mild, a small ratio of them gangrenous and mortal; one practitioner
had 200 cases with 5 deaths, another 200 cases with 2 deaths, another 160
cases with 17 deaths (of 65 tabulated with 9 deaths, which occurred in 35
houses, the first four all died from gangrene in June, 1858). The doctor
at Pinchbeck, in the same district, had some 500 cases of which 300
occurred in the space of about six weeks; most of the 19 deaths in his
extensive series happened in the first cases (this was observed also in
the New Hampshire epidemic of 1735). At Launceston, in Cornwall, there
were about a thousand cases known, the height of the epidemic having been
in the summer and autumn of 1856; among 126 taken as they came in 98
families, 18 died. The mildest and the most severe cases were equally
parts of the epidemic constitution, and occurred side by side in the same
households; many of them were quinsies, ulcerated sore-throats, or the
like, others were gangrenous. In this great variety, only a part could be
reckoned “true diphtheria.” From the first, the remarkable sequel of
paralysis, not only of deglutition but of the motor powers generally, was
remarked here and there. Sometimes an eruption of the skin was seen, but
desquamation did not occur[1372]. Albumen in the urine was somewhat
constant. It is noteworthy, the more so that the coincidence was not
remarked at the time, that the true diphtheritic pellicle,--tough,
leathery, elastic,--was found most distinctively, if not exclusively,
where it was found in 1748, namely in Cornwall[1373].

Although the epidemic was not confined to low and damp situations, yet
there was no mistaking the severity of it in Lincolnshire; and although it
fell upon both clean and filthy houses, yet it is probable that the cases
with most pronounced gangrene or foetor happened amidst the most
unwholesome surroundings. The disease was very general in England in 1858.
When the deaths from it in 1859 (9587) were tabulated for the first time
according to counties, it was found that they came from every part of
England and Wales. The highest death-rate was in Lincolnshire, 1·2 per
1000 on the annual average of 1859 and 1860 (995 deaths in the two years).
Sussex, Kent, Essex and Norfolk had also high death-rates, the
agricultural counties in general having somewhat more than their usual
share of an infective mortality as compared with the industrial centres.
But it would be erroneous to suppose that diphtheria was at all specially
a country disease. The mining districts of Staffordshire, Durham and South
Wales had considerable mortalities, and so had Lancashire and the West
Riding. But the North Riding and East Riding had their full share or even
more than their share; whereas, if it had been scarlatina or enteric
fever, they would have been far behind the great industrial division of
Yorkshire in ratio of their populations. In the more recent prevalence of
diphtheria the country districts have lost their preeminence, according to
the following table of death-rates per million living in registration
districts classified roughly as sparse, dense and medium[1374]:

_Diphtheria Death-rates per million, according to density of population._

  Period    Dense   Medium  Sparse
  1855-60    123     182     248
  1861-70    163     164     223
  1871-80    114     125     132

In Scotland, also, the incidence was the same: e.g. in 1862, of 997
deaths, 360 were in the towns, 617 in the mainland rural and 20 in the
insular districts[1375].

The law of incidence of diphtheria upon town and country respectively has
become a good deal confused by the extraordinary severity with which
diphtheria has fallen in the last two or three years upon most parts of
London and upon the adjoining municipal boroughs of Croydon and West Ham.
The following table compares the annual death-rates per million in all
England and Wales and in London from the year of the first recognition of
diphtheria to the present time.

_Death-rates from Diphtheria per million, in all England and in London._

  Year     England     London

  1855       20          --
  1856       32          --
  1857       82          --
  1858      339          --
  1859      517         284
  1860      261         174
  1861      225         239
  1862      241         288
  1863      315         275
  1864      261         207
  1865      126         144
  1866      140         152
  1867      120         145
  1868      137         155
  1869       47         107
  1870      120         104
  1871      111         105
  1872       93          80
  1873      108          95
  1874      150         122
  1875      142         167
  1876      129         109
  1877      111          88
  1878      140         155
  1879      120         155
  1880      109         144
  1881      121         171
  1882      151         220
  1883      158         241
  1884      185         236
  1885      163         221
  1886      147         205
  1887      157         226
  1888      168         305
  1889      185         371
  1890      179         330
  1891      173         340
  1892      222         460
  1893      302         740

The deaths in London in 1893 were 3196, having been 1962 the year before,
but never more than half the latter total in any year previous to 1888.
Besides Croydon and West Ham, Cardiff is the great town which has come
nearest the London rate, having had O·68 deaths from diphtheria per 1000
living in 1892, while Swansea had only 0·05, Wolverhampton (including
Bilston and Willenhall) only 0·06, Huddersfield 0·03 and Blackburn 0·02.
In London the very high death-rate of 1893 was distributed not unequally
over all the divisions, the highest mortality corresponding to the highest
fecundity.

_Diphtheria in London in 1893._

                 Death-rate                  Diphtheria
  District    from all causes   Birth-rate   death-rate

  Eastern         25·1            37·3         1·00
  Central         26·6            29·0         0·82
  Southern        19·9            31·7         0·73
  Northern        20·0            29·3         0·73
  Western         18·7            26·4         0·52

Diphtheria shows no such decided preference for the late autumnal or early
winter season as scarlatina, but the winter is on the whole its most
fatal season, according to the following annual averages of the quarters
of the year for twenty years from 1870 to 1889 (total of 67,676 deaths in
England and Wales).

_Annual average of Diphtheria deaths in the quarters of the year._

  1st qr.    2nd qr.    3rd qr.    4th qr.

   903        713        730        1025

According to some recent returns under the Notification Act, which are of
doubtful value owing to the laxity of diagnosis (greater perhaps in
throat-disorders than in any other class of diseases), the second and
third quarters of the year have also the lowest mortality in proportion to
the number of attacks[1376]. As to the ages at which diphtheria proves
fatal, they are somewhat similar to those of fatal scarlatina, but
slightly higher all over; thus, while two-thirds of the deaths from
scarlatina are of infants and children under five years, only one-half of
the deaths from diphtheria are under that age. In the first epidemic
period, 1855-61, Farr reckoned that 1553 adults had died of diphtheria
above the age of twenty-five, while the deaths under that age had been
28,216. In its age-incidence diphtheria is very different from croup,
which attacks chiefly children of one, two, and three years of age, the
boys dying in greater numbers than the girls[1377]. But in all comparisons
between diphtheria and croup, as regards sex and age, it should be kept in
mind that many cases of angina of the throat, which end in death by
extension to the larynx and trachea, are registered as croup, even in
epidemics. Diphtheria is the only epidemic disease besides whooping-cough
which is more fatal to female children than to males in proportion to the
numbers of each sex living. The following annual average death-rates per
million for the period 1855-80 show the higher death-rates of females at
certain age periods[1378]:

          All ages  0-    1-    2-    3-    4-    5-    10-   15-20

  Males     157     490   724   617   667   589   325   107    50
  Females   168     377   673   668   746   694   413   159    57

It is not until the third year that female children begin to die of
diphtheria in excess of males; which means that the usually greater risk
to male infants holds good also in this disease for the two first years,
while some difference between the sexes becomes thereafter so marked as to
turn the balance of fatality to the side of the females. Something of the
same kind happens in whooping-cough; and it is probable that in both
maladies the cause lies in the earlier acquisition by the male of
secondary sexual characters in the throat and larynx, as suggested in the
chapter on whooping-cough.

Conditions Favouring Diphtheria.

The circumstances of the great and sudden explosion of diphtheria in 1858
and 1859 are as likely as any to throw light on the causes or determining
conditions of the disease. Those two years were remarkable for the Thames
running so low in summer as to give out a stench, which was thought to
forebode much fever[1379]. The expected epidemic of fever did not come; on
the contrary the fever deaths in London were much lower than usual in 1858
and 1859, and, to judge from the few admissions of each kind to the London
Fever Hospital, enteric fever declined as well as typhus[1380]. It was
diphtheria that came. The lowness of the rivers was due to a succession of
years with rainfall below the average:

    Low rainfall                High rainfall

  1855     21·1 inches        1865   29·0 inches
  1856     22·2   "           1866   30·7   "
  1857     21·4   "           1867   28·4   "
  1858     17·8   "           1868   25·2   "
  1859     25·9   "           1869   24·0   "
           ----                      ----
  Average  21·7   "          Average 27·4   "

The low state of the rivers was an index of a low level of the
ground-water. If diphtheria is to be included among the infections that
have the habitat of their virus in the soil, it will probably be found to
be affected by irregularities in the movements of the subsoil water. A
series of observations have been made which seem to favour that
hypothesis.

    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 point towards 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 of _garrotillo_ in 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 the death-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.

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