Chapter VIII (2)

The great seasons of choleraic disease in the 16th century were the years 1539-40, (which were remarkable all over Europe for dysentery as well), 1557-58, 1580-82, and probably 1596[1409]. The term commonly used in that period was a choleric lask, which meant _profluvium_. In some, if not in all, of those seasons there was unusual heat and drought. It is clear that these were only the years when cholera nostras of the summer season was exceptionally common and severe. According to a medical work of the year 1610, dealing with the indications for the use of tobacco by individuals, including the seasons of the year when it was most admissible, midsummer is characterized in general terms, and perhaps in the stock language of foreign medical treatises, as the season for “continuall and burning fevers, bleareyedness, tertian agues, vomiting of yellow choler, cholericke fluxes of the belly, paines of the eares and ulcerations of the mouth, putrefactions of the lower parts: especially when the summer, besides his heat, is enclined to overmuch moisture, and that no windes blow, and the weather bee darke, foule, close and rainie.... So that in this season, and for these remembered griefes, no man, I trust, will grant tobacco to be verie holesome[1410].” Consistently with this Sydenham says that, while the cholera morbus of August, 1669, was more general than he had ever known it, yet in every year, at the end of summer and beginning of autumn, there was some of it; and he compares its regularity to the coming of the swallow in spring or of the cuckoo in early summer. It was marked by enormous vomiting, purging, vehement pain in the bowels, inflation and distension, cardialgia, thirst, a quick pulse, sometimes small and unequal, heat and anxiety, nausea, sweats, spasms of the arms and legs, faintings, coldness of the extremities, and other symptoms, alarming to the attendants and sometimes causing death within twenty-four hours[1411]. Next year, 1670, in the corresponding season, he describes under the name of a bilious colic, a prevalent malady which, he says, should count rather among chronic diseases[1412]. It was marked by intolerable pain, the abdomen being now bound as if in a tight bandage, now bored through as if by a gimlet. These pains would remit for a time, and the paroxysm come back, the patient shrinking from the mere idea of it with misery expressed in his face and voice. This was evidently somewhat different from the cholera morbus of the summer of 1669; it was apt to end in inverted peristaltic action, with vomiting of the matters of enemata, or in iliac passion[1413]. There was also dysentery in both years, as we shall see.

Morton gives the first choleraic and dysenteric season under the year 1666, and says of its recurrence in the following autumn, that hardly any other disease was to be seen, that the whole town was seized, and that 300, 400 or 500 died of it in a week. This is obviously antedated by two years, just as Morton is two years earlier than Sydenham with the great fatality of measles (1672 instead of 1674). Willis, again, who wrote some twenty years nearer to the events than Morton did, places the great choleraic seasons in 1670 and 1671, instead of 1669 and 1670. Sydenham’s dates are undoubtedly correct, both as borne out by the bills of mortality, and as occurring in consecutive order in the annals which he kept for a period of twenty-five years. The correctness of his dates apart, Willis may be cited for the symptoms of the London cholera[1414].

The onset was sudden, with vomiting and watery purging, accompanied by
prostration: “I knew a great many that, though the day before they
were well enough and very hearty, yet within twelve hours were so
miserably cast down by the tyranny of this disease that they seemed
ready to expire, in that their pulse was weak and slender, a cold
sweat came upon them and their breath was short and gasping; and
indeed many of them, that wanted either fit remedies or the help of
physicians, died quickly of it. This distemper raged for a whole
month, but began to decrease about the middle of October, and before
the first of November was almost quite gone.” The vomitings and
purgings were copious, watery, almost limpid, not bilious. The
sickness was peculiar to London or the country within three miles of
it. It did not seem to be infectious, but to attack only those
predisposed to it; for it would seize those who kept out of the way of
the sick and spare those who attended them. Morton, however, declares
that he was infected in two successive seasons, “dum, mense Augusto,
sedes dysentericorum minus cauté inspicerem.”

These illustrations from the highly choleraic summers of 1669 and 1670 will serve to show the prevalence of cholera nostras among adults in London in former times. Its great seasons were the same as those of cholera infantum, of which numerous instances have been given from the London weekly bills of mortality. The years 1727-29 were specially noted for cholera by the annalists, such as Wintringham, of York. Hillary, of Ripon, having entered in his annals a “cholera morbus” in 1731, adds: “which disease I have observed to appear almost every year towards the latter end of summer[1415].” A letter from Darlington, 29 July, 1751, having mentioned the death of the earl of Derby by “the cholera morbus,” adds that the disease usually rages at the close of summer and towards the beginning of autumn[1416]. Newcastle was much subject to it, as well as to dysentery, Wilson, of that town, devoting an essay to dysentery in 1761 and to cholera in 1765. Lind, who went to Haslar Hospital in the very unwholesome period about 1756-58, found much aguish and choleraic sickness: “Obstinate agues, and what is called the bilious cholic, from being accompanied with vomitings and a purging of supposed bile, but especially the flux, are often at Portsmouth and Gosport in the autumnal season highly epidemical. Since I resided here, I have observed those distempers to rage among the inhabitants, strangers and troops with an uncommon degree of mortality; while, during this period of universal distress at land, ten thousand men in the ships at Spithead remained unaffected with them[1417].” At Manchester, in the burning summer of 1794, a bilious colic, says Ferriar, “raged among all ranks of people[1418].” Clarke, of Nottingham, writing in 1807 of the great prevalence of cholera nostras, calls it “the usual attendant on autumn[1419].”

The appearance of Asiatic cholera in England in the end of 1831 gave rise to much controversial writing for a few months, as to whether the epidemic were really the foreign pestilence. Every effort was made by a certain school to find native precedents for a disease equally malignant; which, if they did not prove the point in question, gave more exact particulars of cholera nostras than we might otherwise have received. The only one of these accounts that need concern us here is Thackrah’s for Leeds and its vicinity in 1825[1420].

The weather had been exceptional. In May, three-eighths more rain fell
than usual, the wind being in the east the whole month. June was
showery and sultry, the thermometer on the 12th marking 87°. July was
sultry, with drought for several weeks to the 3rd of August, when
showers fell. There had been a few cases of cholera in May, June and
July, but it was not until August that the disease became rife in
Leeds and still more in certain villages near it. The symptoms were
purging, vomiting, cramps, prostration, coldness of the extremities,
shrinking of the features, &c. At Moor Allerton, a parish three or
four miles north of Leeds, with a poor scattered population occupied
on the farms, there were found in 60 houses, containing 299 persons,
no fewer than 114 cases of sickness in July, August and September, 81
of these from cholera, with 3 deaths. Dysentery was common, both as a
sequel of the cholera and as a primary malady. At Halton, three or
four miles east of Leeds, with a population better off than in the
former, there were found in 60 houses, with 298 persons, 74 cases of
sickness, of which 63 were choleraic. At Grawthorpe, four miles west
of Wakefield, with a weaving population not poor but of filthy habits,
there had been for two months before the visit of inspection more
sickness than any one remembered. Twenty of all ages had died of the
epidemic, there having been 7 corpses in the village on one morning.
Of 70 houses inspected, only 7 had been exempt from cholera and
dysentery. In one house of 9 persons 7 were ill, 2 with cholera,
others with dysentery and typhus. This was one of the most unhealthy
villages, supplied with water from ponds only. In Leeds the choleraic
epidemic was less than in the adjoining country, and the few deaths
that occurred from it were all among the poor and debilitated. The hot
summer of 1825 was unusual for the amount of cholera nostras. It
prevailed at South Shields that season with unusual severity, the
cramps and spasms being peculiarly manifest[1421].

Dysentery in the 17th and 18th centuries.

The younger Heberden remarks, “There is scarcely any fact to be collected from the bills of mortality more worthy the attention of physicians than the gradual decline of dysentery.” I have shown the fallacy of Heberden’s proof in the first part of this chapter on Infantile Diarrhoea. It is true that dysentery did decline in London, but not on the evidence adduced by Heberden, nor within the noteworthy limits that he supposed. It was at no time one of the greater causes of death in London, and it had already by the middle of the 18th century reached as low a point as it stood at when Heberden wrote. As it is one of the diseases that have become rare in this country, there is a scientific interest in establishing the fact of its decrease, even although its prevalence had been at no time more than occasional.

Hirsch groups the outbreaks of dysentery as of four degrees of extent: (1) localized in a single town or village, or even a single house, or barrack, or prison, or ship; (2) dispersed over a few neighbouring localities; (3) dispersed over a large tract of country in the same season; (4) simultaneous in many countries, or extending over a great part of the globe, and continuing as a pandemic for several years[1422]. The last are the most curious; and of these there are at least two in which Britain had a share, the dysenteries of 1539-40 and of 1780-85. Of the next degree, there have been several in Ireland and Scotland, including those of the great Irish famines of the 18th and 19th centuries, and the “wame-ill” of Scotland in 1439. Of the two minor degrees of extent, there have been, of course, many instances in the towns, counties or provinces of Britain.

A considerable decline of dysentery in London before the end of the 17th century is made probable by various facts that can be gathered from the bills of mortality. When these began to be printed in 1629, dysentery appeared in them under the unambiguous name of bloody flux; there were 449 deaths from that cause in 1629, they had decreased to 165 in 1669 (a year remarkable for dysentery and other forms of bowel-complaint), and to 20 in the year 1690, soon after which the article of bloody flux ceased in the bills. But we are not to judge of the amount of dysentery from the entries under the name of bloody flux alone. In 1650 there began the article of “griping in the guts”; as I have shown, it was mostly infantile diarrhoea of the summer and autumn, but, so long as it lasted, it had probably included some dysentery. Besides the articles of bloody flux and griping in the guts, there was a third article for a time in the bills, namely “surfeit,” a term which came at length to mean dysentery[1423]. Thus the great plague of 1625 is said to have been preceded by a surfeit in Whitechapel; and it is clear from other uses of that word, for example as applied to slaves shipped on the West Coast of Africa for transport to the West Indies, that it meant dysentery more than any other form of bowel-complaint[1424]. Accordingly when we find in the weekly bills of mortality for London that a series of weeks in the dysenteric summer and autumn of 1669 had deaths from “surfeit” to the numbers of 9, 11, 10, 12, 9, 15, &c., we may take it that these were dysenteric rather than choleraic, the more so as the other name “bloody flux” has fewer deaths to it than we might have expected from Sydenham’s general language. These various items in the London bills cannot be used for an exact statistical purpose, but only as indications. Perhaps the most trustworthy indication is the total of 449 deaths from bloody flux in the year 1629, being a twentieth part of the mortality from all causes (8771 deaths). That was a prevalence of fatal dysentery in London far in excess of anything that is known in the 18th century, for example in the dysenteric seasons of 1762 and 1781. So long as plague lasted, dysentery seems to have been somewhat common, and probably most so in the plague years; for, besides the surfeit in Whitechapel with which the plague of 1625 is said to have begun, we find many deaths from bloody flux in the year of the Great Plague itself, 1665. As Sydenham and Willis have left good accounts of the London dysentery of 1669-72, it will be convenient to take from these sources our impressions of the disease in the 17th century.

Referring to the dysentery of 1669, Sydenham says that there had been comparatively little of it for ten years before, not including, doubtless, the plague-year of 1665, when Sydenham was out of town[1425]. Both he and Willis are clear that there was a certain amount of it every year, although it was seldom fatal in ordinary seasons. The ordinary London dysentery, says Willis, though it be horrid or dreadful by reason of its bloody stools, and is most commonly of a long continuance, yet it is not very contagious nor often mortal[1426]. Sydenham says that it was fatal more particularly to aged persons, but highly benign in children, who might be subject to it for months _sine quovis incommodo_. However, in certain seasons it became malignant and caused a good many deaths.

It began usually with chills and shiverings, to which succeeded heat
of the whole body, and shortly after tormina with dejections; but
sometimes the griping and stools were the first symptoms. Always there
was intense suffering and “depression of the intestines,” with
frequent straining at stool. The stools were mucous, not
stercoraceous, and with traces of blood. The tongue might be whitish,
or dry and black; the strength was prostrated and the spirits faint.
After a time the streaks of blood in the motions would be replaced by
pure blood, without even mucus, a change which threatened a fatal end.
Sometimes the bowel became gangrenous, while aphthae would appear in
the mouth and fauces. If the patient were about to recover, the
symptoms would gradually be restricted to the rectum, in the form of
tenesmus. Willis says that the dysentery of the autumn of 1671 was
really a bloody one, and extraordinarily sharp and severe, hurrying
many to their graves. At the outset blood was voided plentifully, with
griping pains; there might be twenty stools in a day. Some were able
to rise after a week; but the malady would go on for several weeks or
even months. It was protracted also in fatal cases, the end being
marked by watchfulness, roughness of the tongue, thirst and thrush in
the mouth. He gives a case of a strong young man who recovered after
having had not only terrible bloody stools, but also bloody vomit,
which, Willis thought, might have come from ulceration of the stomach.
But with good diet and treatment most of those attacked escaped death.
Sometimes it became virulent and, as it were, pestilential, destroying
many and diffusing its infection very largely by contagion.

It was most common, says Willis, in camps and in prisons, by reason of the stench of the places and the evil diet. From what Sydenham was told by Dr Butler, who accompanied Lord Henry Howard in his embassy to Morocco, the dysentery of North Africa was the same as that which prevailed in London, as an occasional epidemic, in 1669-70.

The dysentery of the siege of Londonderry and of the camp at Dundalk, both in the year 1689, have been described elsewhere. During the same reign, Dr William Cockburn got fame and wealth by a secret remedy for dysentery, which was tried first on board the king’s ships at Portsmouth[1427]. In 1693-99, there was dysentery in Scotland and in Wales. Of Scotland in 1698, the climax of the “seven ill years,” Fletcher of Saltoun says: “From unwholesome food diseases are so multiplied among poor people that, if some course be not taken, this famine may very probably be followed by a plague[1428].” A Welsh practitioner, who graduated at Dublin in 1697 said, in his thesis, that dysentery had raged for the space of three years in several maritime regions of South Wales so severely and had made such havock that in not a few houses there were hardly one or two left to bury the dead[1429]. Writing before the seven ill years, Sir Robert Sibbald mentions dysentery as one of the _dira morborum cohors_ that everywhere affected the Scots peasantry in the end of the 17th century, the causes of which were coarse food and excesses in spirit-drinking. In the century following we hear of dysentery in Scotland in particular years, which correspond on the whole to the unwholesome seasons in England. Thus in 1717, special mention is made of a fatal bloody flux in Lorn, Argyllshire. In 1731 there were dysenteries in Edinburgh in autumn, often tedious, rarely mortal. In 1733, during the harvest months, dysenteries were frequent and mortal in Fife, especially along the shores of the Firth of Forth. In the following autumn (1734) many in Edinburgh were seized with a dysentery, which continued more or less epidemic all the winter: “It had the ordinary symptoms of slight fever, frequent stools, for the most part bloody and mucous, violent gripes and an almost constant tenesmus”--being fatal to some and very tedious to others[1430]. This was a well-marked dysenteric period in Scotland, but just as much a rare or occasional experience as the corresponding epidemic a century after in 1827-30. It appears to have lasted in various parts of Scotland until the end of 1737. A regimental surgeon, who was stationed at Glasgow in the end of 1735 and afterwards at Edinburgh, had 190 dysenteric patients (civil and military) from December, 1735, to February, 1738[1431]. The summer and autumn of 1736 appear to have been its more severe seasons; it is heard of at St Andrews and in the country near it, at Kingsbarns and Crail (where “many of the boys” were seized), at Dalkeith, and in Glasgow and the neighbourhood, where one practitioner claims to have treated “some hundreds” with cerate of antimony[1432]. In the great period of epidemic fever shortly after, the years 1740 and 1741, flux in the Edinburgh bills of mortality has respectively 3 and 36 deaths, which would probably have meant thirty to fifty times as many cases[1433].

The English epidemiographists, Wintringham, Hillary and Huxham, mention dysentery in certain years, which were the seasons of high general mortality. Wintringham’s first entry for York is under the year 1717, his second in 1723 (autumnal), a third in 1724 (some fluxus alvi with blood), in 1726 diarrhoeas and dysenteries “called morbus cholera,” and the same for two or three weeks of September, 1727. Wintringham was one of the first in England to emphasize the seasonal connexion between dysenteries and agues. There was undoubtedly dysentery among the many forms of sickness in the disastrous years 1727-29. Huxham includes it among the fluxes which were common at Plymouth in 1734-36. A still greater dysenteric period followed the influenza epidemic of 1743, Huxham being again the chief chronicler of it[1434].

In the second half of the 18th century, two periods were specially noted for dysentery, the years about 1758-62 and 1780-82. The first of these called forth perhaps the only medical piece written by Dr Mark Akenside, physician to St Thomas’s Hospital and author of the ‘Pleasures of the Imagination[1435],’ as well as accounts by Sir G. Baker[1436] and Sir W. Watson[1437]. All three writers agree that the true epidemic prevalence occurred in London in the autumn of 1762. It is clear, however, that Akenside had been treating in St Thomas’s Hospital since 1759 many cases of true dysentery (which he defines as a bowel complaint with gripes, tenesmus and bloody or mucous evacuations). He had more than one hundred and thirty cases of it described in his ward-books in the five or six years previous to his writing (1764); he had proved the good effects of ipecacuanha on many in 1759; and he had remarked that the autumnal dysenteries of 1760, 1761 and 1762 in each case lasted the whole winter, not abating until the spring. Perhaps this may have been a special experience of the Surrey side of the Thames; for both Watson and Baker are clear that dysentery was something of a novelty to them in the early autumn of 1762. Says the former, writing to Huxham on 9 Dec. 1762: “We have had here this autumn a disease which has not been in my remembrance epidemic at London. Very few of our physicians have seen this disorder as it has appeared of late. You mention it as frequent at Plymouth in the year 1743....” And Baker begins his essay by saying that there became epidemic in London in the end of July, 1762, the disease of dysentery--“morbi genus hac in civitate novum feré, aut nuperis saltem annis inauditum[1438].”

The three observers agree that it attacked the poorer classes,
children more than adults, convalescents, lying-in women and the like.
Akenside says that it was mostly a slow non-febrile disease (in the
autumnal outburst of 1762, the subjects of it were more fevered), and
that some patients came to him who had been labouring under it for two
or three months. His account agrees on the whole with Sydenham’s for
the years 1669-72: some had vomiting, some had a painless flux
following the dysentery, some had dropsy as a sequel. In cases about
to end fatally there was a remission of the griping before the end; in
some there were aphthae of the mouth, stupor, and somnolence, with
cold sweats. Watson saw three children (of four or five years) die
from debility a week or more after the gripings and discharges had
ceased; they could keep down no food, and were greatly emaciated. In
another case, a young child, the motions were pure blood, and death
followed on the third day. Baker gives Hewson’s notes of the anatomy
in a case that was clearly one of follicular dysentery, as well as
Charlton Wollaston’s account of two other anatomies (mixed catarrhal
and follicular), with plates of the dysenteric bowel.

Watson, physician to the Foundling Hospital, says that the dysentery, or dysenteric fever, was very prevalent among the children in 1762, the year of its most general prevalence[1439]. It may have been part of that dysenteric “constitution” which caused the following outbreak among the foundlings at the hospital at Westerham, Kent, a branch of the Guilford Street charity: “26 January, 1765. The apothecary visited the children at the hospital at Westerham, January 12th, 1765, and found twenty ill with dysenteries, many of whom had the whooping-cough complicated with it. Two of them are since dead, which, with six that died before he went down, make eight dead of that disease.” Two cases of dysentery were in the infirmary of the Foundling Hospital in London on the 2nd of March, 1765[1440]. These accounts of dysentery in London in the middle third of the 18th century show it to have been then a very occasional malady and a very small contributor to the bills of mortality.

Next to the capital, the town that seems to have had most dysentery in the 18th century was Newcastle, which had been also the seat of frequent and severe plagues. There was much dysentery in it and in the neighbouring places on Tyneside during the autumns of 1758 and 1759, but the disease was not epidemic in 1762, the season of the malady in London[1441]. It was prevalent among the same classes in Newcastle as in London--the poorer households, children, weakly persons. It recurred in the harvest quarter, in fine clear weather, when the days were almost as hot as at midsummer, but the evenings and mornings remarkably cold and the nights frequently foggy. The reason why the lower class of people were most liable to it seemed to be their “negligence in the article of cooling after heats by labour, exercise, &c.” But there may have been something also in the soil and situation of Newcastle which made these common risks to be followed by so special an effect.

The Newcastle dysentery of 1758-59, two or three years earlier than the London epidemic, was the occasion of the essay by Dr Andrew Wilson, a work which compares favourably with the writings of the metropolitan physicians. Among the symptoms of true autumnal dysentery he gives the following:

“Constant fever, drought, parchedness of the mouth and throat,
dejection of the spirits, prostration of the strength, frequent
viscid, acid or bilious vomiting, flatulency in the belly, wringing
pain in the lower part of it, and often in the same region of the
back; these pains sometimes constant, but always preceding stools; an
almost constant pressing to stool, with great pain and irresistible
tendency to it at the same time, called a tenesmus; the stools
generally bloody, always slimy, and full of glary stuff, sometimes
mixed with a whitish matter of less tenacity, which appears in
separate little curdled-like parcels, often with blackish
corrupted-like bile; the stools always odiously fetid; they are seldom
natural without the assistance of purgatives, and then they are often
discharged in hard, dry little lumps; dryness of the skin, except when
clammy unbenign sweats are raised by the intenseness of the gripings
and tenesmus; great watchfulness, their sleep, when accidentally they
drop into any, being short and broken, with recurring pains which
awake them unrefreshed. These are the principal symptoms which attend
a true febrile dysentery. When such a disease is epidemic there are
many slight appearances of it which happily do not extend to all these
complaints, and which easily yield to proper applications.

The signs of danger in this disease are the violence with which all
the above symptoms appear. But the signs of immediate danger are,
decrease of pain, great sinking of the spirits, lowness of the pulse,
beginning coldness of the extremities, parchedness and blackness of
the tongue, aphthae; white scurf or ulceration of the throat and
fauces, and constant hiccup. When there is a cessation of pain,
intolerably fetid and involuntary stools, shiverings, with sometimes a
sense of coldness in the belly, a slight delirium, and often
unaccountable fits of agony, or rather anxiety; then the case is
beyond remedy, and the patient hastens to dissolution. This stage of
the disease is generally attended with a small obscure pulse and cold
extremities, but I have seen it in some particular cases otherwise.

... When dysentery is epidemic, it is not uncommon for people who
escape the dysentery itself to have their stools altered from their
natural colour to sometimes a greenish hue, as if they had eaten much
herbs, sometimes of a clay colour, and sometimes quite blackish, as if
they had eaten a quantity of blood.... In 1759 particularly, it was
very common for numbers of people who escaped the dysentery to be
troubled with flatulencies, slight gripings and twitchings in the
belly, which was generally attended with blackish stools. Stranguaries
were likewise pretty frequent, and icteric complaints, or the
jaundice. The stranguary was a very common symptom in many fevers
which occurred during the prevalency of the dysentery. Another
complaint which frequently occurred during the last dysenteric season
was dry gripes.

The dysentery this last season [1759] differed in many respects from
its appearance in the former season. In the latter season greater
numbers had it in that slight degree which was attended with little
fever and no danger. In many who were seized with seemingly great
violence, it was unexpectedly checked when there appeared all reason
to apprehend it would have run to a much greater length. It was not
uncommon to find it complicated with agues, rheumatisms, &c., into the
latter of which it frequently degenerated. In the former season the
griping pains attending it were confined to the lower belly. In the
latter they were very ordinarily felt also in the back, along, as
might be supposed, the windings of the rectum and colon; yet, after
the dysenteric stools were in a great measure gone, and the disease
over, these pains often remained, or assumed the appearance of a
lumbago or sciatic, with pains striking down the thighs.... The more
the season advances, and the later in the year it is when persons are
seized with this epidemic, the more chronical do the symptoms of it
grow.”

The last sentence is probably the explanation of Akenside’s original point, that dysentery was as much a winter as an autumnal malady, not really abating until the spring. Wilson himself claims originality in the following point relating to the sluggishness of the bowels in dysentery, his treatment having been largely determined by that view of the pathology:

“During the increase and height of this distemper, it is very
improperly called a flux. A proper flux, or diarrhoea, is a constant
flow of immoderately liquid but otherwise natural stools, dissolved by
too great an irritation upon, or too great a relaxation of, the
vessels destined for mollifying the faeces and lubricating the
passages by their humours; by which means they are disposed to dismiss
a superfluous quantity of them. But in the dysentery the passage of
the natural discharges is resisted, and their consistence is often
increased to such a degree that, when they are urged along by the
assistance of purgatives, they are excluded in unnaturally hard and
dry little lumps or balls” (p. 3). The question whether scybala were
an essential character of dysentery was often referred to in later
writings.

Nothing more is heard of dysentery at Newcastle until the date of the opening of the dispensary there, 1 October, 1777. From that date to 1 September, 1779, when the disease was not epidemic there, 72 cases were treated from the dispensary.

Some importance, as regards priority, attaches to one of Dr Andrew
Wilson’s observations of the Newcastle dysentery of 1759: “It was not
uncommon to find it complicated with agues, rheumatisms, &c., into the
latter of which it frequently degenerated.” The pains, he says, were
not confined to the lower belly, but were felt also in the back; or,
after the dysentery was gone, the muscular pains remained as a lumbago
or sciatica, striking down the thighs. This curious relationship of
dysentery to rheumatism, shadowed forth in the Newcastle essay of 1761
[1760], was formally stated by Akenside in his essay of 1764, being
perhaps the best of his various attempted originalities. It was
afterwards taken up in Germany by Stoll, Richter, Zimmermann and
others in the 18th century, and was illustrated from the Dublin
epidemics of the 19th century by O’Brien[1442] and Harty[1443]. The
doctrine of a relationship between dysentery and acute rheumatism has
been discovered in the 7th century writer, Alexander of Tralles, but
erroneously. The Byzantine writer does indeed introduce into two
paragraphs on bowel-complaint the word ῥευματισμός--one of them
relating to the alvine profluvium attending fevers or following
fevers, the other relating to “dysenteria rheumatica[1444].” But it is
clear that he is merely ascribing to the diarrhoea in the one case and
to the dysentery in the other a rheumy nature, on certain theoretical
grounds of humoral pathology; there is no reference to joint pains or
muscular pains, or to anything else connoted in the later use of the
word rheumatism. The idea is originally an English one, from the
middle of the 18th century, and belongs most properly to Akenside,
although Wilson, a not less trained and capable observer, had recorded
the empirical fact three or four years earlier. Akenside was led to
regard dysentery “as a rheumatism of the intestines,” and to maintain
that “the cause and the _materies_ of each disease were
similar[1445].” Stoll adopted these phrases, adding that dysentery
differed from rheumatism of the joints “merely in form and situation.”
But for a few empirical facts, the relationship would be thought
fanciful. These, however, may be finger-post instances, pointing to
the true pathology of a somewhat mysterious malady. They are simple
enough: e.g. cases of dysentery have “degenerated,” as Wilson said,
into rheumatism; or cases of acute rheumatism, treated by purging,
have developed the gripings, tenesmus and stools of dysentery; or, in
a time of dysentery, cases have occurred in which the symptoms of the
latter were joined to those of acute rheumatism, or cases in which the
symptoms of the one disease obtained, say for twenty-four hours, to
give place to the symptoms of the other. Again there are countries
such as Lower Egypt where the frequency of dysentery is not more
remarkable than the frequency of rheumatic fever. Harty points out
that the rheumatic complications of dysentery seem to have arisen only
when the latter malady was improperly treated by opium and
astringents; but, howsoever the signs of affinity were called forth,
they may prove to be true indications for the pathology. The
circumstances of taking dysentery are those of taking rheumatic
fever--exposure to chill after being heated with labour[1446]. In
rheumatism the effect of the chill falls upon the great groups of
voluntary muscles, pain being manifested at the surfaces where the
muscular work is applied, namely the joints; while the redness, heat
and swelling are as if restricted to the tissues by which the muscles
become effective, namely the tendons, aponeuroses, ligaments and
synovial membranes[1447]. In dysentery, it may be said, the effect of
the chill falls upon the great involuntary muscle, that of the
intestine, or upon a section of it, a muscle which serves, so to
speak, as its own tendons and insertions, and is the seat of its own
pains, while the tissues next to the muscular, the submucosa and
mucosa with the lymph-follicles, become the seats of congestion,
inflammation and suppuration. In acute rheumatism, the muscles
generate heat without doing any work; in dysentery there is often
febrile heat (although not invariably), and the work of the
involuntary muscle is paroxysmal and ineffective. In some such way the
parallel suggested by Akenside might be followed out.

After 1762, the next period of epidemic dysentery in England was from about 1779 to 1785, a period when agues also were epidemic, as well as workhouse fevers and typhus under its various names. In London it was prevalent in the autumns of 1779, 1780 and 1781, a strictly autumnal disease like the diarrhoea of children or the cholera nostras of adults. From the list of symptoms, the latter disease must have formed part of the dysenteric epidemic:--“profuse watery evacuations, mucous evacuations mixed with blood, gripings, tenesmus, pain in the back and loins, fever.” Some had tormina without flux. Some few old and infirm died; but usually the malady yielded to treatment[1448]. It is heard of also at Liverpool about 1784[1449], and its prevalence at Plymouth called forth an essay[1450]. It must have been a considerable disease in the dockyard towns; for a body of troops, originally numbering 2800, which arrived at Kingston, Jamaica, in the beginning of August, had been put on board the transports in March with much dysentery and putrid fever among them, so that the diseases with which they put to sea became more violent during the five months’ voyage, and caused many deaths. Arriving at Jamaica, four hundred were sent on shore sick, exhausted with flux and fever, of whom scarce the half recovered in the military hospitals[1451]. Here we have the singular fact of transports from England bringing dysentery to Jamaica. On the other hand, Clark, of Newcastle, who had seen much of tropical maladies, says that the dysentery which became epidemic there in 1781 was introduced first into a dockyard by some sailors returned from abroad ill of the complaint, and that it soon spread among the workmen, of whom several died. But it was epidemic in London the same year; and in Newcastle itself there were extensive epidemics in 1783 and 1785, for which no foreign source was sought or found. In those years it “attacked great numbers of the poor,” as well as some of the richer class, to which Clark’s eleven cases from the epidemic of 1785 mostly belong. In the Tables of diseases treated at the Dispensary, the epidemic dysentery of 1783 and 1785 is credited with 329 cases, of which 17 were fatal; but these, of course, were but a fraction of all that occurred in Newcastle and neighbourhood. Every year until 1805 there are a few cases of dysentery in the Dispensary books; but they become fewer to that year (except in 1801 when there were 23 cases), and at length disappear from the list altogether. A remarkable outbreak of dysentery, within narrow limits, occurred in a fishing village or “town” in the neighbourhood of Aberdeen during some months of the spring and summer of 1789: “It has proved fatal to numbers. As such a disease could not be admitted into our hospital, a temporary one has been fitted up for those that are worst, and the faculty here have given their attendance by rotation[1452].”

Dysentery in the 19th century.

Willan, who was practising in London as early as 1785-6, says that dysentery had not been epidemic there from the autumn of 1780, until the autumn of 1800, his position at the Public Dispensary in Carey Street enabling him to know the prevalent diseases. In the autumn of 1800 the epidemic was extensive. There were, he says, some sporadic cases every autumn, but he never saw a fatal case of it[1453]. In Bateman’s continuation of the same records from 1804, dysentery first appears in 1805 and remains sporadic every autumn. It was “very prevalent” in the autumn and winter of 1808, but not fatal; and it was not unusual among the dispensary patients every year until these records end in 1816[1454]. The years 1800-02 form one of the more distinct dysenteric periods also for Ireland and Scotland. Old Glasgow practitioners in the severe epidemic of 1827-28 recalled the fact that they had last seen the disease about 1802, and the books of the Glasgow Infirmary bore witness to its prevalence from 1800 to 1803 or 1804. In 1801-2 there was a good deal of it also at Hamilton, among a regiment of dragoons as well as among the people at large[1455]. The troops in various parts of Ireland suffered from it in the same years[1456]. In 1808, during a somewhat unwholesome season in which agues also were met with, some cases of dysentery were admitted to the General Infirmary of Nottingham[1457]. An altogether exceptional outbreak of a dysenteric nature occurred in 1823 among the prisoners in Milbank Penitentiary[1458].

The great dysenteric period of the 19th century coincided with, or followed, the two hot summers of 1825 and 1826, the latter of which was probably the hottest and driest summer of the century. Of its prevalence in and near Leeds in 1825, Thackrah says it was “before almost unknown as an epidemic to the present practitioners of this district.” In the same summer it was unusually common in Dublin, and was epidemic the next year in other parts of Ireland as well (_supra_, p. 271). In Glasgow it began about the end of July, 1827, in the flat district to the south of the Clyde, and in the course of the autumn became prevalent in all parts of the city. An outbreak of plague itself could hardly have caused more surprise, so strange was dysentery to that generation. A few deaths by it in one crowded street of the Gorbals were mentioned in a newspaper before the disease had become general, and “gave rise to that groundless fear which pervaded and distracted the public mind during the whole course of the epidemic[1459].”

The symptoms were severe and alarming, but the fatalities were few,
perhaps not more than one in fifty attacks. The proper dysenteric
symptoms usually lasted from ten to fourteen days, and were followed
by diarrhoea, it might be, for many weeks. The morbid anatomy showed
in the mucous membrane of the great intestine the three degrees of
congestion, follicular ulceration and sloughing of the whole mucous
coat (in the sigmoid flexure and rectum). The cases were nearly all
above the age of puberty, and among the poorer classes. September and
October were the worst months. The weather was remarkably close, damp
and relaxing. One practitioner saw two cases of genuine ague in
natives of Glasgow, having never seen a case of ague before. The
ordinary cholera nostras of summer and autumn was much less frequent
than for several years before, and it was the general remark that it
had given place to the dysentery.

Having declined in the winter of 1827-28, it revived in May, and again reached a great height in the autumn of 1828, while cases of it (probably chronic, or renewals of old attacks) continued to the summer of 1830. The following table shows the number of cases treated by the poor’s surgeons in the several seasons, 1827-30; the 435 cases in the autumn of 1827 were nearly a third part of all the cases so treated (1462):

_Cases of Dysentery in Glasgow treated by the Surgeons to the Poor._

Quarter 1827 1828 1829 1830

Feb.-April -- 28 29 26
May-July -- 62 35 26
Aug.-Oct. 435 261 50 --
Nov.-Jan. 143 68 22 --

It extended to the villages and country districts all round Glasgow. It was believed to be somewhat general in Scotland in 1827-28, but the only answers to a circular of queries sent out by the editors of the ‘Glasgow Medical Journal’ came from Hamilton (and Bothwell), Ayr and Callander (including the flooded valley of the Teith and the Braes of Balquhiddar)[1460].

In Edinburgh the outbreak of dysentery began about the end of July, 1828, a year later than in Glasgow, just as the epidemic in that city was a year or more later than in Dublin. Attacks of it were numerous among the patients admitted to the Edinburgh Infirmary for other diseases; but it occurred at the same time throughout the city generally and in the country around; “nor has it been confined entirely to the lower orders.” In the imperfectly kept register of the Infirmary there were 42 admissions, with 11 deaths, from August to October. Christison, who treated some of these, had never seen dysentery before[1461]. The morbid anatomy was the same as at Glasgow--congestions, numerous small ulcerations especially of the transverse colon, or sloughing of considerable portions of the mucous membrane.

In the same years 1827-28 there was much dysentery in the Lunatic
Asylum at Wakefield. It is well known that aged paupers in workhouses
or asylums are peculiarly subject to the epidemic influences that
produce diarrhoeal or choleraic sickness; and there had been much of
that disease in the West Riding Asylum from its opening in 1819. Some
cases of dysentery had also occurred, but it was not until after the
exceptional summer of 1826 that they became common. In 1828 there were
55 cases among 375 inmates, mostly in old and incurable lunatics, the
fatalities being at the very high rate of one in four. The morbid
anatomy was that of true dysentery--follicular ulceration in the
transverse colon, with occasional sloughing of large pieces of the
mucous membrane. The whole sewage of the asylum collected in cesspools
or “tanks of ordure” within a few feet of the wards[1462].

The causes of the rare and surprising outbreak of dysentery in 1827-28 were much debated. In Glasgow it was remarked that the choleraic complaints of the summer and autumn were much less frequent than usual; also that the first season of it, the year 1827, was remarkable for rain every day for some months, and for a close, oppressive, relaxing atmosphere. Brown, of Glasgow, thought the weather might account for it, the labouring class being thereby made peculiarly subject to heats and chills, which, grafted upon the usual bowel-complaints of the season, easily turned them to dysentery. Dr Andrew Buchanan was of opinion that exhalations from the soil were the chief, if not the sole, exciting cause of dysentery, reserving the question of contagiousness. Other forms of miasmatic febrile disease, formerly rare, had, he said, made their appearance of late years and become epidemic. Christison had already spoken in the same sense for the Edinburgh outbreak. For five or six weeks, he said, before the dysentery appeared there in the end of July, 1828, the tendency to bowel affections during the epidemic fever (which was chiefly of the relapsing type) was increased in a very marked degree. The same tendency continued throughout the whole progress of the dysentery; “nay in some instances true acute dysentery was formed during the height or towards the termination of continued fever; and now that the dysentery has in great measure disappeared, or assumed a mild form, the tendency of low gastro-enteric inflammation to accompany continued fever is very strongly marked, perhaps is more frequent than ever.” This may relate to a remarkable outbreak of fever among the richer classes in the New Town of Edinburgh, more talked about than written on, which seems to have been enteric or typhoid, according to the clinical history of a case of it that came from Edinburgh to Hamilton and was recorded by a physician of the latter place[1463]. It was more especially that strange epidemic in Edinburgh that Dr Andrew Buchanan had in mind when he wrote that the dysentery of 1827-28 was not the only disease due to exhalations from the soil with which Scotland had of late been visited[1464]. This is an instructive line to take in seeking an explanation of the dysentery of 1827-28, even if we keep something of the old doctrine of heats and chills as affecting those who labour in a damp atmosphere. The ground-water theory of miasmatic infective diseases was not then formulated; but there has rarely been in our latitudes so signal an instance of extreme drought and heat followed by excessive dampness as in the two years 1825 and 1826, and the year 1827. The second dry year, 1826, was certainly the season when enteric fever was described and figured for the first time in London. It was said, also, that enteric cases occurred among the relapsing fever and dysentery of Dublin in the same year; and enteric cases are known to have occurred in Edinburgh towards the end of the epidemic of relapsing fever and dysentery, which was one or two years later in that city than in Dublin. In Glasgow, where the dysentery was probably a more extensive outbreak than elsewhere, there appears to have been at that time no enteric fever; in London, on the other hand, where there was a good deal of the latter, there does not appear to have been any notable prevalence of dysentery.

Along with the cholera nostras which was unusually common in the autumn of 1831, just before the outbreak of Asiatic cholera, there was some dysentery, notably an epidemic at Bolton[1465]. At the end of the Asiatic cholera of 1832 a succession of cases of dysentery occurred in the Edinburgh Charity Workhouse[1466].

The next occasion of dysentery was the autumn of 1836, which was, like that of 1827, a wet season. The outbreak at Glasgow on this occasion is recorded only in a few figures (the medical journal of the city having ceased to appear for a time), according to which there were 144 cases throughout the year treated by the surgeons to the poor, of which 8 were fatal, and 15 cases sent to the Infirmary, of which 4 were fatal[1467]. At Dundee also, from October to December, 1836, bowel-complaints were not unusual among the cases of typhus, which occurred in hundreds. “Many of the cases of diarrhoea and dysentery,” said Arrott, “occurred in December, and were accompanied by catarrhal and rheumatic symptoms, implying an origin distinct from the bilious diarrhoea and bilious vomiting of summer.” Of 22 cases of dysentery at the Infirmary, 2 were fatal[1468].

Next year, 1837, there occurred in Somersetshire a remarkable epidemic which was for the most part dysenteric. It was seen first at Bridgewater, and in July it caused two deaths at Taunton, where it afterwards prevailed with high malignancy. Of 223 deaths, 206 were set down to dysentery, 16 to diarrhoea and 1 to cholera; the high ratio of children’s deaths in the following table of ages is in accordance with other recent experiences to be given in the sequel:

Over
Ages 0-5 -10 -15 -20 -30 -40 -50 -60 -70 -80 -90 90

Deaths 93 17 11 7 6 3 7 16 26 24 11 2

The monthly mortalities were, 75 in August, 105 in September, 29 in October, 10 in November, 2 in December. The epidemic spread partially amongst the unions around Taunton[1469].

In London from the beginning of registration (1837) until 1846, the deaths set down to dysentery averaged fully a hundred in the year--a statistical fact to which there is nothing corresponding in contemporary writings: Watson said it was hardly ever seen in practice except in the chronic form among sailors and soldiers who had contracted it abroad. During the prevalence of the “Irish fever” of 1846-48, the disease was truly epidemic and a cause of many deaths along with typhus itself, especially in Liverpool and mostly among destitute Irish. In 1846 it was in Milbank Penitentiary[1470]. A most instructive instance of its connexion with the Irish emigration occurred at Penzance in the summer and autumn of 1848.

The brig ‘Sandwich’ sailed from Cork for Boston, U. S., in the end of
May, carrying a number of Irish farmers and their families. Having met
with rough weather and head winds she put in leaky to Penzance on 7
June, sixteen days out from Cork. The provisions had been bad and
there was sickness in the ship, with a very filthy state of things.
Three of the women passengers died on shore of dysentery. The ship
sailed again on 10 July, two more of the emigrants dying of dysentery
before she reached Boston, while two of the crew survived the attack.
On 16 July, two cases of the same disease occurred among the lower
class in Penzance, and thereafter the epidemic spread widely through
most parts of the town and the three adjoining parishes of Madron,
Galval and Paul, causing a great mortality, as in the following table:

_Deaths from Dysentery in Penzance and three adjoining parishes._

1848

Deaths from all
Deaths from Deaths from Total causes in
Dysentery in Dysentery in deaths from Penzance and 3
Penzance town 3 other parishes Dysentery other parishes

July 5 0 5 31
August 37 1 38 71
Sept. 26 12 38 67
Oct. 13 9 22 48
Nov. 1 1 2 31
-- -- --- ---
82 23 105 248

As many as five hundred cases were under medical treatment in the
town. No death occurred there or in the three parishes within the
registration district after 10 November, “but very many in the country
beyond its limits.” Of the 105 deaths in the table, 46 were of young
children, 35 of aged persons, and 24 between the ages of five and
sixty years[1471]. There was no resisting the evidence that an
infection had been introduced by the weather-bound Irish emigrants;
instances were also known of new foci in the country districts having
been created by domestics or others suffering from dysentery who had
been sent from Penzance to their homes. At the same time the summer
had been exceptionally wet, the rainfall having been as follows:

Inches of rain

May 0·777
June 3·287
July 3·277
Aug. 4·972
Sept. 3·042
Oct. 4·425
Nov. 3·981