Memento Mon or Dr. Cliff's Diary: An unusual demographic Document

MEMENTO J.UORI OR DR. CLIFF'S DIARY, AN UNUSUAL DEMOGRAPHIC DOCUMENT By F. HuLL, B..A., PH.D., F.R.HisT.S. A DOOUMENT of unusual interest in the fields of demographic and medical history has recently been rediscovered at Tenterden.1 Rediscovered because it had been known and the vicar of Tenterden holds a transcript made some years ago. This purports to be a record of Jeremiah Oliff and called by him Memento Mori, Omnium Rerum Vicisitudo. It consists of twenty-three leaves, each 16 x 5 in., stitched togethel' at the top to form a file, each leaf being closely written in the same hand, though with a few late additions in another hand. Since Dr. Cliff used the first leaf for an introduction his statement of intent is clear: 'Here is a True and perfect and exa.ct list a.s I have been Able to take In an Alphabeticall Order of all those Persons, Men, Women and Children, that have Dy'd in Tenterden, Beginning March the (T) 18th 1712/3 or thereaboutes, with their names, their Agia as nigh as could be guest at, and what day of the Month and year they dy'd of and also what distemper they dy'd of and also who was their docters that did [for] them in the Time of their sickness.' Re adds that he has listed 1,245 persons up to 1740 'not exactly but thereaboutes' and then lists the abbreviations he has used for months of the year and for the illnesses and causes of death. Finally, at the bottom of the page, he places his Latin title surrounding a skuH and crossbones above an equally gruesome pick and shovel and the date Jan. the 29th [1740/1]. If this document is as complete and comprehensive as its compiler claims, then clearly it should provide valuable information on the pattern of deaths in Tenterden during the first half of the eighteenth century, on the nature of diseases trea.ted with possible evidence for epidemics, and on the medical services available at that time; but first who and what was Jeremiah Cliff and how valid are his claims. The last entry in date on the record is that for Dr. Cliff himself, stating that he was buried on 11th February, 1742/3, and we may assume that until that date the list is reasonably complete and that it covers a period of thirty years. Since it was actually compiled in 1740 the information must have been taken from other records and one can only assume the accuracy of what was noted, especially for the earlier 1 Now deposited in the Kent Archives Office [K.A.O., P364/28/4]. 11 F.HULL years. Jeremiah Cliff left a will dated 28th August, 1742, and proved on 1st August, 1743, when probate was granted to his son, also J eremiah.2 Under this will, while Jeremiah received lands and messuages in Frittenden and Cranbrook, a daughter, Sarah, received £100, the best bed and chest of drawers, the furniture of the best chamber, together with linen, a silver watch and a silver seal bearing Cliff's coat of arms. His baptismal entry has not been found, but he may have come from the Frittenden area where the family held property.s The evidence of the 'diary' shows that Jeremiah married twice and outlived both wives; it also records that another son, Edward, died in Jamaica in 1741. Most significant for this paper is the evidence of both Cliff's will and that of his sister that he referred to himself as 'apothecary' and that any title of 'doctor' was at best honorary, and that he had learned his skill from a knowledge of drugs and the hard school of experience. At the period under consideration Tenterden was a small market town with a population probably less than 2,000 persons. In 1801, the first census accorded a figure of 2,370,4 while the Hearth Tax assessment of 1664 provides a total of 294 households.0 If one accepts a basic average household of 5 to 6 persons, then the 1664 population would have been somewhere between 1,500 and 1,750 individuals, and it seems likely that the latter figure may represent fairly closely the population when Cliff was at work, for the rapid increase in population noted by 1801 is a phenomenon of the second half of the century rather than the first. For this town of under 2,000, it seflms that there were at least five so-called 'doctors' practising, and that it was possible during the thirty years for between thirty and forty practitioners to provide medical services. From this document it is clear that two men, Drs. Cliff and Back, neither probably a trained physician, carried the greater part of this responsibility.6 Each had a son following the same profession and by the end of the period a fifth man, Dr. Medhurst, had joined them though whether independently or as a partner to both or either is unknown. At least three other men, Ed.met, Groombridge and Christian, acted on a number of occasions and may also have resided at Tenterden. 7 It is also clear that the calling in of a second opinion 􀂯 K.A.O., PRC 17/92/84. 3 A sister Katheryn died a.t Cranbrook in 1717 and left property at Frittenden too. K.A.O., PRC 17 /84/496. ' The 1801 census was assesssd on a less comprehensive basis than later ones, but we may accept this figure as· reasonably accurate. 5 K.A.O., Te/JQad 5, chosen because it includes households untaxed by reason of poverty. G Dr. Back was probably a qualified surgeon and his son is recorded on a, map of property in High Ha.Iden, 1754, as an M.B. [K.A.O., USO P8l, 7 A Dr. John Groombridge, licentiate of the Royal College of Physioisna practised at Oranbrook [Munk'e, Roll]. 12 MIJJMIJJNTO MORI OR DR. CLIFF'S DIARY was by no means uncommon. More than one doctor acted in at least 112 of the cases recorded and while, often enough, Back and Cliff acted together there is evidence to suggest that 'consultants' from Cranbrook, .Ashford, Maidstone, the-Medway Towns and Canterbury were called in on occasions . .Although many of the men whose names are recorded were probably not doctors in the modern sense, they were respected members of society, and when Dr. Back, sen., died in 1739 his colleague noted not merely that he ,vas 76 and died of a violent cold, but that 'he had practised Phisick and Surgery 54 years and 5 weeks'. An impression left by this document is that there was some degree of specialization even among the 'doctors by experience' . .Although the evidence is only slight, it suggests that Back was a fever doctor while Cliff may have been noted for his treatment of pleurisy. Groombridge seems to be called in for smallpox cases and so forth. The general picture, therefore, i.s that however inadequate diagnostic skill and medical methods might have been the people of Tenterden and district were remarkably well supplied with general practitioners at the time in question. Dr. Cliff claimed in his introductory note to have recorded 1,245 deaths up to January, 1740/1, but the 'diary' as it survives only records 1,219. It seems that either he estimated his total or that something is now missing. Certainly at least six entries for the letter B are now so damaged as to be valueless, but there is no other evidence for loss of entries. More important, the figure of 1,219 is 129 above the record of burials in the parish register for the same period. This discrepancy is emphasized because in four separate years the annual totals in the register exceed those given by Cliff. On the other hand, he may have included a few extraneous items, e.g. his son Edward, who died in Jamaica, but more significant he had access to non-conformists as well as .Anglicans. Quakers are referred to more than once, and among the more hazardous occupations appears to be that of Presbyterian parson of Tenterden. On the whole, it would seem that despite some irrelevances, this list is a more comprehensive indication of deaths at Tenterden between 1712 and 1742 than any other known source. The fluctuation in totals from year to year is considerable though the average number of deaths per year is 39. In 1717 and 1740 only 24 were recorded whereas in 1720 the total was 63 and in 1734 no fewer than 66. One would hope that some indication of the reasons for considerable variation might become app8rent but, although the graph of annual dea.thsS suggests periods of relatively high mortality alternating with those with a lower death rate, there is insufficient evidence to provide any positive thesis. One must accept, however, that a normal death- • See Fig. 3. 13 F.HULL rate would be between thirty and forty a, year, and that any year showing a total below thirty or over forty-five is distinctly exceptional. A more significant set of figures is provided by a table analysing deaths by age and sex.9 Even this table helps in part to destroy the statistical validity of Cliff's work simply by emphasizing the known high level of infant mortality. Of the 1,219 cases recorded no fewer than 336 (27 · 5 per cent) are for infe.nts not exceeding one year of age, and, what is more, out of the 447 infants and children who died up to the age of ten years, 264 (59 per cent) are listed without indication of sex. FIG. 1. Table of Deatmi at Tenterde.n, 1712-42, by .Age and Sex. Age Unknown Ditto . . 0-1 yrs. 1+-10 . . 11-20 . . 21-30 . . 31-40 .. 41-50 . . 6Hl0 . . 61-70 . . 71-80 . . 81-90 .. 91+ . . . . . . . . . . . . . . . . . . . . .. . . . . . . Sex unlmown :Ma.le Female Infant 53 2 - Other age - 24 26 222 26 23 42 31 38 1 42 30 - 54 60 - 47 56 2 63 56 - 57 66 - 60 68 - 41 31 - 19 8 - 2 4 Total 67 5 0 271 111 73 114 103 121 113 128 72 27 6 The infant mortality figures, therefore, seriously deplete those remaining for statistical purposes and preclude any useful analysis by sex before the age of 11. It should also be noted that the parish register records 840 live births during this period suggesting that about 40 per cent of children died during the first year of life. After the age of 11 the figures show a remarkable stability by both sex and age until the full term of three score years and ten. After 70, however, the implication is that there was a slightly higher expectation of life for men than for women, and no fewer than 21 males died at over the age of 80 compared with 12 females. Two other general matters are worthy of mention before analysing causes of death. The first, that in 349 (28 per cent) of the cases the cause of death was unknown to Dr. Cliff. One suspects that complete honesty would place many more cases in this category, for diagnosis was an uncertain art, but it can be said that this figure includes a high percentage of the infant deaths and that the word 'infant' is almost sufficient as a cause of death unless a specific infection was present. The second factor of interest is that in 168 instances while Cliff apparently assumed that 9 See Fig. 1. 14: MEMENTO MORI OR DR. CLIFF'S DIARY medical advice had been given he was not aware of the name of the doctor and that on an additional 96 (7 · 8 per cent) occasions h e wa1> able to state 'no doctor'. For the purposes of further analysis attention must be concentrated on the 870 persons for whom a cause of death is given. These fall into a large number of oategories10 some of which are not dependent upon medical knowledge. For example, six: persons committed suicide; in seven cases Oliff is honest enough to admit that poverty and starvation played a crucial part; and there are no fewer than twenty accident cases. Among all these some points of interest arise: there was Mrs. Parton who 'hanged herself in her garters' in 1722 and was inconsiderate F10. 2. Incidence of Death8 from Consumption in Age 0-roupa at Tenterden, 1712-42. Age groups Male . . Female . . . . . . . . 11-20 21-30 9 8 10 13 31-40 41-50 51-60 61-70 12 12 8 6 10 5 7 3 enough to do so in Dr. Cliff's house! There were the inevitable falls from horses, .and one child, Young Waller, who fell into a marlpit in 1726. Two road accidents occurred, one when the carrier from Rye died after his cart had passed over his head and neck in 1728. One child was burnt and there were two cases offatal scalding; in 1741 Bate's child died of a cut from a glass bottle, and drowning accounted for three deaths, including Reynold's child, aged 2, who was drowned 'in a little puddle of water'. Occupational hazards a.re represented by a death from a pitchfork and bites from a hog and a boar, the latter wound having gangrened. Finally, in this class is William Wood, the barber, who died in 1736 from a cudgel blow given him by Richard Heath. The greatest difficulty in analysing causes of death arises from the problem of diagnosis, and one is faced by the fact that over and above the lack of modern medical skill, of antiseptics and anaesthetics, the eighteenth-century doctor was unable to diagnose the real cause of death _in all but a very few cases. He saw certain common states affecting health, e.g. pyrexia or dropsy, and unless there was some clear physical evidence of disease, as in smallpox, was unable to probe the real cause of the symptoms he treated. The present-day examiner of such records is, therefore, faced with generalizations from which he, too, can only hazard a guess at the real disease or cause of death. To be faced with 'bedridden' or 'lethargy' as the cause of death is scarcely sufficient by twentieth-century standards, nor do the 250 or so cases of 11 See Fig. 6 for a. complete list of causes • . 15 F.HULL fever without differentiation provide the statistician with much valid material. Naturally, there are a number of clear-cut cases: 23 babies were still-born and 24 women died in child-bed or as a result of miscarriage. A dozen patients appear to have been insane and 28 are simply recorded as having died of old age or of being 'decayed' or 'worn out'. In four instances drink is cited as the cause, though it also figured in some other male cases. Among the less usual causes of death are hare-lip, scabies, rupture of the navel, dislocation of the collar-bone and the patient who 'dosed to death'; but a number of well-known diseases also appear. These include 46 cases of smallpox and l of French pox, 3 of erysipelas, 8 of measles, 6 of whooping cough and 8 of gravel. Hints at the economic and social conditions lie in the 12 fatal cases of worms and worm fever, and there are also 4 cases of green sickness (? chlorosis), 5 of palsy and of ague and 4 of rheumatism. Many patients, as suggested, are treated for conditions rather than specific illnesses; thus, 7 died from gout and 23 from dropsy usually in conjunction with some other malady, and related groups of conditions seem to provide a better pattern than individual casos. Thus, convulsions and fits (other than apoplexy) accounted for 21 deaths and apoplexy for another five, but nowhere does heart disease find mention. Were the 33 cases of sudden death mainly caused by heart failure, coronary thrombosis and so forth 1 Although there is no direct evidence, it seems probable that some at least should be so recorded. Cancer to be recognized required some visible sign, so that it was possible to specify three cases of breast cancer and one of cancer of the navel, but how should tumour of the knee, ulcers in the side and bladder, gout in the stomach, mortification, jaundice and decay, internal bleeding, imposthumes, cholic and bloody flux with thrush be interpreted, states which caused over thirty deaths1 Then, too, there were 13 who died of lethargy, and no fewer than 58 who died from lingering sickness. Finally, there are 259 cases of fever to which must be added a number of instances where fever was the second cause, and the very considerable number suffering from diseases of the chest. These include three coughs and two violent colds, six who died of asthma--two with fever as a complication, 40 cases of pleurisy and 130 patients recorded as having consumption, some with a secondary complaint. This list of diseases carries few surprises even if it presents consider. able diagnostic problems, and one wishes that Oliff had been as zealous in recording the medical oases he cured as well as those who died. A full account of sickness would then be possible and some meaningful statistics possibly result. Nevertheless, some further analysis is possible even if the problems which result are not wholly answered. The pattern of disease can be examined to some extent and so can the incidence of 16 MEMENTO MORI OR DR. CLIFF'S DIARY specific maladies with social implications. For this purpose two types of analysis were undertaken; special attention was paid to the figures for smallpox, fever and consumption; and a monthly analysis of causes of death carried out for 1720 and 1734 the two years when the deathrate rose more than 33 per cent above normal. One problem can be stated forthwith: in both fever and consumption oases there is often 65 6 55 50 45 4 35 30 25 20 15 I I I 10 I I 5 I ... 0 1712 . ., I I I I I I I , ... L r-J I r-•1 -, I I I I II ,. ., ,.•.I tI i ... , t I .• .• . .!" .. .:•"t I I I : 1... I • I I I 1 􀀛-􀀜-J ,-, .. , r·, I I I I t. I ,.,..__ t l ! t.J ... : ....... .J l .. , , .• l ... , :·1 r·' ' "'•"' l.- 1715 1720 1725 mo ms FIG. 3. Total Annual Deaths in Tent.erden, 1712-42. 1740 mn Number of Deaths by which Diary exceeds Parish Register. ■ Number of Deaths by which Register exceeds Diary • . . • Total number of Deaths from Fever. the complication of some other disease. Sometimes one can reasonably assume that fever merely completed the work of old age or whatever the second recognized cause might be, but in a number of cases this is more difficult. Pulmonary tuberculosis is frequently associated with pyrexia, if then Dr. Cliff gives 'consumption and fever' as his diagnosis, is he indicating that a consumptive patient has succumbed to an additional illness; and what is one to make of a death from 'ague and fever', when ague is usually interpreted as malaria? On the whole, it seems more probable that the use of the word 'fever• indicates a specific 17 2 .F.HULL sickness and in the argument below both fever and consumption have been treated as independent and uncomplicated causes of death. The analysis for 1720 and 1734 clearly indicates the inadequacy of this list for accurate statistical work for it is apparent that two or three additional infant deaths or the death of two or three members of one family from an infectious disease can create an immediate distortion of the monthly figures. Indeed, the analysis for 1734 shows such a wide spread of disease that even the indication that January and February and September and October are the danger months provides no evidence of epidemic or other specific cause. Of the 66 deaths, 31 occurred during the􀃽e four months and of these 9 were infants. Although fever attacked Tente.rden in May and June and again in December, only five deaths were recorded for the whole year from this cause. 1720, however, presents a very different case. Of the 63 deaths, 24 occurred in February, March and April, and 13 of these were children under the age of 10, four dying of measles during March. Since this represents half the total number of deaths from mea-s]es recorded over thirty years, it must be suggested that an epidemic of this disease attacked Tenterden in March, 1720. Indeed, the spring of this year was altogether bad: three fever deaths occurred in January, and in the fir:st six months there had been six fatal cases of pleurisy. Fever appears to have lingered in the town during the whole year, and with ten deaths from this cause between September, 1720 and January, 1721, epidemic conditions must again be suggested. On the other hand, 1720 was free from smallpox, and the incidence of this infection is one of sudden outbursts followed by a period of quiescence. The years 1712-16 were bad, a peak being reached in 1715 with eight deaths and, in 1716, with six, but this was followed by a decade v..ith. very few fatal cases. In 1728 to 1729, there were nine deaths, from 1730 to 17 40 only three a.re recorded to be followed by a sudden outbreak with four deaths in 1741. These figures are far too small for any conclusions to be drawn. In 1741, three persons in one family died of smallpox: does th;s indicate a very limited outbreak, or special severity or careless nursing in one of many centres of the disease 1 The most that can be suggested is an endemic disease with very few fatalities as the norm but with sudden outbreaks possibly of epidemic proportions in 1715-16 and 1728-9. The figures for fever a.re even more tantalizing. Were all the fatalities due to one disease1 Were such experienced men as Drs. Back and Oliff really unable to distinguish between different kinds of fevers1 Throughout the whole period fever took a steady toll, and only during 1729 and 1731 were there less than five fatal cases in a year.11 At the other ex􀃾reme, 14 died in 1719, 1725 and 1737, 16 in 1720 and, in 1713, there 11 See Fig. 4. 18 MEMENTO MORI OR DR. CLIFF'S DIARY were no fewer than 27 fatalities. If the whole number of deaths is analysed by month, the totals are revealing. July, .August and February are relatively low with 13 deaths over the thirty-year period and June, September, November and December also have totals below twenty. For January the figure is 29 and for October 35, while March, April and May show 32, 34 and 43 deaths, respectively. In other words, over the whole period a distinct pattern emerges of times of maximum risk in 44 40 36 32 28 24 20 16 12 8 4 O+------------------- JAN. FEB. MAR. APR. MAY JUN. JUL. AUG. SEP, OCT, NOV. DEC. Fm. 4. Gross Monthly Totals of Deaths from Fever at Tenterden, 1712-42. spring and early autumn and another slightly less dramatic period in mid-winter. So noticeable is this pattern that a n exception such as June, 1734, when four persons died of fever only serves to emphasize the normal picture. Bearing in mind the lack of sanitation, is it too much to speculate that the annual spring toll was the result of enteric fever and other diseases resulting from bad food, water and lack of hygiene; that the October rise may well be associated with outbreaks of scarlet fever, especially noted as an autumnal cm;nplaint; and that January represents the attacks of influenza? With consumption, however, the interest is different. This killer does not work by sudden epidemic onslaught but by a silent undermining of resistance and strength. It is no respecter of persons, though its incidence may reflect the living conditions of the age. The significance of consumption figures lies mainly in the age groups most 19 F.HULL FIG. 5. OauseB of Death aB reoorded by Dr. Oliff Accidents, 20. Ague (some with fever), 5, Bee also dropsy. Apoplexy, 6. Asthma (2 cases with fever), 6. Bed-ridden, 6. Bladder, see ulcer. Bleeding a.nd bleeding inwardly (usually associated with old age), 8, Bee also consumption. Bloody flux and thrush, 1. Cancer of breast, 3. Cancer of navel, I. Childbed and miscarriage (one with VD), 24. Cholic, 6. Colds a.nd coughs, 6, see also delirious, fever. Consumption (including 'deep', 'bleeding' and with fever and one case of phthisis), 124. Consumption (with jaundice, fistula, ulcer in. leg, dropsy e.n.d worms), 6, see also gout, lingering sickness. Convulsions, 6. Coughs see cold, delirious, fever, whooping-cough. Decay, see jaundice, old age. Delirious (one with cough), 3. Diarrhcea, see lingering sicknees. Dislocation of collar bone, 1. Distracted, see mad. 'Dosed to death', I. Drink (as a single cause), 4. Dropsy (including oases with ague, fever and jaundice), 23, see al.,o consumption, gout, lingering sickness. Erysipelas, see St. Anthony's Fire. Fever (undifferentiated, but 4 with cough), 263, see al.,o ague, asthma, consumption, delirious, dropsy, gravel, lethargy and coma, lingering siokneas, pleurisy, rupture, St. Anthony's Fire, worms. Fistula, see consumption. Fits, 16, see al.,o lingering sickness. Foot, see mortification. French pox, I. Frenzy, see mad. Gangrene, 4. Gout (including cases with consumption, dropsy, gravel and mortification), 7, see also rheumatism. Gout in stomach, 2. Gravel (2 with fever), 8, see al.,o gout. Green sickness, 4. Harelip, 1. Impostbume, 3. Jaundice and decay, 1, see al.,o consumption, dropsy. 20 MEJMJJJNTO MORI OR DR. CLIFF'S DIARY Knee, Bee Tumour. Leg, Bee consumption, lingering sickness, mortification. Lethargy and coma (including 4 cases with fever), 13. Lingering sickness (including oases with consumption, diarrhce&, dropsy, fever, fits, sore leg), 58. Luna.tic, see ma.d. Mad (distracted, frenzy, lune.tic, melancholy, 'pining siok'), 12. Measles (one with thrush), 8. Mortifioa.tion of foot or leg, 4, see also gout. Na.vel, Bee Cancer, rupture. Old age (decayed, dotage, worn out), 28, see also bleeding. Pa.lay (dead or numb}, 5. Phthisis, see consumption. 'Pining sick', see mad. Pleurisy (including 7 cases with fever), 40. Poverty, 7 Rash (unidenti fied). Rheumatism (1 with gout), 4. Rupture (of navel a.nd with fever), 2. St. Anthony's Fire, 3. Scabies, I. Side, see uloer. Smallpox (including 'bloody pox'), 46. Stillborn, 23. Stone, 1. Suddenly, 33. Suicide, 6. Thrush, see bloody flux, measles. Tumour in knee, 1. Ulcer in bladder or side, 2, (in leg see oonsumption). Unknown, 349. Venereal disease, see childbed, French pox. Vomiting, 1. Whooping cough, 6. Worms and worm fever, 12, Bee also oonsumption. Worn out, Bee old age. affected. Fig. 2 (page 15) indicates clearly the social implications of this disease. It attacked the young women of child-bearing age and it attacked men in their prime who should have been at the height of their powers and providing for families. Consumption and fever accounted for nearly one-third of the deaths recorded by Cliff, sufficient comment on these two killer diseases and the economic and social damage which they must have caused. If the same age-groups as those in Fig. 2 are also examined for those 21 F.HULL people whose disease defied diagnosis, one finds 23 men between the age of 11 and 70 dying of unknown causes, a third of them being over 60 years of age. No fewer than 34 women, however, died of unknown causes, 17 (50 per cent) of these aged between 41 and 60. Moreover, in 8 of these 17 cases a second or even a third opinion were taken. In view of the diagnostic difficulties already noted, do these oases hide such matters as cervical and uterine cancers? Fxa. 6. Doctors and Number of Oases attended, by each. Austin, the surgeon, 1. Baok, sen. and jun., 382. Barrett, 1. Bates, of Ashford, 3. Beeching, I. Blackmore, I. Bodenham, 6. Boderick, 2. Botting, of Battle, l. Boyce, of Canterbury, I. Butts, I. Christian, 13. Cliffe, sen. and jun., 312. Cookman, 2. Coombes, of Cranbrook, 1. Curteis, of Wrotham, 9. Duke, of Maidstone, I. Edmet, 18. (?) FentaU, 1. Groombridgef, 10. Hope, 2. Knight or Knightly, 3. Lott, 4. Maresh, I •. Medhurst, 76. Munn, of Hastings and Woodchurch, 4. Parker, 4. Pocock, 1. Smith, of Maidstone, 3. Temple, I. Thorpe, of. Rochester and Ch11,tham, 3. · Trowell, I. · · · Walter, of Cranbrook, 7. Wethersby, 1. White.ore, of Maidstone, 2. Young, 8. Uncertain London•, ,Wadhurst and Maidstone doctors, 3, Unknown, 168. No doctor, 96. t A Dr. John Groombridge, A.M. of Trinity College, Cambridge, was liconeed by the Royal College of Physicians in 1697 and praotised in Cranbrook. • In addition one case refers to Wm. FuTby, who had 'a long lingering sickness, the gravel, after he had been out and a stone taken away from him by Mr. Chessoldon at St. ThomM's Hospital1 London'. 22 MEMENTO MORI OR DR. CLIFF'S DIARY Such, then, is 'Dr. Cliff's diary', a record which despite its defects throws some light on the causes of death in one small Kentish town in the early eighteenth century. It demonstrates the terrible destruction of infant life, the loss of many young women from consumption and in child-bed, and the all-pervading risk offever. It presents many problems and questions to which no satisfactory answer can be given and, finally, despite the limited nature of the evidence it throws light on the dedicated work of men like Back, Cliff and Medhurst, who visited rich and poor alike, served the parish workhouse as well as the jurats of Tenterden, and strove to understand the challenge of disease and death in their day and age. AOKNOWLEDGMENT The Kent County Council contributed to the cost of this paper. 23