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Exterminated by the bloody fluxDr David Boyd Haycock aa Wolfson College , OxfordPublished online: 08 Feb 2011.

To cite this article: Dr David Boyd Haycock (2002) Exterminated by the bloody flux, Journal for Maritime Research, 4:1,15-39, DOI: 10.1080/21533369.2002.9668318

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Exterminated by the bloody flux

Journal Issue: January 2002

Dr David Boyd Haycock

Wolfson College, Oxford

Introduction

For every sailor who died at sea from the wounds and injuries they received in battlehundreds more succumbed to diseases. Voyages of even smaller naval vessels oftenexperienced the death of one or more crew members. The difficulties of preservingbodies many days or weeks away from the shores of Britain required burial at sea to beroutinely undertaken. Only those of great importance were brought to land for formalburial.

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On 11 October 1770, on his first voyage to the Pacific and after two years away fromEngland, Captain James Cook and the crew of the Endeavour sailed into Batavia inthe Dutch East Indies for repairs. Free from scurvy, up to that point there had not beena sick man among them. But this happy situation rapidly changed. On 26 DecemberCook recorded: 'We came in here with as healthy a ships company as need [go] to Seaand after a stay of not quite 3 months l[e]ft it in the condition of a Hospital Ship’. Thecrew had been ravaged by dysentery, which, exacerbated by malaria, had killed thirty-one men by the close of the voyage in July 17711. So much for the East Indies. Sevenyears later the Scottish naval surgeon James Lind (1716-1794), who had served in theWest Indies, wrote that it was reckoned the British dominion of Jamaica 'until lately,buried to the amount of the whole number of its white inhabitants once in five years.’He estimated that 'nineteen in twenty have been cut off by fevers and fluxes; thesebeing the prevailing and fatal diseases in unhealthy countries through all parts of theworld.’2 To consult eighteenth-century naval and military medical tracts is to witnessthe pressing importance that was held in discovering the cause and effecting a cure fordysentery. For as the former English surgeon-general in Jamaica, Benjamin Moseley(1742-1819), wrote in his Treatise of tropical diseases, during the American War ofIndependence the French, Spanish and English all saw a 'great part’ of their WestIndian forces 'exterminated by the Bloody Flux.’3 Dysentery, he wrote, was thereforea subject in which the welfare of mankind is deeply interested, and often the glory andhonour of a nation. If the cause of humanity were not alone a sufficient motive to induceto this research, we need but turn our eyes on the political field; there we may behold thebest concerted measures defeated by its influence. The page of military history weepsless for the slain in battle, than for those who have fallen victims to this calamity.4

Such were the fatalities from fevers and fluxes that in 1797 the Physician to the ChannelFleet, Thomas Trotter (1760-1832), wrote that whilst the European colonies in theIndies, Africa and America had brought 'riches and commerce’, yet they had also'brought a train of diseases peculiar to their climate, and fatal to the constitutions ofnorthern nations, and which leave us to doubt whether or not we ought to regard theseacquisitions as beneficial to society.’5

Yet despite the importance with which this disease was held in the period, the numerouseighteenth-century texts on dysentery have not previously been systematicallyexamined in their own right, and the disease receives only passing reference in Coulterand Lloyd’s volume on medicine and the navy between 1714 and 1815.6

In part, the reason for this omission is obvious: dysentery was simply toocommonplace to have attracted much attention from modern historians of medicine.And, despite its physical similarities to Asiatic cholera (see below), it did not havethe exotic shock factor of that disease, nor does it have the immediate medicalsignificance of an affliction such as smallpox. But as Roy Porter and GeorgeRousseau have pointed out in their recent study of gout, scholars’ concentrationon diseases such as smallpox, tuberculosis, typhoid and yellow fever at theexpense of less epidemic disorders, 'arguably creates an imbalance that needsredressing.’7 Given, therefore, its contemporary importance and its subsequent

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virtual disappearance from the sanitized West, the 'bloody flux’ seems worthy ofmore detailed historical attention. What follows, therefore, is a short account ofthat malady, focusing on eighteenth-century conceptions of the disease. Thoughdysentery did occur fatally amongst the general population in Europe at this time,new works on the disease generally came from men who had spent time overseas asmilitary or naval physicians. It is hoped that this study will provide a useful resourcefor other historians working within the field of eighteenth-century maritime medicine,and reinstate it as a disease of profound importance to the period. But given theextent of the primary sources devoted to the disease, all that can be offered at thisstage is an overview of the principal issues involved.

The Pathology of Dysentery

Before proceeding to examine the eighteenth century texts, it is necessary toestablish from a modern medical perspective what exactly dysentery is. The OxfordEnglish Dictionary defines it as 'A disease characterized by inflammation of themucous membrane and glands of the large intestine, accompanied with griping pains,and mucous and bloody evacuations.’ Its name is derived from the Old Frenchword dissenterie, from Greek, 'afflicted in the bowels’, and the name was used byHippocrates in his De Victus Ratione: 'When the body is heated, and there is anacrimonious purging, with corrosion and ulceration of the intestine, and bloody stools,the disease is called a Dysentery, and is a severe and dangerous disorder.’8 'Flux’is similarly defined as 'an abnormally copious flowing of blood, excrement, etc. fromthe bowels or other organs; a morbid or excessive discharge. An early name fordysentery.’ It comes from the French, flux, from Latin fluere, to flow. Dysentery is thusan infectious intestinal disorder which strikes rapidly, causing inflammation - and, inadvanced stages, chronic ulceration - of the intestines, leading to abdominal crampsand extreme diarrhoea of often (though not always) bloodied and muciferous stools. Itis often also accompanied by fever. Despite the name 'bloody’ flux, blood is not alwayspresent or visible.9 But these definitions do nothing to give an idea of the acute sufferingof the disease, and its often fatal course. Andrew Wilson, a physician from Edinburgh,described the case of a young servant girl in his own household taken sick during anepidemic of dysentery in Newcastle upon Tyne in September 1758:

I found her as violently ill as any I have ever seen, who wasnot in the last stage of the disease: Constant violent gripesand tenesmus, great heat and drought, a quick but not afull pulse, bloody, slimy stools, but no natural ones, from thevery first invasion of the disease; and, as she had almost noremission of pain, she got no sleep.

The girl died 'on the fourteenth day, with little or no delirium until within a few hoursof death’.10

It is important to note that it was unknown until the very end of the nineteenthcentury that the common appellation of 'dysentery’ was actually being applied to two

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distinct diseases, now clearly distinguished as 'bacillary’ and 'amoebic’ dysentery. Thiserror is unsurprising, as the immediate external symptoms of the two are essentiallyidentical. Following an incubation period of between one and six days, attacks ofbacillary dysentery appear abruptly, and can range from the mild to the acute. Chroniculceration of the intestines occurs in advanced stages, causing the bloodied stoolscharacteristic of 'bloody flux’. Severe dehydration and poisoning by bacterial toxinscan kill the victim within a period of some two to fifteen days. Modern bacillarydysentery epidemics in Africa and Latin America have resulted in death rates of upto 15% of those contracting the disease. Amoebic dysentery, caused by the protozoaEntamoeba histolytica, is in contrast a more chronic and insidious disease thanbacillary dysentery, and, importantly, is a long lasting and intermitting illness markedby frequent remissions. A distinguishing post-mortem feature of amoebic dysenteryare liver ulceration and abscesses as well as secondary infection in the lungs, brain,and spleen, none of which appear in the bacillary form.11 Both forms of dysenteryare transmitted by the ingestion of food or water which has been contaminated, eitherthrough faeces in the water supply, or dirty, unwashed hands preparing food, or carriedby insect vectors. The bacteria responsible for most cases of bacillary dysentery areinfectious enough to be passed on by hand-to-hand contact. Both food and waterare more easily contaminated during drought conditions, and the sick, the elderly andchildren are particularly susceptible. Amoebic dysentery can be spread by carrierswho may currently be showing no signs of the disease. As already noted, whilst itis more common in hot climates, where unhygienic conditions may be exacerbatedby environmental circumstances, dysentery in both its forms also strikes in temperateregions. However, in temperate climates bacillary dysentery is the more commondisorder, and though there are many types of bacillary dysentery, epidemics are almostalways caused by shigella dysenteriae type 1. The modern medical treatment for casesof bacillary dysentery is with antibiotics (though resistant strains are emerging) andoral rehydration therapy with water and mineral salts, but prevention rather than cureremains paramount.

The post-period definition of the two types of dysentery causes potential confusion in amodern discussion of historical sources, and inevitably complicates interpretations ofthe cause of the disease, though it may be noted that the aetiology and pathogenesisof outbreaks of diarrhoeal illnesses commonly remain obscure even today.12 To addfurther complication, dysentery was sometimes confused diagnostically with anotheracute disease of the bowels, 'cholera morbus’, as well as with simple diarrhoea.Cholera morbus, also known as 'English’, 'European’, 'Summer’ or 'Autumnal’ cholera,was a bilious disorder, and must be clearly distinguished from Asiatic cholera, whichdid not appear in England until 1831. Asiatic cholera is, in fact, an extreme form ofdysentery, and not cholera (i.e. a bilious disorder) at all. Although it was a relativelycommon (if declining) early modern European affliction, cholera morbus received fewcontemporary monographs. The similarities between these disorders of the gut weresuch that one seventeenth-century doctor observed that there was sufficient similaritybetween dysentery, cholera and diarrhoea, 'in so much that sometimes it may bea doubtful business, how to distinguish the one from the other.’13 This confusionextended to naming the disease in mortality records. Causes of death such as 'griping

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in the guts’ or 'surfeit’ could include those dying of dysentery or severe diarrhoea, aswell as of other bowel complaints.

Surgeon's medicine chest, belonging to Sir Benjamin Outram (1774–1856)

However, in 1797 James Fisher, an American medical student, wrote that whilstdysentery 'may possibly be mistaken for diarrhoea or cholera morbus’, it could bedistinguished from both by the fact of its being 'contagious’, whilst the other two werenot, nor were they generally accompanied by fever.14 Another American student, DavidAbeel, wrote in 1794 that the 'diseases which may be mistaken for dysentery arediarrhoea and cholera; but a little attention will enable the Physician to establish theproper diagnosis.15

Theories on Dysentery

In the early modern period dysentery and cholera morbus were considered classicseasonal diseases. In 1653 in his Speedy help for rich and poor Hermannus van derHeyden, a physician from Gent, observed that such epidemical diseases as these

are wont to seize upon people about the beginning ofAutumn; and sometimes also sooner, according to thetemper of the foregoing Summer, whether they had beenhotter, or cooler: & they some years rage so violently,as that they last the greatest part of the said seasons,miserably afflicting people all that while, and destroying manyof them.16

Following a severe period of dysentery, cholera morbus and 'dysenteric fever’ between1669 and 1672, Thomas Sydenham (1624-1689), the subsequently authoritativeEnglish physician on domestic epidemic diseases and fevers, explained that asuccession of very hot and dry summers had meant that 'the blood and humors …arrived to a great adustion and sharpnesse’ so that 'cholera morbus[,] gripeing in thebowels without stooles and dysenterys became very epidemicall’.17 He wrote that 'thedysentery we speak of, is the very fever itself, with this particularly, that it is turnedinwards upon the intestines, and discharges itself that way.’18 Moseley consideredthis an 'excellent aphorism’, but complained that Sydenham’s successors had made

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little further use of it than quoting it, 'as their rules laid down for treating the diseasesufficiently prove.’19 He lamented that 'the labours of medical writers, hitherto, havemet with so little success, and that their best endeavours have only shewn, how littlewe know, and how much we have to learn, in treating this disease.’20

It was generally agreed that dysentery and cholera encountered in hot climates wasthe same as that encountered in Europe. In his Essay on the diseases incidental toEuropeans in hot climates (1777) James Lind wrote of his belief that the afflictionsof different climates bore 'every where a great similitude to each other; and that theviolence or malignity of the fevers and fluxes, to which [Europeans] are subject, depend,in great measure, upon the degrees of heat and moisture, but more particularly uponthe nature of the soil and of the winds.’21 John Clark (1744-1805), a former surgeonin the East India Company’s service and author of the aptly titled Observations on thediseases which prevail in long voyages to hot countries, particularly on those in theEast Indies; and on the same diseases as they appear in Great Britain, wrote that boweldiseases were 'every where essentially the same’.22 Likewise, when John Hunter (d.1809), who had been superintendent of military hospitals in Jamaica between 1781and 1783, came to mention cholera in his Observations on the diseases of the armyin Jamaica, he explained that he did not think it necessary to discuss treatment of thissubject, 'because though a frequent disease in the beginning of the sickly season inJamaica, it is no way different from the same complaint that appears in this country[England] in the months of July and August, if the summer prove hot.23

stablishing the specific cause (or causes) of dysentery. Its apparent seasonality wasone feature considered key to diagnosis, with attention centring on two factors: weatherand diet. Van der Heyden had blamed European dysenteries on reclaimed land, lakesand marshes dried out by the Sun, which 'breath forth the like Contagious Aire … forby this means, both from the Putrefaction of dead Fishes, and other Creatures, andperhaps from some Venomous ones too, dying therein for want of Water, this MalignantVapor is drawn up, and spread abroad.’24 Although Hippocrates and other ancientphysicians had noted the dangerous effects of 'bad air’, through the experimentsby such natural philosophers as Stephen Hales and Joseph Priestly there was anincreasing interest in air and its general effect on health during the eighteenth century.As the Scottish physician John Arbuthnot (1667-1753) pointed out in his influentialEssay concerning the effects of air on human bodies, epidemical diseases were'commonly the Effects of the Temperature of the Air’. As the weather changed withthe seasons, so particular diseases could often be expected 'at stated Seasons of theYear’, with their duration and symptoms seeming

to depend upon the Alterations of the Weather, and the Stateof the Air preceding and consequent upon these Alterations.I think this may be inferr’d from the great Uniformity that isobserv’d in the Symptoms of the Epidemical Diseases of thesame Season. … A Person in perfect Health going into aPlace infected with an epidemical Disease, shall be seized

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with it without any other Error in his Diet, and even withoutSuspicion of Infection25

Whilst the 'Weather and Diseases of Countries have a good deal of Uniformity’,Arbuthnot believed extremes in weather conditions accounted for extremes in diseasesof epidemic proportions, or for uncommon characteristics in their symptoms: 'theunusual Excesses of Heat, Cold, Moisture, and Drought, produce either a greaterPleanty, or unusual Symptoms in Diseases; and operate more strongly, or theAlterations are sudden and extreme.’26 Indeed, Cook blamed the deaths of his menat Batavia on the 'unwholesome air’ which, he wrote, 'I firmly believe [sic] is the deathof more Europeans than any other place upon the Globe of the same extent, such atleast is my opinion of it which is founded on facts.’27

Diet, meanwhile, was another contender for the cause of dysentery, and was likewisea fashionable subject for eighteenth-century physicians trying to locate the sourceof human diseases in general. In 1718 in The state of physick: and of diseasesthe physician John Woodward (1665-1728) declared that 'The first Scenes, and theBeginnings of all Things, good or bad, to the Body, are in the Stomach. As Impressionsare made there, and Things transacted, rightly, or wrongly, the Body, baring exteriorAccidents, is well, or ill’.28 When the Devonshire physician John Huxham recorded about of dysentery that 'raged very greatly’ in and around Plympton in the spring of 1743,he attributed such anomalies to 'unfavourable’ seasons, when 'the Diseases peculiar tothem will be very greatly varied; so that those, which were usually met with in Autumn,will be rife in a warm moist Spring’. In Plympton’s case he suggested that this mighthave been 'owing to an immense Quantity of all Kinds of Fruit, which the Summer andAutumn of 1742 abounded every-where with’.29 A surfeit of fruits and/or cider drinkingwere commonly suggested - though much disputed - causes of autumnal dysenteries inEurope, and of fluxes in general abroad. Daniel Defoe was well aware of this last fact:when the shipwrecked Robinson Crusoe discovers vines on his Caribbean island hetakes care 'to eat sparingly of them, remembering, that when I was ashore in Barbary,the eating of Grapes kill’d several of our English Men … by throwing them into Fluxesand Feavers’.30 But Lind reckoned that whilst vegetables and 'the drinking of bad water’had both been 'highly blamed’ for causing fluxes, he thought that 'whenever this is thesole cause, the diseases will be uniform, at all seasons of the year; and the use of goodwater will prevent them: neither of which, upon experience, we find to be the case, inthe countries of which we treat.’31

If dysenteries occurred outside of their predicted season, and amongst those who hadnot eaten surfeits of fruit or drunk of bad water, there had to be something more toexplain the cause of the disease. One seriously considered cause was stellar andplanetary events, which had a long tradition as possible causes of plagues in general.The potential influence of planets on disease, particularly fevers, remained of interestto physicians throughout this period - helped in the early eighteenth century by thepopularity amongst British physicians of Newtonian physics and the gravitational theoryof action at a distance. For example Richard Mead (1673-1754), a leading Newtonianphilosopher and physician to George I, published A treatise concerning the influence

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on the Sun and the Moon upon human bodies. There he explained that epidemicfevers were caused by 'some noxious qualities of our atmosphere’ and that 'it seemsreasonable to suppose’ that such changes were influenced by the moon.32 In 1777 Lindobserved that it was 'a common observation’ that the moon or tides 'have a remarkableinfluence on intermitting fevers’, and that it had been calculated that in 1762 some'30,000 natives and 800 Europeans died in the province of Bengal, upon an eclipse ofthe moon’.33 Francis Balfour, a surgeon of the Bengal Medical Board, wrote numerouspapers on this subject. A treatise on the influence of the Moon in fevers was publishedat Calcutta in 1784 and republished in London and Edinburgh the following year, witha third edition of his collection of treatises on sol-lunar influences on fever appearing in1815.34 Even in 1828 James Annesley of the Madras Medical Establishment noted inResearches into the causes, nature and treatment of the more prevalent diseases ofIndia that the 'influence of the moon in the production of dysentery, as well as of fevers,has been much discussed’. He believed that 'a sol-lunar influence, cannot be denied byany experienced practitioner.’35 Thus one regularly finds physicians speculating uponplanetary influences as an exciting cause of dysentery, or at least including planetarydata in their case studies of the disease. Inevitably, this avenue of inquiry ultimatelycame to nothing.

One of the most detailed eighteenth-century surveys of the problem of how dysenteryarose came from the pen of Sir John Pringle (1707-1782). Trained at Leiden and settlingin Edinburgh, he later became President of the Royal Society and physician to GeorgeIII. He gained his experience of dysentery whilst acting as physician-general to theBritish forces not in the Indies, but in Flanders in 1744 during the war of the AustrianSuccession. His Observations on the diseases of the army was first published in 1752,quickly went through a number of editions, and soon gained a European- and American-wide reputation. David Abeel wrote in 1794 that dysentery was 'a disease to whichPhysicians have only of late years annexed precise and accurate ideas’, adding thatPringle was 'among the first whose observations have tended to enlarge our ideas onthe nature of this complaint.’36 Like Van der Heyden, Pringle associated dysenterywith 'ague’ or 'malaria’ - literally, 'bad air’. This bad air he divided into four types: thefirst arose

from the corrupted water of marshes; the second, fromhuman excrements lying about the camp, in hot weather,when the dysentery is frequent; the third, from straw rottingin the tents; and the fourth kind, is that which is breathed inhospitals crowded with men ill of putrid distempers.37

The association of dysentery with 'corrupted water’ and human excrement was alreadyfairly well established, though it was thought that the harm was done by ingestionthrough the nose into the lungs rather than through the mouth into the gut. As atranslation of a German tract on Common diseases incident to armies observed in 1767,healthy soldiers could be 'especially infected by the putrid exhalations of the fœcalmatters, if they use the same bog-houses as the sick.’38 Attempts to overcome fluxesand fevers by fumigation, fires, gunpowder and more pleasant smells on board ship

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were, however, in Trotter’s opinion a waste of time. He wrote in 1799 that 'The differentperfumes which have been introduced into the practice of Physic, and employed in theapartments of the sick, to cover offensive flavours, we verily believe render the air stillmore noxious, however grateful they may be to the sense of smell’.39 The olfactoryrather than the ingested source of dysentery - of 'malaria’, 'marsh miasma’, or 'vitiatedair’ - remained the popular explanation for its cause well into the nineteenth century.Henry Dewar, who observed numerous cases of diarrhoea and dysentery whilst servingwith the British army in Egypt in 1801, believed that if the diseases were contagious(a question we shall examine in detail below), this was effected through the senses ofsmell and taste, for the sensation of these organs, particularly in a disordered state,have 'an immediate influence on the intestinal.’ Thus not only a patient’s stools weredangerous because of their odour, but his breath as well, for it was 'also probable,that the vapour which proceeds from the lungs, and that which is brought up by theœsophagus in eructations, or even what is secreted in the internal f[a]eces, and carriedoff in vapour with the breath, contains the contagious effluvia of this disease.’40 Thisinterpretation persisted. In 1828 James Annesley, whilst unable to provide an answer towhat exactly 'marsh effluvia’ was, expressed his belief that it was 'chiefly to the internalsurfaces of the lungs and air passages that we are to look as the channels throughwhich malaria makes its hurtful impression upon the animal frame.’41

But there were influences other than air alone. Pringle considered cleanliness animportant preventative against dysentery, but not for the modern reasons of sanitation.Perspiration was considered a necessary process for keeping the physical frame inequilibrium: equilibrium required the removal of excess matter, be it faeces, urine,menstrual blood or sweat. If any of these patterns were upset or irregular, it wasbelieved that debility would inevitably follow. Thus if the body could not eject unwantedmatter through the skin as sweat, it would build up and cause damage to the internalsystem: dysentery or cholera morbus thus represented the subsequent violent removalof an unnatural excess of bile or humours. As such, some practitioners considereddiarrhoea to be a positive symptom, illustrative of the bodies attempt to heal itself.William Buchan, author of the hugely popular Domestic medicine, first published inEdinburgh in 1769, wrote that diarrhoea should not be considered a disease at all, 'butrather a salutary evacuation’.42 (Annesley went so far as to suggest in 1828 that if 'thegeneration and retention of morbid secretions and fÆcal matters in the large bowels’went untreated, the susceptible patient’s 'mental faculties’ could 'become disorderedin various grades … until complete insanity is established.’43) Pringle explained howit 'is well known how necessary it is to keep up the perspiration; and also, how muchthe uncleanliness of the person will concur with other things to frustrate that intention.’He therefore recommended that when patients were first admitted with fevers their feetand hands should be washed, 'and sometimes their whole body, with warm water andvinegar, and giving them clean linen.’44

Moseley in his Treatise on tropical diseases did not actually consider dysentery tobe confined 'to cold, hot, wet, or dry seasons; particular food, water, liquors, or fruit;but chiefly depending on some secret influence in the atmosphere, to on suddentransitions of the air, and such other causes as expose people to have this discharge

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hastily stopped.’45 Thus whilst he accepted that eating immoderately of certain fruitsor drinking certain water, might cause an individual case of dysentery, he believed that'the cause of epidemical diseases is no more to be considered from particular cases,than the natural life of man is to be estimated, by the age of those that fall by casualty,or perish by untimely death.’46 However, autopsy of those dying from dysentery didnot seem to provide any answers. Trotter wrote in 1797 that he had 'only dissectedone subject for this disease; nothing uncommon was detected: nor do I think that thedissections of other physicians, have thrown any light on the pathology of Dysentery,so as to direct a better method of cure.’47 Liver abscesses, a telling feature of thecystic form of amoebic dysentery, were noted by some eighteenth-century practitioners,particularly in India. Lind, for example, observed that Europeans in India, 'especiallysuch as live intemperately, are also subject to fluxes, and to an inflammation or diseaseof the liver, which last is almost peculiar to India’48. But these liver abscesses were notrecognised as indicating the presence of a disease distinct from bacillary dysentery untilthe late nineteenth century. John Peter Wade, a physician in the East India Company’sBengal Establishment, actually interpreted the dysentery as an effect - rather than acause - of these abscesses. In 1792 he published the results of the dissection of ayoung Portuguese man who had died of dysentery whilst on board ship, and reportedhis discovery of a large abscess on his liver. He concluded that the patient’s symptoms

though by no means to be misconstrued by a practitionerof any experience in India, from the great number of similarcases which occur in that climate, might easily have beenattributed to another source by the generality of physiciansof Europe. It might have been pronounced a dysentery onlyby some, and by other probably a hectic, from a consumptionof the lungs. His emaciated habit might have confirmed suchsuspicions. It was evident that the dysentery was only asymptom of the affection of the liver …49

Wade’s remarks indicate the difficulty of making a diagnosis in this period, thoughthey also show an awareness of the need for post-mortem examination. In this bookMoseley, however, withheld any account of his dissections of those dying of dysentery,as they were 'demonstrative only of its effects, which are sufficiently known to allpractitioners.’50

Contagion

The question of whether or not its 'exciting’ or 'remote’ cause (i.e. the element thatactually caused the disease, rather than the 'predisposing cause’ which rendered onemore susceptible to it) was contagious was another great controversy surrounding thestudy of dysentery. The eminent Scottish physician William Cullen (1710-1790) hadspent time in Jamaica early in his career, and in his First lines of the practice of physic(1776-1784) observed that 'upon the whole, it is probable, that a specific contagion isto be considered as always the remote cause of this disease.’51 In Medicina nautica

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Trotter defined contagion as 'something propagated from diseased bodies, or fromsubstances that have been in contact with them, producing a similar disease in otherpersons.’ This included 'what have been called fomites, whether we consider them aswearing apparel, bedding, or other articles that have been imbued with human effluvia,of persons labouring under infectious diseases.’52 He explained that he was

of the opinion with others, that the exhalations or excretionsof the sick, are the vehicles of contagion. It is these whichimpregnate the atmosphere with noxious matter; they affectin like manner, bed-cloaths or apparel, and every thing thatcan imbibe them, when in contact with the diseased body.53

The corrupted, diseased body was, therefore, considered by many physicians assupplying the contagious force, for as we have seen, air was considered thetransmitting agent. But physical contact could also be a cause of contagion. Foetidmatter was particularly blamed by Pringle, who observed that 'the great source ofinfection seems to be the privies, after they have received the dysenteric excrementsfrom those who first fall ill’, with 'the infection’ being 'carried from one to anotherby the effluvia, or clothes, or bedding, &c. of the tainted person, as is the caseof the plague, small-pox and measles.’54 Henry Dewar observed that sailors withdysentery returning to England from hot climates had 'spread the infection among thepeople about the harbour, who frequented the same necessaries, when no dysenteryhad previously raged in the neighbourhood.’ There had been reported cases of thishappening in Newcastle upon Tyne, and Dewar considered this clear proof of thedisease’s contagiousness.55

Such an interpretation was questioned, however, by John Rollo (d. 1809), an armysurgeon-general who had studied at Edinburgh and served with the Royal Artillery inthe West Indies. In Observations on the acute dysentery (1786) Rollo wrote that only'in certain circumstances’ did dysentery become contagious, and he was 'inclined tothink the subject merits a further investigation.’56 But he still linked dysentery withplace and air, observing it 'primarily to arise, in all countries, from causes connectedwith situation, and a certain state of the weather; and it is not till some time after ithas been thus produced, and in peculiar circumstances, it is even said to becomecontagious.’57 The young Irish physician William Harty (1781-1854) tried to overcomethe problem of contagion by arguing at length in his 1805 treatise, Observations onthe simple dysentery, and its combinations, that seemingly contagious dysentery wasactually 'two distinct, and otherwise independent diseases’ which 'appear conjoined,as one single disease, but which, when separate, are found uniformly to differ intwo respects: the one consisting in a deranged state of the whole system; the otherin a local affection; the former always contagious; the latter never.’ In short, simpledysentery was not contagious; it only became contagious when it was combined withtyphus fever.58 But it was clear that if contagion was active in dysentery, keepingpatients closely confined together was dangerous, and a cure would be hard to effectin such circumstances. Cleanliness and ventilation became key theoretical aspects ofprevention and cure. Despite his doubts over the initial contagiousness of dysentery,

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Rollo observed that there was 'no disease, particularly in those situations in whichit is said to have become contagious, where cleanliness is so peculiarly necessary.’The 'greatest attention’ should also be given to bedding, he explained: 'it ought to befrequently changed, taking care, at the same time, to have it renewed perfectly dry.’59

There were, however, complete dissenters from the contagion position. These includedMoseley, who in Diseases of Jamaica claimed never to have seen a case of contagionin dysentery, and stated that he did not believe 'there is any such thing.’60 Moseleyargued that 'if contagion were supported by infected bodies’ then 'no person shouldescape infection … who was within the sphere of its action’, whilst those 'who wereintirely secluded from it, and free from all contiguity to infected people, or substances… should be exempt from it.’61 Indeed, Moseley went further, claiming that there were

no epidemical nor contagious diseases, that attack the veryperson who breathes the same air, or that is in contactwith the infection; else whole regions would be intirelydepopulated. The habit must be graduated, or adapted, forthe reception of a disease. In some constitutions of body theaccess is easy, in some difficult, and in others impossible.But where the revelation of this mystery is to be found, noone can tell.62

Like Moseley, Fisher believed that if dysentery occurred directly from contagion 'weshould see the dysentery prevailing at some season of the year in most countries, asis the case with small-pox, measles, &c. diseases which all allow depend on specificcontagion.’ Furthermore, 'If contagion was always the cause, many persons in the sameneighbourhood would be affected with it, as is generally the case with most diseasesdepending upon specific contagion’. However, Fisher considered Moseley’s opinionthat it was never contagious to be 'absurd’.63

The question of why some people were struck down by dysenteries (and other diseasessuch as fever) whilst others in the same immediate neighbourhood were not, explainsthe focus on 'exciting’ and 'predisposing’ causes in the study of epidemic diseases. Aswith 'bad air’, contagion theory suggested that all those exposed to an infected patientshould subsequently contract the disease. That they did not led some physicians,as we have seen, to doubt the very idea of contagion, whilst others suggested themitigating role of secondary causes: a body only contracted epidemical disease if itwere physically or mentally - or even morally - weakened, or 'predisposed’. The ideathat disease possesses a moral element was not new: from the biblical era to the middleages, from the early modern period to the present day, plague (be it Black Death orAIDS) has been interpreted by some as a divine visitation, a retribution for human sinsand follies. By the eighteenth century such interpretations were more sophisticatedthan they had been in the Middle Ages, but were predicated upon similar notions thatpersonal behaviour could determine susceptibility. Trotter, for example, observed thatpeople over about forty-five were not ordinarily receptive to fevers in hot climates. It wasthe 'youthful constitution’ that left it vulnerable and liable 'to be affected by contagion,

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more at one time than at another.’ This was the state of debility which Trotter believedsucceeded.

to all prÆternatural excitement; such as fatigue after labour;the langour which follows debauch, as hard drinking andexcessive venery; cold after being over heated; approachingthe sick-bed with an empty stomach, fear of being infected,&c. We can only reason on those predisposing causes,weakening the defences and leaving the body in a state tobe acted upon by the contagion64.

Sexual activity and drunkenness were considered two of the most dangerouspredisposing causes, weakening the defences and leaving the body open toattack. Trotter recounted an anecdote he had heard in one of Cullen’s lectures:a young gentleman 'passing the night in houses of a certain description,’ coming’the next day, debilitated with debauch, into the clinical ward, where he is exposedto contagion’, is struck down by typhus.65 In such circumstances Trotter advisedmental activity 'or something that strongly engages the attention, as these have beenreckoned among the preservatives against infection.’66 New arrivals in the tropicswere considered particularly vulnerable. Moseley (who believed in predisposition, ifnot contagion) warned that on first arriving in the West-Indies, 'though the use of thenecessaries of life, and the moderate gratification of natural desires, are by no meansinterdicted, yet every excess is dangerous; and temperance in all things is necessaryto be observed by men, women and children.’67

Animalcules

Although the combination of bad air and predisposition was widely presumed to bethe cause of dysentery and choleras, a theory of the disease based on microscopicanimalcules had been proffered as early as the later seventeenth century. In 1789Moseley in his Treatise quoted the conclusion to Pringle’s Observations on thedysentery:

'I was inclined to refer the cause proxima, or the immediatecause of the disease, to this putrid ferment; but having sinceperused a curious dissertation published by LINNÆUS, infavour of KIRCHER’S system of contagion by animalcula, Ithink it reasonable to suspend all hypothesis till the mattershall be further inquired into.’68

In 1794 David Abeel also referred to this thesis of 'Living animalculæ’, noting that in

the Amœnitates Academiæ, there is a curious dissertation onthis subject, where the author attempts to prove, that livingsmall animalculæ, lodged in the intestines, are the cause of

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dysentery, but as we have no evidence of these, we mustconsider the theory as merely an hypothesis, or the chimeraof fanciful imagination.69

The hypothesis alluded to here was published in 1760, in volume five of Linnaeus’sAmœnitates academiæ. These collections contained the dissertations of Linnaeus’sstudents, but were edited and embellished by him, and have generally been creditedto him. The work in question here was written by John Nyander, whose dissertation,submitted in 1757, referred to the work of two earlier natural philosophers whosewritings had helped him to formulate his thesis of microscopic contagion: the GermanJesuit natural philosopher and writer Athanasius Kircher (1601-1680) and the Dutchmicroscopist Anthony van Leeuwenhoek (1632-1723).70 Using the recently inventedmicroscope, Kircher had observed miniscule 'worms’ in putrefying matter suchas meat and milk.71 Leeuwenhoek, who ground his own lenses to an unrivalledquality, had isolated and observed bacteria and protozoa in rain, pond and wellwater, as well as in the human mouth and intestines. Nyander described epidemicdysentery as 'an internal itch of the intestines’, and suggested it was caused by'Mites, lurking in acid drinks, which are propagated from thence by privies, andengender contagion.’ 72It might be thought that such a theory of disease would gainmore common currency, utilizing as it did the new technology symptomatic of thenew science of early modern Europe. Yet despite Pringle’s cautious acceptance ofthe thesis, and his own authority in the medical world of Enlightenment Britain, thesubject received little or no further research in the eighteenth century. John Swanin his notes to Sydenham’s remarks on dysentery observed that a possible causewas from eating fruits 'covered either with a poisonous coat, to the malignant eggsof insects, that float in great abundance in the air, at this time, and so mixed withthe blood and juices.’73 But this is hardly an argument for a germ theory of disease.Trotter also noted that some had ascribed contagion in epidemic diseases to certainanimalcules in diseased clothes and laundry. Yet whilst finding that this 'mode ofaccounting for the fact, was certainly bold; but I do not think it can be called any thingelse; for these little animals have never been seen even with a microscope; and Icannot help concluding, that like some other animals which we have heard of, theyare fabulous.’74 The exact reasons for resistance to the theory are hard to establish,but Catherine Wilson has suggested that theories of animalcules too tiny to be seenby the naked eye may in part have been rejected by eighteenth-century physiciansas they made it even easier for quacks and mountebanks to fool the gullible.75 Thereis more room for investigation into this interesting question, however.76

Prevention and cure

Without accurately identifying the origin and cause of dysentery, and with the ongoingdebate over whether or not it was contagious, prevention proved difficult and a realcure seemed impossible. John Swan, translator of Sydenham, believed that therewas 'scarce a disease which requires more skill in order to its rational cure than thedysentery.’77

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For Rollo, 'the Dysentery is a disease, in which the treatment has been ambiguous andperplexed.’78 The Admiralty’s Sick and Hurt Board, responsible for the general healthof seamen, regularly received suggestions for new remedies and medicines throughthe century, and the search for a cure was obviously as important as the search for thecause.79 At times this had disastrous effects, for example trials of a medicine madeup of soap, sugar and rum were undertaken at the naval hospital at Haslar and then atprisoner of war camps in Forton and Portchester. Most men given the treatment died.80Despite such fatal experiments, the generally recommended 'cure’ was a combinationof bleeding to relieve the inflammation of the intestines and the accompanying fever,and purgatives (such as rhubarb) and emetics (such as tartar) to empty the bowels andthe stomach respectively. As rehydration was what the patient required most, theseactions could only serve to worsen their situation; surprisingly, physicians paid verylittle attention to the dehydrating effects of dysentery and cholera, and this remainedthe case well into the nineteenth century.81 Moseley explained that his recommendedcure began with bleeding,

followed by a vomit which commonly relieves the stomachfrom a load of acid, poraceous, bilious impurities. But ourgreat expectation from vomiting is, that its action on themuscular fibres of the stomach, forces open the extremearterial capillaries, forwards the circulation onto the surfaceof the body, and induces to sweat.82

As we have seen, excess heat was the classical defining feature of a fever, and as bloodwas considered the body’s heat-giving source, so blood-letting was seen as a cure forfever: excess heat implied excess blood. Similarly, the post-mortem identification ofintestinal inflammation suggested an excess of blood in the system, which needed to beremoved to effect a cure. Hence blood-letting was the generally accepted practice forthe treatment of the disorder. (The Physician to the Fleet William Cockburn (1669-1739)in his Nature and cure of fluxes (1724) reflected at length on the theory of ancientphysicians that an attack of dysentery would always follow an amputation, as theexcess blood required by the lost limb could only be expelled in this way.83) Attitude tobleeding, though, depended on climate, and was less advised in hot ones. Clark wrotein 1808 that bleeding 'has been esteemed absolutely necessary in the beginning ofmost fluxes’, but advised that in hot climates this 'would only serve to impair the patient’sstrength; and, if it did not prove immediately fatal, would, at least, precipitate hisfate.’84 Nevertheless, despite these wise words, bleeding continued to be advised bymany physicians, and was subsequently frequently recommended in the treatment ofAsiatic cholera, even though the lethal dehydrating effect of that disease usually madeblood-letting difficult or impossible. In 'obstinate’ cases of dysentery Clark suggestedin some detail the use of mercury, and this was also tentatively recommended by JohnHunter.85 Opiates had an obvious constipative effect (though they were also used asa pain relief or even a cure), but again , this treatment was controversial. Hunter notedthat Sydenham 'in many cases is disposed to trust the cure entirely to them, whileothers, of almost equal authority, condemn them universally in this disease.’86

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Title page to Observations on the Diseases Incident to Seamen, Gilbert Blane

Fashionable cures were also ecommended. Moseley specifically recommended DrRobert James’s famous fever powder, patented in London in 1746, as if 'properlygiven’ it cleansed 'the primÆ viÆ’ and also induced a sweat.87 Ipecacuanha, orBrazilian root, was described by the former Physician to the Fleet Gilbert Blane(1749-1834) in his Observations on the diseases incident to seamen as 'one of thebest anti-dysenteric remedies we know’ and 'not only gives a temporary relief, buttends to carry off the disease.’88 Ipecacuanha had first been brought to Europefrom the New World in 1658 and was given in the form of an infusion or decoction,generally with the intention of causing the patient to vomit. In 1846 Edmund Parkesin Remarks on the dysentery and hepatitis of India would recommend its use inlarge doses, and it has subsequently been found that when used in this way to be aspecific against amoebic dysentery 'at least as powerful as quinine is against malaria,or indeed any other known drug’, but it is not effective against bacillary dysentery.89Thomas Dancer observed in The medical assistant; or Jamaica practice of physic(1801) that dysentery 'if rightly treated in the beginning, is, for the most part, easilycured, but otherwise it becomes chronical, and very difficult to get rid of.’ His cureinvolved 'cleaning well the bowels in the beginning, and keeping them open; byrestoring the perspiration and easing the pains or gripes’.90 Promptness of treatmentwas always advocated, though this factor worked in favour of physicians, who could

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blame the tardiness of the patients in coming to them if their treatment subsequentlyfailed. The Scottish physician George Cleghorn, author of the influential Observationson the epidemical diseases in Minorca, observed in 1751 that almost all the casesof dysentery that came under his observation on the island, 'unless they werespeedily cured in the Beginning, at best proved obstinate, and too frequently fatal,in spite of the many boasted Specificks for this Distemper’.91 He therefore advisedphysicians to take 'the utmost Diligence’ when 'applying the proper Remedies beforethe Strength of the Patient be exhausted, and the Coats of the Intestine too muchinjured.’ He felt that the 'want of Means’ for keeping the 'common Soldiers’ clean, andthe lack of adequate 'conveniences’ for them was particularly damaging, and 'wished,that those who have the Direction of our Fleets and Armies would order [them] to beprovided both in the Ships and Hospitals.’92

Conclusion

Prevention, and not cure, would be the only solution to dysentery or cholera morbusthroughout the eighteenth and nineteenth centuries, and continued to be the generalapproach to diseases in the twentieth. Yet significantly both diseases appear to havebeen in decline in Europe through the eighteenth century. Trotter recorded in 1797 thatwhilst dysentery 'has frequently been attended with great mortality in the King’s ships,and particularly in tropical climates, it has however, been little known in the ChannelFleet.’93 Without further research the reason for this disparity cannot be established. Ofcourse, there is the issue of climate to contend with, but it could also be that improvedhygiene and cleanliness on board ship led to a decline in incidence of the diseasein more temperate waters. This may parallel a general decline in such diseases ofthe gut in Western Europe from the early eighteenth century onwards. In 1801 inhis Observations on the increase and decrease of different diseases in London thephysician William Heberden declared that the gradual decline in deaths from dysenterywas 'not to be paralleled in the history of any other disease on record’.94 AlthoughHeberden’s study of the London Bills of Mortality is sadly unreliable,95 John Landersin a 1993 study has noted the 'statistical elimination of the summer burial peak’ inLondon in the years after 1700. Landers suggests that this may have been the result of'the amelioration of some old-established form of gastric disease, perhaps the choleramorbus or the “dry gripes” described by Sydenham, as the seventeenth century gaveway to the eighteenth.’96 Landers suggests this may have been associated eitherwith climactic changes and/or a change in the nature of the pathogen, leading to theemergence of a more infective but less severe form of the disease.

In a final irony, in his 1987 study The eighteenth-century campaign to avoid disease,James Riley noted the importance of insects as disease vectors, and wrote that theymay be 'charged specifically’ with the transmission of 'filth diseases’. He has suggestedthat the decline of incidence of such diseases as dysentery and cholera morbus in theeighteenth century might be explained by early modern environmentalists’ attempts totidy up their cities and to drain marshes and standing water. He adds that by shiftingthe site of contamination from the refuse pit to the water supply, the nineteenth-centuryepidemics of Asiatic cholera may have been 'an ironic measure of the success of the

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eighteenth-century campaign to avoid disease.’97 With the arrival of Asiatic cholera inEngland in 1831 - carried by ship to Sunderland and then Newcastle from Hamburgand the Baltic states - many of the debates surrounding the cause and treatment ofdysentery and cholera morbus resurfaced, pointing to the importance of this earliermaterial, and the importance of gut disorders in early modern health and hygiene.However, many of the old beliefs persisted. Even at the very end of the nineteenthcentury, the idea that a 'lowering of one’s guard’ could actually bring on an attack ofdysentery remained. According to the Dictionary of national biography, for example,a piece of bad news received by Thomas Wolsey is supposed to have 'brought ona severe attack of dysentery’, whilst 'anxiety’ over completing a book on Americanbirds is blamed for contributing to a terminal attack of dysentery in the ornithologistAlexander Wilson, and the astronomer Stephen Joseph Perry catches a dysentery afterdisregarding the 'danger from pestilential night air’.98There is much room for additionalresearch and discussion on this seemingly banal disease, and it is hoped that this paperwill have brought some of those broader permutations to light.

Text © Dr David Boyd Haydock, 2001

Acknowledgements

This paper was written with the support of Leverhulme Research Grant F/793/Aunder the direction and assistance of Professor George S. Rousseau, De MontfortUniversity, Leicester.

Footnotes

1. J.C. Beaglehole (ed.), The journals of Captain James Cook on his voyagesof discovery, volume 1: The Voyage of Endeavour, 1768-1771 (Cambridge:Cambridge University Press, 1968), pp. 443-4; see also Christopher Lloydand J.L.S. Coulter, Medicine and the navy, 1200-1900, vol. 3 1714-1815 (4vols., Edinburgh & London: E. & S. Livingstone Ltd, 1961) pp. 311-2.

2. James Lind, An essay on the diseases incidental to Europeans in hotclimates. With the method of preventing their fatal consequences. London,1777, pp. 9-10. Trevor Burnard has identified yellow fever as the principalkiller of Europeans in Jamaica, a disease to which the West African slavepopulation were generally or partially immune. See his ‘“The countriecontinues sicklie”: white morality in Jamaica, 1655-1780’, Social history ofmedicine, 1999, 12:45-72.

3. Benjamin Moseley, A Treatise on tropical diseases; on military operations;and on the climate of the West-Indies, 2nd edition, London, T. Cadell, 1789, p.iii.

4. Moseley (1789), pp. 188-9.

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5. Thomas Trotter, Medicina nautica: an essay on the diseases of seamen,volume 1, London, 1797, p. 9.

6. On the medical history of dysentery, see Arthur L. Bloomfield, A bibliographyof internal medicine: communicable diseases, (University of Chicago Press,1958), especially pp. 34-42, and Philip Manson-Bahr, The dysentericdisorders: the diagnosis and treatment of dysentery, sprue, colitis and otherdiarrhoeas in general practice (London, Cassell and Co., 1943). CharlesCreighton, A history of epidemics in Britain, volume 2: From the extinction ofthe plague to the present time (first published in 1894, 2nd edition, London,Cass, 1965) discusses dysentery along with infantile diarrhoea and ‘choleranostras’, pp. 747-92. This includes an extensive discussion of outbreaks ofthe disease in Britain from the sixteenth to the nineteenth centuries. Themost modern extensive discussion of dysentery in the eighteenth century isJohn D. Post, Food shortage, climactic variability, and epidemic disease inpre-industrial Europe, Ithaca and London, Cornell University Press, 1985,especially pp. 227-79, which discusses dysentery in the context of theepidemic diseases of the early 1740s.

7. Roy Porter and G.S. Rousseau, Gout, the patrician malady, New Haven andLondon: Yale University Press, 1998, p. 2.

8. Quoted in Moseley (1789), p. 190.

9. For a full account of dysentery, from which the information in this section istaken, see Dialogue of diarrhoea online, at www.rehydrate.org.

10. Andrew Wilson, An essay on the autumnal dysentery, (London, 1761), pp. 49,52.

11. The causative organism of amoebic dysentery also appears in two forms,resulting in a different disease course: one motile, the other in cyst form. Themotile form produces symptoms similar to bacillary dysentery, whilst the morecommon cyst form produces the chronic, intermitting disorder. For accounts ofthe discoveries, see Bloomfield (1958), pp. 37-8, 41-2, 374-7.

12. G.C. Cook, ‘Influence of diarrhoeal disease on military and naval campaigns’,Journal of the Royal Society of Medicine, February 2001, 94: 95-97.

13. Hermannus van der Heyden, Speedy help for rich and poor. Or certainphysicall discources touching the vertue of whey, in the cure of the gripingflux of the belly, and of the dysentery. &c., London, James Young and JohnSaywell, 1653, pp. 22.

14. James Fisher, An inaugural dissertation on that grade of the intestinal state offever known by the name of dysentery (Philadelphia, 1797) pp. 12-13.

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15. David G. Abeel, An inaugural dissertation of dysentery, (New York, 1794) p.10.

16. Heyden (1653), pp. 172-3.

17. Kenneth Dewhurst, Dr Thomas Sydenham 1624-1689): his life and originalwritings, London, Wellcome Historical Medical Library, 1966, 123. BritishLibrary MS Locke c.29, ff. 19-20 (1670). See John Swan, The entire works ofDr Thomas Sydenham, newly made English from the originals, London 1742,pp. 133-55.

18. Swan (1742), p. 8

19. Moseley (1789) p. 198

20. Moseley (1789) p. 188

21. Lind (1777) p. 163

22. John Clark, Observations on the diseases which prevail in long voyages to hotcountries, particularly on those in the East Indies; and on the same diseasesas they appear in Great Britain, 3rd edition, London, Murray, 1809, p. 215.

23. John Hunter, Observations on the diseases of the army in Jamaica, and onthe best means of preserving the health of Europeans in that climate, firstpublished 1788, 3rd edition, London, T. Payne, 1808, pp. 216-7

24. Van der Heyden (1653), p. 174

25. John Arbuthnot, An Essay concerning the effects of air on human bodies,London, J. and R. Tonson and S. Draper 1751, p.151

26. Arbuthnot (1751), p. 159.

27. Beaglehole (1968) p. 443.

28. John Woodward, John. 1718. The state of physick: and of diseases; with aninquiry into the causes of the late increase of them, London: T. Horne, 1718,p. 1.

29. John Huxham, Observations on the air, and epidemic disease, from thebeginning of the year 1738, to the end of the year 1748, volume 2, London,1767, xv, pp. 139-42.

30. Daniel Defoe, The life and strange surprising adventures of Robinson Crusoe,of York, mariner, London, W. Taylor, 1719, p. 116

31. Lind (1777) p. 7.

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32. Richard Mead, A treatise concerning the influence of the Sun and the Moonupon human bodies, and the diseases thereby produced, London, J. Brindley,1748, p. 68.

33. Lind (1777), pp. 88-89.

34. Francis Balfour, A collection of treatises on the effects of Sol-Lunar influencein fevers; with an improved method of curing them, 3rd edition, Cupar, 1815.

35. James Annesley, Researches into the causes, nature and treatment of themore prevalent diseases of India, and of warm climates generally, London,1828, vol. 2 p. 247

36. Abeel (1794), p. 5. Margaret Pelling has noted that fever rather than cholerawas the driving force behind the public health policies of the Victorian period.See Margaret Pelling, Cholera, fever and English medicine, 1825-1865,Oxford University Press, 1978, and also John V. Pickstone, ‘Death, dirt andfever epidemics: rewriting the history of British “public health”, 1780-1850,’in Terence Ranger and Paul Slack (eds.), Epidemics and ideas: essays onthe historical perception of pestilence, Cambridge University Press, 1992, pp.125-48. See also Mark Harrison ‘“The tender frame of man”: disease, climateand racial difference in India and the West Indies, 1760-1860,’ Bulletin of thehistory of medicine, 1996, 70:68-93.

37. John Pringle, Observations on the diseases of the army, 5th edition, London:A. Millar, D. Wilson, T. Durham and T. Payne, 1765, p. 84.

38. Baron van Swieten, physician to their Imperial Majesties, A short account ofthe most common diseases incident to armies, 2nd edition, London, T. Becketand P.A. De Hondt, 1767, p. 64.

39. Thomas Trotter, Medica nautica: an essay on the diseases of seamen,volume II, London, 1799, p. 50.

40. Henry Dewar, Observations on diarrhoea and dysentery, particularly as thesediseases appeared in the British campaign of Egypt in 1801, London, 1805, p.96.

41. Annesley (1828)

42. Buchan, Domestic medicine (1769), p. 370, pp. 381-2, quoted in Charles E.Rosenberg, Explaining epidemics and other studies in the history of medicine,Cambridge University Press, 1992, p. 47.

43. Annesley (1828), 2.113.

44. Pringle (1765), p. 92

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45. Moseley (1789), p. 199.

46. Moseley (1789), pp. 201-2.

47. Trotter (1797), p. 385.

48. Lind (1777), pp. 99-100.

49. John Peter Wade, The nature and effects of emetics, purgatives, mercurials,and low diet, in disorders of Bengal and similar latitudes, London, J. Murray,1792, p. 339.

50. Moseley (1789), p. 197, footnote

51. Cullen, First lines of the practice of physic, 4 vols., Edinburgh, 1776-1783,paragraph 1075.

52. Trotter (1797), p. 173. Trotter is referring particularly to typhus contagion, buthis remarks here carried equally for dysentery.

53. Trotter (1797), p. 176.

54. Pringle (1765), pp. 254-5.

55. Dewar (1805), pp. 96-7

56. John Rollo, Observations on the acute dysentery, with the design ofillustrating its causes and treatment, London, 1786, p. 19

57. Rollo (1786), pp. 22-3

58. William Harty, Observations on the simple dysentery, and its combinations,containing a review of the most celebrated authors who have written on thissubject, and also an investigation into the source of contagion in that, andsome other diseases, London, Callow, 1805, pp. iii-iv, vi-vii.

59. Rollo (1786), p. 73.

60. Moseley, (1789), p. 254.

61. Moseley (1789), p. 257.

62. Moseley (1789), p. 259

63. Fisher (1797), pp. 15-16

64. Trotter (1797), pp. 199-200

65. Trotter (1797), p. 200.

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66. Trotter (1797), p. 205.

67. Moseley (1789), p. 17. See Christopher Hamlin, ‘Predisposing causes andpublic health in early nineteenth-century medical thought’, Social history ofmedicine, 1992, 5:43-70.

68. Quoted in Moseley (1789), pp. 365-6, 1768 edition of Pringle’s Observationson dysentery.

69. Abeel (1794), p. 19

70. On Nyander’s dissertation, with an English translation, see M.E. DeLacy andA.J. Cain, ‘A Linnean thesis concerning contagium vivum: the “exanthemataviva” of John Nyander and its place in contemporary thought,’ Medical history,1995, 39:159-85. For Nyander’s dissertation, see Amœnitates Academiæ:seu dissertationes variae, physicae, medicae, botanicae, Leiden, 1760, pp.92-105.

71. Catherine Wilson, The invisible world: early modern philosophy and theinvention of the microscope, Princeton University Press, 1995, pp. 155-7. Seeespecially chapter 5, ‘Animalcula and the theory of animate contagion’

72. DeLacy and A.J. Cain (1995 ), p. 180

73. Swan (1742), p. 143

74. Trotter (1797), pp. 179-80.

75. Wilson (1995), pp. 169-70, 172.

76. Benjamin Marten advanced a similar, but rejected, theory in his A new theoryof consumptions: more especially of a phthisis, or consumption of the lungs(London 1720, R. Knaplock, A. Bell, J. Hooke, and C. King). He suggestedthere (p. 51) that ‘The Original and Essential Cause’ of tuberculosis ‘maypossibly be some certain Species of Animalcula or wonderfully minute livingCreatures, that, by their peculiar Shape, or disagreeable Parts, are inimicableto our nature’. He accepted, however, that this theory ‘will doubtless seemstrange to abundance of Persons’

77. Swan (1742), footnote, p. 147.

78. Rollo (1786), p. 44.

79. See P.K. Crimmin, “The Sick and Hurt Board and the Health of Seamen, c.1700-1806”, in Journal for Maritime Research, December 1999

80. Ibid.

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81. For a sensible account of the symptoms of Asiatic cholera as being the effectsof dehydration, see the account by the army officer W.S. Prior, A treatiseon the mistreatment of cholera morbus; or, a recovered cholera patient’sdescription of the origin, symptoms, and proper treatment, in opposition tothe present poisonous mode of treating that malady, London: B. Steill and G.Berger, 3rd edn, 1833.

82. Moseley (1789), p. 214.

83. William Cockburn, The nature and cure of fluxes, London, 3rd edition, 1724.

84. Clark (1809), 220. See also Huxham (1767), pp. vii-viii.

85. Clark (1809), 230-61, Hunter (1808), pp. 300-02.

86. Hunter (1808), p. 190.

87. Moseley (1789), p. 216.

88. Gilbert Blane, Observations on the diseases incident to seamen, London,Joseph Cooper, 1785, p. 438. Blane recommended its use in ’small doses’two or three times daily, except of those of ‘athletic constitutions’, such asseamen. [439.] Clark, by contrast, reported that he had used the drug in smalldoses ‘with very little advantage’ and considered it a ‘failure’. Clark (1809), pp.222-3.

89. Leonard Rogers, Dysenteries, their differentiation and treatment, OxfordUniversity Press, London, 1913, pp. 27-29.

90. Thomas Dancer, MD, The medical assistant; or Jamaica practice of physic:designed chiefly for the use of families and plantations, Kingston, Jamaica,1801, pp. 94-5.

91. George Cleghorn, Observations on the epidemical diseases in Minorca. Fromthe year 1744 to 1749. To which is prefixed, a short account of the climate,productions, inhabitants, and endemial [sic] distempers of that island, London:D. Wilson, 1751, pp. 228.

92. Cleghorn (1751), pp. 228-9.

93. Trotter (1797), p. 377.

94. Quoted in Harty (1805), pp. 92, 95.

95. See Creighton (1894/1965), pp. 747-92.

96. John Landers, Death and the metropolis: studies in the demographic historyof London, 1670-1830, Cambridge University Press, 1993, p. 239. See alsoCreighton (1894), p. 774. See Simon Szreter, ‘The importance of social

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intervention in Britain’s mortality decline, c. 1850-1914: a re-interpretationof the role of public health’, Social history of medicine, 1988, 1:1-37, andAlex Mercer, Disease, mortality and population in transition: epidemiological-demographic change in England since the eighteenth century as part of aglobal phenomenon, Leicester University Press, 1990, pp. 74-96. Also seePost (1985), p. 262.

97. James C. Riley, The eighteenth-century campaign to avoid disease,Basingstoke and London, Macmillan Press, 1987, pp. 135-7.

98. Dictionary of national biography, Oxford University Press. The articles onWolsey and Wilson were both written in 1900, and that on Perry in 1895, bythree different contributors.

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