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].

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:

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

The returns were incomplete at first; and, for London, the figures of only three parishes are given:

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.

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:

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).

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.

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.

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.

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.

The deaths by infantile diarrhoea have a seasonal rise more marked than that of any other malady. In the curves formed by Buchan and Mitchell of the rise and fall of the deaths by various diseases in London throughout the year, that of diarrhoea was the sharpest, rising to a high peak in the third quarter of the year (July-Sept.). “Speaking generally,” says Dr Ogle, “it appears from the returns of mortality in London that the diarrhoeal mortality becomes high when the mean weekly temperature rises to about 63°F.[1402]” The season is practically the same throughout the British Isles. But in warmer countries, such as the more southern of the United States of America, infantile diarrhoea is “the April and May disease.” It is not the fatalities only, but the cases as a whole, that fall decidedly upon the third quarter of the year[1403].

Causes of the high death-rates from Infantile Diarrhoea.

Sydenham said that the diarrhoea or bilious colic of London in the month of August differed toto coelo from that of other seasons of the year; and Harris, writing in the year of Sydenham’s death (1689), said that more infants, affected with the epidemic gripes, died in one month of the hot season, from mid-July to mid-September, than in other three that are gentle. If this were taken to mean that the infantile mortality from all causes was trebled by the prevalence of diarrhoea during the eight warmest weeks of the year, it would be nearly borne out by the weekly bills of mortality, according to the examples given of them from the more fatal years. So far from the deaths of infants in London by summer diarrhoea having increased in the present century, they would appear to have diminished greatly. The two worst weeks of an unhealthy summer or autumn raised the London deaths in former times relatively as much as the whole diarrhoeal season would do now. If this great change for the better be admitted as correct, it may throw some light upon the causes of excessive infantile diarrhoeal mortality in London in former times, and in some other English towns at the present time.

The London populace in the 17th and 18th centuries were not only the single great urban community in the kingdom, but they were far more “urban” than now, in Milton’s sense of being

“long in populous city pent,
Where houses thick and sewers annoy the air.”

The houses stood closer together, many of them back to back in courts and alleys. The streets were narrower. The inhabited area had few or no open spaces besides the bed of the Thames. Not only the City and Liberties, but also the out-parishes were compact, as if within a ring fence, joining on to the open country abruptly, and not as now in straggling suburbs. It was hardly possible to take children out for an airing, except in the west end. When Lettsom about 1770 applied the fresh-air treatment to convalescent cases of typhus, he had to send the patients to loiter on the bridges spanning the Thames. As Cobbett said, London was a “great wen,” in the correct sense of a shut sac which grew by distension. The soil was full of organic impurities, including the decompositions of many generations of the dead. A hot summer in former times raised effluvia from the ground such as the modern residents have no experience of. The life indoors was equally adverse to infants. Fustiness was favoured by the window-tax; a tenement-house was apt to be pervaded by the excremental effluvia from the “vault” at the bottom of the stair. The worst time of all in London was the great drunken period from about 1720 onwards. Doubtless drink was then used, as it is sometimes now, to drug the fretful infants into torpor; but it told also upon them indirectly, inasmuch as dissolute parents would have bred children with mala stamina vitae[1404]. In all these respects there has been so great an improvement in London that, although its population now exceeds four millions, its death-rate from infantile diarrhoea, a distinctively urban disease, exceeds only by a little the mean of all England and Wales.

While the mortality from infantile diarrhoea in London has undoubtedly decreased since the 17th and 18th centuries per head of the population, it is equally certain that there has been within the present century a great relative increase of the deaths from that cause in the country generally. The reason is that there has been an enormous increase of population and that the increase has been almost wholly urban. The rise of new manufacturing towns, with the great extension of the borders of old towns, as in Lancashire and Yorkshire, has inevitably brought to the front this distinctive fatality of town-bred infants. If the additional millions had been dispersed in village communities over the face of the country, as in Bengal, the mere density of population per square mile would have had its effect on the public health, but not the same effect. There are now two or three provincial cities comparable in size to 18th century London, and there are some twenty more large enough to be in the same group. In most of these the mortality from infantile diarrhoea has held its ground, for all the improvements in sanitation and in well-being whereby the death-rate from all causes has been considerably reduced. It is mainly owing to that disease, and to whooping-cough, that the death-rate in the first year of life, although it has ranged widely from year to year, has fallen but little in the successive decennial periods. The bad eminence of some towns in the list already given is probably due to a composition of causes, among which the situation, soil, depth of ground-water, and the like, would count. It is remarkable, however, that there are only a few of them, such as Liverpool and Hull, that have been the chosen seats of great epidemics of Asiatic cholera. On the other hand, Leicester and Birmingham never had an epidemic of that disease, while Preston and the cotton-weaving towns of Lancashire generally have had but slight outbreaks of it. Again, the deaths from diarrhoea have been more purely infantile in the group of towns which have had little or no Asiatic cholera[1405].

That which distinguishes the Lancashire and West Riding towns with highest proportions of diarrhoeal death-rates in their infantile death-rates generally, as well as such towns as Leicester, Worcester, Northampton, Coventry and Norwich, Birmingham, Nottingham and Stoke-on-Trent, is the extensive employment of women in factory work and other labour of the factory kind. The Census returns do not adequately show this for married women, who may be returned simply as of the married rank whether they be wage-earners or not; but it is well known that the female labour of industrial towns is to a large extent the labour of child-bearing women. Among the towns that stand highest for infantile diarrhoea, Preston, in the Census of 1881, had 32 per cent. of its adult female population occupied in the cotton mills; Leicester had 20 per cent. of all its women occupied in various industries, of which the chief are the hosiery and boot-making; Northampton only 13 per cent., all at boot-making; Worcester, a percentage, unknown for the city, occupied mostly at glove-making; Norwich about 10 per cent. of its women returned as employed at boot-making, silk manufacture, and various smaller industries.

One obvious result of married women engaging in factory labour, or piece labour of the same kind at home, is that they do not suckle their infants; and it has long been known that infants brought up with milk from a feeding-bottle are much more liable to diarrhoea than infants brought up at the breast. But the feeding-bottle is now too universal an appurtenance of infancy among all classes and in all places to be a sufficient explanation without something else, although there is no doubt that feeding-bottles which are not kept very carefully clean are a real danger in the particular way. Again, young children above the age for suckling or feeding by the bottle are attacked by summer diarrhoea in about the same proportions (e.g. at Leicester) as infants under one year, although they do not contribute an equal quota to the death-roll.

In the discussions upon this question it has been commonly assumed that the fault lies with the mother after the birth of her child, and all the remedial measures, such as crèches for the infants of workwomen, have that assumption underlying them[1406]. I believe that this is a very inadequate account of the cause of this great modern evil, and that the remedies proposed are mere palliatives which are destined to fail. The importance of the matter may justify me for once in making an excursus into physiology and pathology.

While the connexion of rickets in the child with the laborious or anxious preoccupations of the mother during gestation can be followed out in physiological or pathological detail, the connexion with the same of a disposition to summer diarrhoea remains empirical, except in so far as it is a part of the rickety constitution itself. Some congenital weakness, we may suppose, attends the functions of digestion and assimilation, and, under the relaxing influence of continued high temperature, leads to vomiting and purging, to which many infants succumb through the eventual implication of the cerebral functions.