Decrease of Typhus and Dysentery after 1849.

The potato famines of 1845-48 were a turning-point in the history of Ireland. From that time the population has steadily declined and the well-being of the people steadily improved. By the Census of 1871 the population was 5,386,708, by that of 1881 it was 5,144,983, by that of 1891 it was 4,704,750. Registration of births and deaths, which began in 1864, shows the following samples:

Year Births Deaths
1867 144,318 98,911
1871 151,665 88,720
1880 128,010 102,955
1888 109,557 85,892

The enormous amount of pauperism which followed the great famine was at length brought within limits: from 1866 to the present time it has been marked by a steady increase of out-door relief, and by some increase in the numbers within the Union Workhouses; the out-door paupers have increased from 10,163 on 1 Jan., 1866, to 53,638 on 1 Jan., 1881, the absolute number of indoor paupers having remained, on an average of good and bad years, somewhat steady in a declining population.

The public health has been undisturbed by great epidemics since the potato famine, although the effects of that calamity did not wholly cease until some years after. It is best estimated by the mean annual average of deaths among a thousand inhabitants, a ratio which has been low for the provinces of Connaught and Munster, and not excessive for the provinces of Ulster and Leinster. The following tables are of the death rates in two sample years, 1880 and 1889 respectively[525]:

1880 1889
Connaught 15·3 12·4
Munster 19·5 15·1
Ulster 20·0 16·8
Leinster 23·3 18·3

Four healthiest counties:

1880 1889
Mayo 14·5 Galway 11·8
Sligo 15·3 Kerry 12·1
Galway 15·6 Leitrim 12·1
Roscommon 15·8 Cavan 12·2

Four unhealthiest counties:

1880 1889
Dublin co. 31·7 Dublin co. 24·5
Waterford co. 24·9 Antrim 21·2
Louth 22·6 Down 18·6
Antrim 21·9 Armagh 17·0

The higher death rates of some counties are chiefly owing to their greater urban populations. The health of the cottier districts is remarkably good, and is rarely if ever disturbed by any morbus miseriae. The cabins, except in a few remote parts, are more comfortable than they used to be, the diet is better, the clothing is better, the education of the children is better. The present happier lot of the Irish peasantry can be measured not unfairly by the statistics showing the decrease in the number of cabins of the lowest class, and the increase of dwellings in the higher classes.

The history of fever and dysentery in Ireland subsequently to the great epidemics of 1846-49 has few salient points. Dysentery, the old “country disease,” has steadily declined to about a hundred deaths in the year, while the considerable mortality from diarrhoea, nearly two thousand deaths in a year, is nearly all from the cholera infantum or summer diarrhoea of children in the large towns. The history of the continued fevers is made complex by the modern identification of typhoid or enteric fever. According to the testimonies of several, it played but a small part in the epidemics of 1846-49, even in Dublin itself[526], and it can hardly be doubted that its recent increase in that city is not apparent but real. The following table from the year 1880 to the present time will show how the deaths from continued fever are now divided in the registration returns:

Year Typhus Simple
continued		 Enteric
1880 934 1073 1087
1881 859 774 813
1882 744 657 844
1883 810 593 853
1884 628 572 693
1885 505 443 716
1886 394 380 772
1887 405 385 740
1888 362 330 741
1889 359 250 968
1890 391 231 855
1891 266 183 859
1892 268 210 714

This decline of typhus in a country where for many generations it seemed to be a national malady is a remarkable testimony to the influence of the changed conditions which have made typhus rare everywhere.

There are some interesting points in connexion with Irish typhus since 1849. After the subsidence of the great epidemic of relapsing and typhus fevers (1847-49), says Dr Dennis O’Connor, of Cork, “intermittent fever made its appearance, and, as long as it lasted, scarcely a case of continued fever was seen. As soon as the last cases of intermittent disappeared, the present epidemic broke out (1864-65), and still rages with much severity. This alternation of continued and intermittent fever is remarkable. Indeed it might have been observed that the fever of 1847 passed first into a remittent form, and gradually into the intermittent which prevailed more or less for ten years subsequently[527].” The same succession of relapsing fever by intermittent fever was observed after the epidemic of 1826 by Dr John O’Brien, of Dublin[528]. The epidemic of fever which Dr O’Connor describes for Cork in 1864-65, appeared in Dublin about the same time—the latter half of 1864. It was of the nature of typhus in both cities, cerebro-spinal in part, but probably not typhoid[529]. At Cork it had some peculiarities—a croupous-like exudation on the tongue, resembling thrush in the mouth, and a dark mottled rash (rubeola nigra), or fiery red spots on a dark red ill-defined base. “The true typhoid rash has been seen but seldom, and the petechiae of genuine typhus, so frequent in former epidemics, have been equally rare. The latter I attribute to the improved condition of our poor in good clothing and the ventilation of their dwellings.” The intellect was little disturbed in this fever, there was usually a crisis about the fourteenth day, and there were no relapses. The sequelae were peculiar—“great nervous debility, leading to a semi-paralysed state of the limbs,” congestion of the lungs, sometimes solidification, or gangrene or suppuration of them. It occurred at a time “when the food of the people is most abundant and of the best quality.” There had been three bad harvests in succession from 1860, but it may be inferred from a Dublin article of August, 1863, that no epidemic of typhus had arisen in Ireland down to that date, although there was much typhus in England, especially in Lancashire owing to the “cotton famine.” When the epidemic did arise in Dublin, Cork, and doubtless elsewhere in Ireland, in the latter part of 1864, to continue throughout 1865, it was not connected with scarcity or distress among the common people. On the other hand, Dr Grimshaw, of Dublin, found that it was subject to influences of the weather, as if the infective principle had been a soil poison like that of plague, yellow fever, cholera, or enteric fever. Taking the Cork Street Fever Hospital for his study, he made out that there was a very close correspondence, from the 29th of May to the 31st of December, 1864, between the fluctuating pressure upon its accommodation and the periodic rises in the atmospheric moisture and heat, the crowd of patients being always greater when a high temperature coincided with a large rainfall[530]. One would not have been surprised to find some such law as that in enteric or typhoid fever, although a correspondence from day to day is subject to many sources of fallacy; but, by all accounts, the disease was typhus, the last of the considerable outbreaks of it in Ireland hitherto, and an outbreak that seemed to require, both at Cork and Dublin, the language of Sydenham’s epidemic constitutions for its adequate description. For a good many years, the continued fever of Dublin has been chiefly enteric or typhoid. As late as 1862 a physician to the Fever Hospital, unconvinced by the method of Sir William Jenner, believed that he observed a transition from the old typhus into the new enteric: “The change at first seemed to be to the gastric type; to which was shortly added diarrhoea in nearly every instance; and this latter, again, occurring in a large number of cases which presented all the characters of typhus, including a dense crop of petechiae[531].” Assuming that there had been a mixture of cases of enteric and typhus fevers, the latter must have had diarrhoea among the symptoms, as they often had in special circumstances (as well as tympanitis). Since that time the species of typhus has greatly declined, and the species of typhoid has considerably increased. The remodelling which Dublin has undergone, like all other old cities, explains the one fact. The notorious Liberties have been in great part rebuilt, and the conditions of typhus, as well as its actual fomites, to that extent removed. On the other hand, something has happened to encourage the soil poison of enteric fever. It is not easy to say what are the conditions that have favoured the enteric poison in modern towns; but there can be little doubt about the fact in general, or that Dublin and Belfast are among the best fields for the study of the problem[532].

CHAPTER III.

INFLUENZAS AND EPIDEMIC AGUES.

Epidemic agues are joined in the same chapter with influenzas for the reason that they can hardly be separated in the earlier part of the history. Until 1743 the name influenza was not used at all in this country. The thing itself can be identified clearly enough in certain instances from the earliest times. But there are periods, such as 1657-59, 1678-79, and 1727-29 when short waves of epidemic catarrhs or catarrhal fevers came in the midst of longer waves of epidemic agues, “hot agues,” or intermittents, the whole being called by the people “the new disease,” or “the new ague,” while by physicians, such as Willis and Sydenham, they were taken to be the distinguishable constituent parts of one and the same epidemic constitution. The last period in which epidemic agues were so recognised and named in England was from 1780 to 1785; and in the midst of that also there occurred an epidemic catarrh—the “influenza” of the year 1782. It is possible that our own recent experience of a succession of influenzas, or strange fevers, from 1889 to 1893, in some respects the most remarkable in the whole history, would have seemed an equally composite group if they had fallen in the 17th century and had been described in the terminology of the time and according to the then doctrines or nosological methods. Without prejudice to the distinctness and unity of the influenza-type in all periods of the history, I am unable, after trying the matter in various ways, to do otherwise than take the epidemics of ague in chronological order along with the influenzas. As the history will require the frequent use of the name “ague,” and, in due course, that of the name “influenza,” it will be useful to examine at the outset their respective etymologies and the meanings that usage has given to them.

Originally the English name ague did not mean a paroxysmal or intermittent fever, or a fever with a long cold fit followed by a hot fit, or the malarial cachexia with sallowness, dropsy and enlarged spleen, or any other state of health arising from the endemic conditions which are known as malarial over so large a part of the globe in the tropical and sub-tropical zones. It meant simply acuta, the adjective of febris acuta made into a substantive. Thus Higden’s reference in the Polychronicon (which is exactly in the words of Giraldus Cambrensis a century and a half before) to the febris acuta of Ireland is translated by Trevisa (14th cent.): “Men of that lond haue no feuere, but onliche the feuere agu, and that wel silde whanne”; and by an anonymous translator: “The dwellers of hit be not vexede with the axes excepte the scharpe axes, and that is but selde[533].” Again in the MS. English translation of the Latin essay on plague by the bishop of Aarhus, the acute fever which is described as the attendant or variant of bubo-plague proper (well known long after as the pestilential fever, a malignant form of typhus), is thus rendered:

“As we see a sege or prevy next to a chambre, or of any other particuler thyng which corrupteth the ayer in his substance and qualitee: whiche is a thing maye happe every daye. And therof cometh the ague of pestilence. And aboute the same many physicions be deceyved, not supposing this axes to be a pestilence.... And suche infirmite sometime is an axes, sometime a postume or a swellyng—and that ys in many thinges.”

The same use of ague is continued in the first native English book on fevers, Dr John Jones’s ‘Dyall of Agues,’ which has chapters on plague as well as on pestilential fever and on all other fevers including intermittents. In Ireland the name of ague was applied until a comparatively late period to the indigenous typhus of the country, as if in literal translation of the febris acuta first spoken of by Giraldus in the 12th century. Ague in early English meant any sharp fever, and most commonly a continued fever. The special limitation to intermittents appears to have followed the revival of the study of the Graeco-Roman writers on medicine, Galen above all, in the sixteenth century. But Jones, who was freer than the more academical physicians of his time from classical influences, is shrewd enough to see that it was a mistake to transfer the experiences of Greece verbatim to England and to make them our standard of authority: he is speaking, however, not of intermittents but of the simple ephemeral fever, or inflammatory fever of one day:

“Such as have the fever of heat or burning of the sun, sayeth Galen, theyr skin is drye and hot as that which is perched with the sun; of the which, in this orizon and countrye of oures, we have no great nede to entreate of, leaving it to the phisitions and inhabitantes that dwell nerer to the meridionall line and hoter regions, as Hispaine and Africke[534].”

At a later date, when the Hippocratic tradition had displaced the Galenic, Rogers of Cork, perhaps the earliest writer on fevers whose observations are essentially modern, has occasion thus to reflect upon the extreme deference of Sydenham to his Greek model: “Again we learn from Hippocrates that fevers in the warmer climates of Greece, at Naxos, Thasos or Paros, ran their course in certain periods of time, which no ways answers in regions removed at a farther distance from the sun,”—Rogers himself having had no experience of intermittents among all the fevers and dysenteries that he saw from 1708 to 1734, although Cork was surrounded by marshes[535].

At the time of the Latin translations of Greek medical writings by Linacre and Caius in the Tudor period, there were in this country actual experiences of strange fevers, which were interpreted according to the Greek teaching of quotidians, tertians and quartans, with their several bastard or hybrid or larval forms. These, as I have said, were certainly not the endemic fevers of malarious districts; they were, on the contrary, widely prevalent all over the country during one or more seasons in succession and more occasional for a few years longer; then there would be a clear interval of years, and again an universal epidemic of “the new fever,” “the new acquaintance,” “the new ague” or the like.

Sydenham, for example, has much to say of agues or intermittents prevalent in town and country for a series of years, and then disappearing for as long a period as thirteen years at a stretch. But he does not count these as the agues of the marsh; his single reference to the latter is in his essay on Hysteria, where he interpolates a remark that, if one spends two or three days in a locality of marshes and lakes, the blood is in the first instance impressed with a certain spirituous miasma, which produces quartan ague, and that in turn is apt to be followed, especially in the more aged, by a permanent cachectic state[536]. If Sydenham had intended to bring all the intermittents of his experience into that class, he would not have left the paludal origin of them to a casual interpolated remark. On the other hand, he refers the epidemic agues, which occupy his pen so much, to emanations from the bowels of the earth, according to a theory of his friend Robert Boyle, applied by the latter to epidemical infections in general and to epidemic colds or influenzas in particular. Sydenham and his learned colleagues were not ignorant of the endemic agues of marshy localities, but they made little account of them in comparison with the aguish or intermittent fevers that came in epidemics all over England.

In admitting the reality of such agues, we must be careful not to ascribe them to such conditions as Talbor, the ague-curer, found in one village in Essex. We must be careful not to do so, because there are plausible reasons for doing so. The ground is much better drained now than formerly; there is less standing water, fewer marshes, a much smaller extent of water-logged soil. But the malarious parts of England have been tolerably well defined at all times; and at all times the greater part of the country was as little malarious as it is now. It is the frequent reference to agues in old medical writings that has led some modern authors to construct a picture of a marshy or water-logged England, for which there is no warrant. Cromwell died of a tertian ague which he caught at Hampton Court; therefore “the country round London in Cromwell’s time” must needs have been “as marshy as the fens of Lincolnshire are now.” The country round London was much the same then as now, or as in John Stow’s time, or as in the medieval monk Fitzstephen’s time, or as it has ever been since the last geological change. The ague of which Cromwell died in the autumn of 1658 was one of those which raged all over England from 1657 to 1659—so extensively that Morton, who was himself ill of the same for three months, says the country was “one vast hospital.” Whatever was the cause of that great epidemic of “agues,” and of others like it, we have no warrant to assume that “the country round London,” or wherever else the epidemic malady prevailed, was then as marshy as the fens of Lincolnshire[537].

The other name in the title of this chapter, influenza, appeared comparatively late in the history. It is an Italian name, which is usually taken to mean the influence of the stars. It may have got that sense by popular usage, but the original etymology was probably different. As early as the year 1554 the Venetian ambassador in London called the sweating sickness of 1551 an influsso, which is the Italian form of influxio. The latter is the correct classical term for a humour, catarrh, or defluxion, the Latin defluxio itself having a more special limited meaning. It was not astrology, but humoral pathology, that brought in the words influxio and influsso; and I suspect that influenza grew out of the latter, but not out of the notion of an influence rained down by the heavenly bodies.

It was in 1743 that the Italian name of “influenza” first came to England[538], the rumour of a great epidemic, so called, at Rome and elsewhere in Italy having reached London a month or two before the disease itself. The epidemic of 1743 was soon over and the Italian name forgotten; so that when the same malady became common in 1762, some one with a good memory or a turn for history remarked that it resembled “the disease called influenza” nearly twenty years before. After the epidemic of 1782, the Italian name came into more general use, and from the beginning of the present century it became at once popular and vague. The great epidemics of it in 1833 and 1847 fixed its associations so closely with catarrh that an “influenza cold” became an admitted synonym for coryza or any common cold attended with sharp fever. Lastly, the series of epidemics from 1889 to 1893 effectually broke the association with coryza or catarrh.

Before influenza became adopted as the common English name towards the end of last century, what were the names popularly given to the malady in this country? The earliest references to it are in the medieval Latin chronicles under the name of tussis or cough, or in some periphrasis. In the fifteenth century the English name was “mure” or “murre,” which appears to be the same root as in murrain. Thus the St Albans Chronicle, under the year 1427, enters a certain “infirmitas rheumigata,” which in English was called “mure”; and the obituary of the monks of Canterbury abbey has two deaths from “empemata, id est, tussis et le murra[539].” In the Tudor period there is no single distinctive name, unless it be “hot ague”: in 1558 the name is “the new burning ague,” in 1562 “the new acquaintance,” in 1580 “the gentle correction,” and at various times in the 17th century “the new disease,” “the new ague,” “the strange fever,” “the new delight,” “the jolly rant.” Robert Boyle called one sudden outbreak “a great cold.” Molyneux, of Dublin, mentions “a universal cold” in one year (1688), and “a universal transient fever” in another (1693). The earlier 18th century writers mostly use the word catarrh or catarrhal fever, either in Latin or in English, the popular names probably continuing fanciful as before, as for example Horace Walpole’s “blue plagues.” That which stands out most clearly in the English naming from the earliest times is the idea of something new or strange; but the newness or strangeness pertained quite as much to the agues as to the catarrhs. The notion of ague may be said to be uppermost in the 16th and 17th centuries, that of catarrh in the 18th and 19th; while our very latest experiences have once more brought a suggestion of ague to the front.