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Home , Erysipeloid, List of epidemics, Sweating sickness

HISTORY OF * By JOHN F. TOWNSEND, M.D.

CHARLESTON, S. C.

N tracing the history of the etiol- was “a gaseous emanation of telluric ogy of influenza one finds much of origin”19; and later it was thought to interest. For one can thus visualize be some volatile or fixed principle the history of the etiology of emanating from the bodies of men in general; from the belief inand animals.20 Baron de Tott claimed Iancient times of its origin in some immunity from these emanations by impending fate or superstitious dread, directing, with his cane, the removal on through the intervening stages to of the bodies that had died of the the more modern ideas of errors of in Constantinople.20 and by , In 1411 the French physicians for claimed that the cause was a contagion . . . the ravages of epidemics like the de Pair, in 1414a contagion de le bise or great cataclysms of nature have in all north wind.19 This and the ages appealed to the imagination and one of 1427 were supposed to be air- excited the terror of mankind. To the borne. simple savage of the earlier generations, as Dr. Johnson quotes Van Swieten among the savage tribes of the present who calls it “a malignant catarrh that day, an obvious similarity must exist arose as it were from a certain vapor, between the havoc wrought by the fury since thick clouds of an ill smell of the elements—and that no less fatal— preceded it for some days, then it accomplished by the sudden outbreak of suddenly broke out seizing almost some malignant disease spreading with instantly a thousand persons.”20 This inconceivable rapidity and making count- description resembles the disease that less victims. and pestilence, meteors, recently occurred from some ill-smell- volcanic eruptions and storms being alike ing gas of unknown origin. It was abnormal and mysterious occurrences, called nebelsouch or fog plague in the direct intervention of some super- 1889-90, when the fog was supposed to natural agencies were deemed requisite to have caused many deaths.19 account for their apparent deviations Hildanus, becoming more concrete, from the settled order of the universe; all supposed that the cause of the Plague were attributed to the anger of an at Lausanne and the neighboring offended diety, as when Zeus, for an insult districts was not only a contagion, but to his priest, by his thunder, sent sickness also some vicious quality of the air, into the Argive camp. which travelled from the sick to the On mules and dogs the infection first began well “sitting near.”20 In the monthly And last the vengeful arrows fix’d in man. report of the Paris Faculty of Medi- As knowledge increased the medical cine in 1658 we find a paragraph men of ancient days assumed other stating that the disease was due to causes of influenza. Some held the “les variations de I’atmosphere.” In cause to be a morbid miasma that Italy, at the same time, the same floats in the air,20 others held that it view was held. The theory of its * Read before the Medical History Club, Charleston, S. C., October, 1931. causation from temperature variations contagion, as opposed to the miasma- received further support from Spren- tic cause, was clearly defined by gel, who, writing of the epidemics of Hay garth.4 1742 and of 1782, said that influenza Dr. Johnson, writing of the 1793 was due to a “sudden change from epidemic, gives instances of influenza sudden heat followed by sudden cold,” occurring on vessels that had left a while Muncio, writing of the 1762 healthy port with a healthy crew, and epidemic, expressed the same thought, weeks later had influenza break out. when he said that it was caused by He says that while the warship Atlas sudden cold followed by sudden heat.19 was in the China Sea influenza broke The chemical composition of the out on board ship, and that it was later air was again advocated as a cause in found to have started in Canton, 1742, when influenza was said to be China, at the same time. But as an due to a phlogistic gas, over-stimulat- argument against the theory of con- ing the weakened body, producing a tagion, he gives reports of influenza catarrh. And, when the chemistry of breaking out in isolated, widely sepa- the air was still better known, Most, in rated huts in the mountains with no 1820, becoming more specific, claimed communication between them. This that influenza was due to an excess of fact, and the instance of the warship oxygen in the air.19 Atlas, may lead one to believe in the But a real advance in the contagious Epidemic Constitution, which idea theory was made in 1762, when the will be developed later. disease was traced to people coming We find that in 1782 the Medical from infected areas; and in 1782, to Council of declared that influ- persons, clothing and articles coming enza was caused by persons inhaling from infected districts. It was then air-borne or swallowing water-borne said “that it began in a town or city insects.19 The name la grippe was also and spread to the neighboring villages; said to refer to insects, which by con- that both on land and sea isolated taminating the air were supposed to imported cases invariably preceded cause the influenza. The same, with the general outbreak,” thus bringing respect to insects, has been said of forward prominently the contagious dengue.4 cause. From early ages, in 1529, food And so it went, miasma or conta- poisoning has been blamed as the gion, contagion or miasma, but actually cause of some of the manifestations of the miasmatists were hard pressed to influenza, as in Germany it has been explain the transference of influenza said to have been caused by eating observed clinically, and the contagion fish. In 1752 Swabian sausages were advocates were equally hard pressed thought to be the cause; or it was when confronted with records of whole thought to be due to ergot, causing communities succumbing in a night, Kriebelkrankheit; or to radish seed as was recently illustrated at Cape causing raphania. It was also said to Town in 1918.17 Therefore, as clini- be due to partaking of rye, peas, cians we might hold to the contagious chickens, and many other articles view, while as epidemiologists we turn of food or drink; all of which were to the miasmatic hypothesis.19 But it declared to have caused illnesses now was not until the 18th century that diagnosed as influenza, with this pecu- Iiarity, that many of the cases of food that the in the epidem- poisoning were found to be nervous or ics was of an unstable variety, which cephalic in their symptomatology, on culture became stable; that it was “die Nervenkrankheit, as Haberkron a pleomorphic organism.9 That the in 1772 called it.” These epidemics disease is closely associated with a were also called Kreibelkrankheit pleomorphus streptococcus of the in Germany, and Raphania in pneumococcus group is now held by , Scandinavia and Russia until many; Donaldson thought that it 1800.7 belonged to type iv.3,17 The bacterial cause was, of course, This view was also held by Rajch- not understood in the early history of mann who predicted the 1918 influenza, but Seiffert in 1883 was .3,17 one of the first to study the bacteriol- Crookshank says that bacteriologi- ogy of this disease. He found a Strep- cally the of influenza are tococcus pyocyaneus to be the cause. due to some or filter-passing In the 1889 epidemic Klebs discovered ,7 and that epidemics of special- the flagellata, while Rilbert, Vaillant ized! types are caused by association and Vincent found the cause to be a with other organisms; or that the streptococcus, but Weichselbaum, cause of the epidemic may be a pleo- Kruse, Pansini and Marmorek as- morphus coccus or some physical cribed influenza to the diplococcus of condition that actuates that pleo- pneumonia.19 morphus coccus.17 Others have held We have studied the parasites which that the , between the develop under laboratory conditions pandemics of influenza, depends upon and have held disease to be bound up some interaction between the “pri- with them. For instance, Creighton mary cause,” whatever that is, and claimed that “the bacillus influenza the various “satellite influences.” Into was the sine qua non of influenza,” this question symbiosis comes, “for but, says Hamer, “we forget that a the organism may be linked now with particular parasite may be merely one one and now with another ferment or of a series, and that it may in some enzyme. ” (Dixon.7) This doctrine may cases be replaced in that series by find application, for example, in the another parasite, and for the time connection between the tubercle being and under the local conditions of bovine or of human origin; or the in question cease to have any connec- parasite or associated parasites of tion with the disease at all. The and vaccinia; of scarlet records of epidemics suggest that some fever and ; (I have often such explanation must be looked for, seen these occur consecutively in the in order to reconcile the extraordinary same house but not necessarily in the persistence of disease types, with the same patient); of dengue and in- no less remarkable variability of the fluenza; of enteric fever and ; organism to which the bacteriologist of and . We attaches importance, as the cause of may even conjecture that immunity the disease.”7 in some instances may mean that the Then an idea, that has since gained parasite has been harnessed to some many adherents, was brought forward other parasite or enzyme which robs by Robert Donaldson. He thought it of its virulence. (Hamer.7) Here, of course, we must not lose sight Pfeiffer himself of 217 cases examined of the fact that the particular organism to during life obtained only 51.6 per cent which the bacteriologist has drawn atten- positive and of 30 cases examined post tion, may of itself be a mere subparasite, mortem only 66.6 per cent positive.9 capable of living symbiotically with the If Pfeiffer’s bacillus is the causal parasite in chief. Thus the influenza organism of influenza, then there is organism may at one time live in associa- also a pandemic of 62.9 per cent of tion now with one or more groups and then again with some other differently total cases of some disease due to some constituted groups of satellite influences, other organism, according to an aver- thus accounting for the variations in age of the findings of all bacteriologists manifestations of influenza, especially except Pfeiffer. during the interpandemic period. The manifestations of influenza are fairly Epide mics of Inf luen za constant in the agregate, at each pandemic The epidemic of 1510 was accepted phase, but undergo remarkable trans- by all but there are accounts of formations in passing from one pandemic , that we now consider to to another.7 have been influenza, that occurred in b.c . 412, and also in b.c . 393, when So, one pandemic passed into an- the Carthaginians were besieging Syra- other through the intervening trailers cuse, and in b.c . 43 in . In a .d . and precursors by means of the activa- 591-92 the disease was characterized tion of carriers of the organism, by much yawning and sneezing, which whether this activation occurred by gave origin to the custom of making the influenza bacillus or by the the sign of the cross over the mouth streptococcus or otherwise. But only when yawning and saying “God pre- when this activation was due to the serve you” when anyone sneezed.19 streptococcus did fatal and compli- Also there were epidemics in a .d . cated cases occur.8 837, 876, 889 and 932.1 But authentic The prodromes and trailers of epi- history begins with the epidemic of demics will be briefly referred to 1173, which was noted by Hirsh, for later. fatalities in pregnant women. In the In discussions of the bacteriology of epidemic of 1307 it was called by the influenza, Pfeiffer’s bacillus has been French le tac; also le horion. The mean- prominent. But Donaldson in writing ing of these names will be explained of “the bacteriology of influenza, with under Nomenclature. Other epidemics special reference to Pfeiffer’s bacillus,” occurred in 1323 and 1327-28. In says: 1387 the disease was so prevalent that hardly one in ten remained healthy, In the 1918-19 pandemic of 19,145 but few succumbed. It occurred again examinations during life it was found in in 1403-04 and 1410-n.19 34.4 per cent of cases and of 3056 post- Pasquier says that there were at mortem examinations it was found in least 100,000 cases in Paris in 1413-14; 39.8 per cent of cases. These cases repre- sent a majority of the cases examined in another epidemic occurred in 1427 many countries by many bacteriologists.9 and the 1510 epidemic was noted for . . . Taking an average of nearly 20,000 frequent abortions in women, while in cases, 62.9 per cent were entirely negative 1529 there was a pandemic of sweating as far as the Pfeiffer bacillus is concerned. sickness in all countries except France and Italy.1 It was then referred to as Epidemics occurred in 1675 an<^» the pestis Britannica. 1712, Camerarius called it Scblaf- In 1551 the epidemic in France was krankheit.* The nervous manifesta- called le coqueluche, or, the fad of the tions seem to crop out all along the moment and the same frivolous term line. There were epidemics in 1718, was applied to the terrible pandemic of j727, j729, 1732-33, and 1741-42, 1580.1 in Edinburgh, “not one out of six or In 1557 was another one of the seven escaped. ”19 They again occurred English sweats; which, on account of in 1767 and 1781-82. That of 1781-82 its posting character, received the was most widespread. It started in the name of “stop gallant and know they British army in in November. master.”7 Some say that the “sweat- It was in China during the same ing sickness” was not the same as autumn; in Siberia and Russia in influenza. They may be right, but December; Germany in February, many physicians, of many periods of 1782; and Sweden in April; medical history, have identified them England and Scotland in May; France as being the same disease, on account and Italy in June; and in in of their possessing the characteristics August, again illustrating its posting known to be those of influenza.7 Some character.19 say that the dates here given are not The one in 1793 was described by those of influenza epidemics but Robert Johnson, who observed that Dwight M. Lewis8 says that “what are epidemic and wrote of it.20 There often thought to be independent dis- seems, then, to have been much in- eases and independent complications fluenza, a sort of epidemic constitution of such diseases are seen on careful from 1799 to 1804, and the one that examination to be interdependent dis- occurred in 1816 was especially fatal eases and interdependent complica- to children, killing in a few hours, as tions. Many physicians have correlated occurred in some of the cases in 1918. all the diseases here mentioned as Epidemics also occurred in 1827, being influenza.6,7 The correlation of 1830-33, 1836-37, 1843 and the one in epidemics, the identification of the 1847-48 was noted for its bronchitis various epidemic illnesses, as being of the capillary form which was very influenza, will be referred to later, fatal.19 There were epidemics noted in when opinions by Heusinger, Willis, 1850-51, 1855-58 and 1875-76, and in Camerarius, Scheifferlius and others 1889-90 it was in both the western and will be quoted. eastern hemispheres, where it was To continue the : called the morbus maximus epidemicus. The great epidemic of 1580 was noted Pandemic influenza again occurred in especially for two symptoms, being 1918-19. so sudoral as to suggest the return of Periodicity for epidemics has been the English sweat and so encephalic as claimed by some but has not been to be called by Brunner the Haupt- proved. Sydenham, I think, wrote on krankheit. There were other epidemics that feature.19 in 1593 and in 1647. Cases of influenza The average duration of a pandemic first occurred in North America in is about three months.4,19 1626-27, but-the first epidemic occur- Epidemics have not been proved to red in the western hemisphere in 1647.19 spread from east to west or from west to east as some claim, but they spread different typical epidemics as being all radially and by leaps and bounds and influenzal.6,7 One brief reference: Heu- always by roads of intercommunica- singer in his “Commentatio Semio- tion, using the route of travel, by Iogica” connected Guidetti’s account person to person and country to of the 1712 epidemic with that of country, illustrating their posting Willis in 1658; and Camerarius that character.7 The posting character is of 1712 with that of 1580. And Scheif- defined by Crookshank4 as involving ferlius in 1727 in a rare essay entitled large areas of the globe and prevailing “De morbo epidemio convulsive, per in affected communities for some three Holsatiam grassante oppido raro,” or four months at one time. identified that malady with that of Some epidemics are very wide- Willis (1652-58) and that of 1580. spread. The one of 1781 has already “He was severely criticized for this been geographically outlined but the but was vindicated by the occurrence one of 1580 also involved millions of of recurrent waves of influenza from people and a wide territory: Asia, 1729 to 1733, that continued through- Africa to Constantinople, Venice, out the .”6 Many others have , France, , Hungary, drawn together under one disease the Bohemia, Denmark, Sweden and many different types of influenza as it Russia.19 has occurred from its first recognition Influenza has often been called a until now.7 new disease, novus morbus, on ac- We are therefore impelled to quote count of its diversity of manifesta- Fernel, Schiller and Benedetto, to tions. Epidemics are also diverse. recognize that certain diverse special Different epidemics seems to pick out diseases represent the recto and verso different organs; the toxin picks out of one and the same pathological and one type of tissue and seems to limit epidemiological concept.4 itself to that tissue, as in one epidemic pneumonia predominates, in another Prod rom es and Trail er s of Epidem ics gastrointestinal involvement; while With pandemics there were trailers in another it may be mastoditis.1,19 that came after the pandemic, some- In different countries there are differ- times attacking the same people who ent manifestations, even in the same had already been sick, repeating ten, epidemic, as in 1718 it was called in twenty, or more times and often with Picardy, surette du Midi; in France different types of influenza in the la fievre miliare; and in England the recurrence. Hamer quoted several .7 And the 1820 cases illustrative of these repetitions in epidemic was identified with the same patient. That epidemics have sudorale; with this should be con- predecessors and trailers has long been sidered the great increase in cases of noted. Hamer wrote learnedly on this “mucous” and “ulcerative ” of subject. Crookshank has shown by 1918 and 1920, which were trailers of historical survey that influenza has a the 1918 pandemic.4 characteristic tendency to herald it- Thus we recognize many manifesta- self in the form of predromes of tions of influenza epidemics, but, in paralysis or other manifestations of order that there may be no confusion, encephalomyelitis, but he recognized many observers have correlated the that the “epidemic stupors” are no new disease but that they have been epidemic, occurring in 1581 were recorded with variations for 450 years, described by Ronsseus—they were as predecessors or, as some say, avant like those in Belgium in 1557, which coureurs or prodromes of a pandemic. were supposed to be due to ergot; the Hippocrates recognized this when he illness began with spasticity or palsy said that the prevalence of encephalo- of hands or feet, with half closed eyes, has always stood in a certain oculi semi apertis, open mouth filled relation to epidemics and endemics of with ropy mucous and tongue as if “burning fevers,” which we now call paralysed, all like . This is influenza.7 parallelled by the account given by For instance, Malcoups of Brussels BreinI of the spasmodic form of Heine- divided the historic influenza into two Medin disease in Australia in 1917, catagories; the one vernal, catarrhal occurring as prodromes of the 1918 and benign, as in 1658, 1742-43, and pandemic; in both groups there were 1780; and the other autumnal or severe gastrointestinal disturbances. hermal and marked by “prodromes Leichtenstein, writing of the 1550 nerveux caractere adynamique gravite epidemic, and also Blakiston and plus grande, ”as in 1580, 1676, 1730, Graves, recognized and wrote of poly- 1737, J775 and 1837. The cases of morphic nervous manifestations of encephalitis Iethargica seen in May, influenza that occurred as trailers and 1918 should be reckoned among the avant coureurs of pandemic influenza.1 prodromes nerveux of the pandemic of Many of the epidemics of 1825, influenza of the autumn of 1918, which called dengue, were incidences of in point of fact combined Malcoup’s “Spanish influenza” of the type seen two catagories.6 in May and June of 1918, which were Literature is full of illustrations of the precursors of the pandemic of that physicians who have correlated the autumn.7 prodromes or avant coureurs and the Huxham noted that the vernal trailers of epidemics and whose writ- catarrh of 1743 was followed by ings are too numerous to quote. How- trailers in 1745 in the prisoners at ever, Lombard expressed the aphorism Plymouth with a mortification of the that embodies the experiences of Hip- feet.4 This in 1889 was recognized as a pocrates, Bellonious, Barthelini, the sequela or trailer of influenza, a two Kammeisters and of Guidetti, similar condition occurring after that when he said “La grippe est sou vent epidemic. precedee par une constitution emine- ment nerveuse, dont les caracteres Nomen cla tur e principes sont de porter Ie trouble dans It is curious to remark the regular and les fonctions du cerveau et des nerfs constant pace which the science of health encephaliques, ” to which Ducros, and philosophy have kept with each Montain, Petroquin and Recamier other. As long as philosophers imagined the elements of natural bodies to be four, agreed.7 That is in brief, the opinion of physicians supposed human bodies to many; a few illustrations are: The consist of as many humors, but as soon as trailers of the 1550’s epidemics were the corpuscular philosophy became pretty noted by Leichtenstein and avant generally received, medicine had her coureurs of the 1580 epidemic by acrimony, spiculae and salts of various Bellonius. The trailers of the 1580 sizes. In like manner when astrologers took the lead of true science and people until 1918 that the Royal College of began to fancy all terrestial things to be Physicians confirmed the word in- governed by the heavens, some Italian fluenza in the place of Zeviani’s il doctor found that this distemper pro- catarro epidemicod ceeded from the influences of the stars, Thus we see that very early it was and gave it the name of influenza. called “pest,” “pestilence” or “a [Robt. Johnson.] plague.”1 Then it was called catarrh As Sir Thomas Watson says: “they in the 16th and 18th centuries, but put the cause for the effect. ”4 Of these was called influenza by the Italians as there are several illustrations, but I early as 1357; and finally influenza by will name only four. everyone. Buonissegui in 1357 called it, in Those are the foremost names of Tuscany, the grande influenza and influenza, though its names are said that to save the patients the cost legion; varying geographically and of doctor’s visits, the doctors were temporarilly. allowed to visit their patients only Geographically it was called morbus once daily. Sozoma similarly named Hungarius, morbus Gallicus, suette de the famous epidemic of 1387, while Midi, la suette de Picardo, or the Calenus declared the epidemic of Picardy sweat, which in 1847-48 1579~8° t0 be ab oculta coeli influential was thought to be essentially cholera The fourth illustration is more descrip- sudorale (Hirsh); in Spain, pantomima; tive: “In 1658, about the end of April, in France in 1772, la fievre miliare. suddenly a distemper arose as if sent In Germany, especially in 1528, it was by some blast of the stars, which laid called the sudor Anglicus or the Eng- hold on very many together, that in lish sweat, or less euphoniously, the some towns in the space of a pestis Britannica; in Russia the Sibe- week about one thousand fell sick rian fever, and the Chinese fever in together.”7 Siberia. America called it influenza The Venetian envoy in in Europa, European catarrh or Spanish writing home of the sweating sickness influenza.4 Each country was blaming of 1551 used the word influsso; in- the other for it. It was called fluxio and influsso were then freely fever where the two empires the used in respect to all catarrhal and empire of influenza and the empire of sudoral maladies. Influsso is there- dengue, met.7 fore astrological and humoral in its In 1580 in England it was called connotations, while influenza is philo- the “gentle correction” or later “the sophical and astrological but not Jolly rant,” the “Dunkirk rant,” humoral.1 or in 1709 the “Dunkirk ague.”4 The word influenza was first used in On account of the symptoms of the professional English in 1767, in the 1580 epidemic, the encephalitic forms, translation of Professor Huxham’s which were like those exhibited by a book, “De aere et morbis epidemicis,” sheep with cysticerci within the skull it but the first allusion by an English was then called mal de castrone, and physician to the word influenza, as in Germany in 1487 the Haupweh, the the name of an epidemic, was in 1743 head trouble, was given as a name for in an “Essay on Fevers,” also by the influenza trailers of the 1580 John Huxham.4 However, it was not epidemic. And in 1775 Andral called influenza “hydrophobia without the valley and encephalitis or influenza in bite of a dog.”6 a town a few miles away.1,7 He thinks Then there were names given to it that all of these cases were influenza. on account of some particular symp- Again, in 1915, there was in London tom. The names le tac, meaning a an epidemic of influenza with lung and coup de fer, and Phorion, meaning a cerebrospinal complications that finds sudden punch between the shoulders, its analogy in “a new fever,” described are expressed by the Londoner as by Sydenham in 1685, also with lung “getting the knock,”5 or the “knock- and central nervous system symp- me-down-fever. ” In Spain it was toms; in each there was often a trancaze, a blow with a bar; the purpuric rash.7 Scbnupfenfieber in Germany and the mal di castione, or coughing sickness in Symp tom s Italy. In fact in 1173 it was called Of the symptoms of influenza tusso gravessimo.™ Robert Johnson in 1793 said that one The present name for whooping of the characteristics of this disease cough, coquelucbe, was used by the was “the sudden transformation from French for influenza in 1414, 1551 and high health to sickness, often as it in the great epidemic of 1580. were instantaneously.” “There is,” That sickness follows as the result he says, “no disease to which the of sin was believed not only by the human body is liable that is so exten- Jews of Christ’s time, but by the sive in range, so sudden in attack French in 1411, when they thought (the German Blitzkatarrb or lightening that influenza came as a visitation on catarrh carries out that idea) and so those for singing a lewd song then in furious at the beginning, so rapid in its vogue, “Tu as chante la chanson.”19 course, and at the same time attended Dengue and influenza were by many with so little danger.” supposed to be the same, dengue being Time permits of speaking only the summer form of influenza. (Den- briefly of some of the symptoms. gue is by some said to be derived from The cough is especially prominent dans le dos, le dando.)5 for its persistence, especially as a Because the symptoms of influenza sequela. In 1410-11 in Paris, it was so did not always correspond to or match severe as to cause in some cases the concept of influenza then held, a rupture of the pregnant uterus.19 new epidemic was often thought to be In the epidemic of 1427 it prevented a new disease; for instance Randolph, the people from attending church; but the English ambassador to the Scotch from the contemporaneous writings Court, writing to London in 1562, we learn that it did not prevent them called it the “new acquanyntance, ” from attending the theater. stating that it “spared neither Iorde Epistaxis was noted by Hippocrates nor Iadye. ”19 and was regarded as a favorable Hamer says that different manifes- symptom in the epidemics of 1414, tations of the same epidemic used to 1580, 1729 and 1837. It was frequent be thought to be different diseases. in recurrence rather than persistent, in For instance, he finds historical records the epidemics of 1737, 1755, and 1803, of cases of sausage poisoning in one and, in the 1918 epidemic, was noted village, in a neighboring by Conner in 25 per cent of cases in some hospitals, especially in the cases pathetic and the parasympathetic sys- that later developed pneumonia.14 tems, an inhibition of one means an Johnson in 1793 mentioned a patient increase in the activity of the other. who lost 20 ounces of blood. He also says that the most striking In 1580, on account of coincident general feature of this autonomic or symptoms referable to the bile duct, parasympathetic predominance is that that epidemic was called by some bearing upon the complex factors of catarrhalis biliosus. vascular wall function. As the result Sometimes there was a bloody spu- of the paresis of the constrictor fibers tum11 and cyanosis, the mauve or there is a dilatation of the vessels and heliotrope cyanosis that was so fatally a serous or hemorrhagic exudate.11 characteristic.10 Some of these cases If cephalic there is pain in the head, a of cyanosis in the Russian epidemic of serous or non-purulent (the 1742-43 terminated in diarrhea or “hydrophobia without the bite of a dysentery, which seems to show, in dog”). The head pain is at times in- the terminal stage of the case, an tense, of a bursting character.11 If the affection of the vegetative nervous cranial nerves are involved there may system innervating the gastrointes- be disturbances of smell, optic neuritis, tinal tract, as there was in the early ocular paralysis, deafness, vertigo, stage a disturbance of the vago-auto- disturbances of taste, facial palsy and nomic nerves supplying the lungs. various fifth nerve neuralgias. Or, if This affection of the vegetative system peripheral spinal nerves are involved, will be referred to later. we get neuritides or neuralgias from Diarrhea, pneumonia and rhinor- exudations in the nervi vasorum of the rhea, a great flux from the nose, were nerve sheaths.11 In Scotland (and it is noted in 1693.11 Webster, in 1761, strange how symptoms occur to suit noted a running from the nose and the people) there was a most charac- Heimer in 1762 noted it as the cause of teristic sensation of tracheal excoria- erysipeloid irritation of the upper lip.14 tion that the imbibing of Scotch Fernel, Benedetto and Ballonius re- relieved. All of which, to go back to garded the catarrh as a distillation Jelliffe’s explanation, are due to a from the brain which came as a sweat, vegetative disturbance, the most strik- a flux, of the mucous membrane and ing features of which are the disturb- which, if repulsed or arrested, choked ances of the pneumogastric and sym- the nervous system, producing what pathetic adjustment. The sympathetic we now call encephalitis or myelitis.6 paresis with over-action of the auto- Camerarius in 1712 observed ptosis, nomic causes the edematous flooding of the oculi semi apertis, a prominent the pure “influenza pneumonia,” the symptom of the present-day cases.10 pneumonia being thus not a complica- That was the epidemic that he called tion, but a part of the disease. Schlafkrankheit on account of the The gastrointestinal symptoms from sleepy appearance. this vegetative disturbance are gastro- Jelliffe advances an unique hypothe- succorrhea and the like. sis in relation to causation of the symptoms. He says that, the involun- Compl icatio ns tary functions of the body being under The complications are many. Some the opposing control of the sym- are of interest. In the throat there is sometimes a Pregnancy has always been noted marked difference between the objec- as one of the most serious complica- tive symptoms and the subjective tions, for it has been noted that a symptoms, for at times, when there temperature of io 3°f . or more, or is little that can be seen, there is much especially a cyanosis, is particularly subjective complaint, or vice versa.14 apt to make a uterus become active, Hoarseness and cough were promi- and if abortion or premature labor nently noted in the Roman epidemic in occurs the mortality was as high as 1593, also 111 ^e epidemics of 1673, 80 per cent (Titus and Jamison) 1712 and 1737. Sometimes there occurs or as low as 50 per cent.15 As has a paresis of some of the intralaryngeal been mentioned, cough may cause muscles.14 Years ago such a case was the uterus to rupture. In 1510 women diagnosed in Charleston. The child’s often aborted. In 1647 it was especially father thought that the condition was fatal to pregnant women. In the 1782 due to and moved to epidemic there were in London “many another city, changing the outlook cases of miscarriage and some deaths. ” and surroundings of his family. Bradycardia is frequent in the early Anosmia, if associated with dis- stages from involvement of the synap- orders of taste, is apt to be permanent. ses in the mid-brain, and of the Sinusitis occurs in 4-6 per cent of cromaffin tissues. Glossopalatine or cases, but it tends to recover, even spinal accessory involvement mani- without treatment, in marked con- fests itself as taste disturbances and a trast with mastoiditis, which is serious, general disgust for food. This was espe- even with treatment. Middle ear cially noted in the 1742-43 and 1780 complications were noted in the epidemics. Sciatica is also extremely epidemics of 1580, 1732, 1788, 1789 common, being mentioned by many and 1835, and it was early recognized authors.11 that the eustachian tube caused the middle ear complication. H. Lawson Con cep ts of Dise ase s : Epidemi cs an d Whale makes the interesting observa- Epid emic Const itut ion tion that an influenza mastoid may As physicians we observe the phe- occur without an intervening middle nomena presented by the patient. ear involvement.14 The epidemic of We then express their order of occur- 1733 was noted for giddiness, an rence and their likenesses by means internal ear involvement. of concepts. The formation of a Intracranial complications from concept is not an act of perception but otitis were early noted. Frances n, is an act of the mind. A disease con- cept, therefore, is a mental act and King of France, husband of Mary of is as immaterial as an Euclidian line, Scotland, had an intracranial com- but the disorders of function, their plication, a condition then recognized manifestations and their results, as as due to the discharging ears (Alex- attributed to the patient, are reali- ander Dumas). ties. Disease concepts are not realities Neuralgias and neuritides with but are bills of exchange on the count- palsies and zosters14 of every regional ing house of medical practice, to be distribution, central as well as pe- cashed, discounted, or rejected in ripheral, have been seen. accordance with their value at the current rate of the bank of medical pas d’un homme, mais de la cite, et experience. A disease like influenza meme de tout un pays. Civitatem has no existence, except at most in non virum curabis. ”3 Epidemio- the Aristotelean sense, anterior to Iogically we think of cases as symptoms the concept; just as a lawyer con- of epidemics, and of epidemics as siders that a crime is only a crime as a symptoms of pandemics. result of a law. Anterior to the law the crime does not exist.2 Epid emic Cons titut ion We give a name to the disease con- The epidemic constitution was phi- cept, calling it , losophized about by Hippocrates; or influenza. When we match the idealized by and materialized symptoms presented by the patient by Bellonius in the in his with the disease concept we make our book called “Epidemies and Ephem- diagnosis and the patient is said to erides.” Sydenham practiced clinical have a case of the disease. As we learn analysis and epidemiological synthesis. more, observe more and better, our The epidemic constitution may be disease concept changes. Because in- described as follows: fluenza did not match with the disease There appear many cases in a concept held at various times, in- community which are often attributed fluenza was frequently called a new to local conditions; as food poisoning disease; as a new delight, a new (canned tomatoes, ergotism, botul- acquaintance, morbus novus, and morbo ism), drain errors, overcrowding, or neuvo or morbus insolitus. New con- rhaphania. Some of these may be cepts mean new symptom groupings nervous cases as solanism or they and rearrangement of our ideas con- may be some form of meningitis. cerning the manifestations of certain There are interesting and unusual classes of sick persons. Just as a forms of cerebral, bulbar, spinal and disease is a concept of symptoms plus neurotic diseases. There are also an intracorporeal cause, so an epidemic respiratory cases which are diagnosed concept is a concept of cases plus an as pneumonia of a peculiar onset and extracorporeal cause, and a pandemic course. concept is a concept of epidemics plus Others are gastrointestinal in their an extracorporeal cause.3 manifestations and have, as a diagno- We refer symptoms to the disease sis, some form of enteric fever, as concept for diagnosis. We refer cases typhoid, dysentery or gastric fever. to the epidemic concept for diagnosis There are also cases of and we refer epidemics to the pan- and of colitis (the scorbutus of the demic concept for diagnosis. The Renaissance period), or there is the sufferer from the epidemy is not the serous effusion in the peritoneal person who harbors the disease but cavity, “the tumid belly,” as it was the community within whose terrain diagnosed by Sydenham, as a part of play the agencies that disseminate the the epidemic constitution; or cases germs and favor their pollulation; are seen of anomalous or peculiar and the cause relates rather to the forms of common specific fevers or of population and to the prevalence. septic throat, of the fourth disease, As Brochin says: “Dans les epidemies, of Iastrim, of glandular fever and the benignes ou dangereuses, il ne s’agit like.17 “Many diseases appear new and “Then the all mysterious and puzzling. Even the bubbles down as trailers, which in lower animals are affected, domestic each succeeding year become more as well as wild.” These conditions unlike the pandemic.”7 succeed one another for a year or two Thus an epidemic constitution is or more and should be called by not a material thing like a flower or epidemiologist the avant coureurs. At vegetable; it is a concept of a con- this time the epidemic is often not dition, and by comparison of our looked for. observations with that concept a Then comes the general widespread and diagnosis is made of an epidemic con- evident general disturbance of public stitution. An epidemic constitution, health, a perfectly recognizable manifesta- is, therefore, seen to consist of (1) the tion. In the pre-pandemic period the avant coureurs, (2) the pandemic, and endemics and epidemics are less typical (3) the trailers. but become more typical as the pandemic That brief exposition of an epidemic period is approached and less typical constitution may to some seem like a after the pandemic ends. During the meaningless theory, but as a case in pandemic or “the influenza crisis” much point, this is the epidemic constitution happens that is afterwards forgotten. of the 1889-90 pandemic. For instance; surgical operations “go There were, according to Menitier, -wrong. ” There are odd forms of suppura- avant coureurs in the form of pneu- tion or peculiar inflammations of veins and of cellular tissues are seen with monia in Paris in 1885; followed, unusual frequency; anesthetists meet with according to Cordier, by an outbreak difficulties; obstetricians have calamities; of poliomyelitis in France in 1886; and aural and ophthalmic specialists are the same malady in Norway also in puzzled; and alienists are consulted con- 1886, reaching Sweden in 1887-88. cerning baffling and strange psychoses.17 In the Mediterranean in 1888 it was Moreover, the veterinary surgeons are called a “new disease” and according busy; for there are epidemics here and to Marathner, manifested itself as a there among horses, dogs, cats and rabbits disease similar to the Heine-Medin and fowls; and paralytic affections such as disease in Geneva and as a new form “limber neck” are common in the stable of pneumonia in Italy in 1888; in and in the farmyard, [cf. Heusinger.7! Virginia it was also called a new Nor is it only the domestic and captive animals that suffer; for, as in 1918, we disease; some thought it to be dengue. heard of reindeer in Labrador and Lap- In the Near and it was a land, and baboons at Gibraltar and the vast epidemic, locally recognized as Cape dying mysteriously and in great dengue, and the “dengue” at Hon- numbers. And again there is indisputable kong in September and October, 1888, evidence that during the great influenza was diagnosed by Sir James Catlie periods there are widespread changes in as true epidemic influenza. It was the world of insects, of vegetables and of traced to Cairo, Palestine and Con- fungoid life.17 stantinople, then to Spain in 1889, This fact is brought out in the as a new gastric and ; etiology of influenza, as related to and also in Rio de Janeiro, as reported birds and in the Argive Camp where in the Lancet, it occurred as a new dogs and cattle were affected.19 In and comatose fever; in Germany as 1833 influenza was called epizootique. poliomyelitis; in Russia as rhaphania, now called encephalitis Iethargica. Barbadoes and St. Kitt’s there died Then the trailing epidemic of - 5000 and 6000 respectively. The most myelitis following in 1890-95.17 It is fatal complications are pneumonia,19 of interest to note how many times it and pregnancy. was called a “new disease.” Crook- As to incidence of infection, that shank described the epidemic con- also varies, but is generally high. In stitution of the 1918 pandemic: 1323 “all in Florence, Italy, were It may, in a word, be said, that if the affected.” In 1510 “not a family and epidemiological happenings during an scarcely a person escaped.” In 1729, influenzal constitution be analyzed, we in Lausanne, 2000 of the 4000 in- find that we may consider them as form- habitants were sick and “in Plymouth, ing a series or sequence of epidemics England, and district, not a house on grouped around a pandemic diffusion of the average was free.” In Edinburgh the classical type. Influenza, then, is not in 1758 “not one in seven escaped.” the name of a specific disease and nothing In 1410-11 Pasquier says there were more, but it denotes and must denote a at least 100,000 cases in Paris.19 complex concept, which essentially resem- But, for instance, in 1410-11, “ex- bles in its construction the concept, for cept for cases with chronic disease instance, of war. And, just as the notice of and que venesectione sunt, hardly one special wars, associated campaigns, battles, skirmishes and hand to hand encounters in 1000 of those attacked died” are embraced in the greater concept of war (Weims). The excessive mortality of itself, so our notions of influenza embrace the earlier epidemics was due to the the subsidiary and constituent notions of inordinate passion for venesection.19 certain kinds of epidemics, outbreaks, This may also account for the 20 to foci, and cases, and even of single 60 per thousand mortality in Eulen- symptoms such as epistaxis and hiccough. burg in 1729. In 1510 bloodletting in In I'1928-29 there were many Italy was followed by fatal results. cases of recurrent epistaxis and of Bleeding and purgatives are now said low blood pressure from affections of to have been injurious, but in 1580 the chromaffin, “which are of vast in Italy and Spain bloodletting was importance when studied from the practiced with dire results, killing viewpoint of the happenings with 9000 in Rome (Schenkius) and de- populating Madrid and which they may be associated.”17 All words, merely words, say some, (VoIIalba). “Nearly all those who were but the account given by Quidetti bled died” (Saillant). In 1742-43 of the epidemic constitution of 1712 venesection caused many deaths in Italy as in previous epidemics.19 parallelled word for word, as to some Andral thought influenza was itself of the passages, with that in London in 1918.6 The past checks with the never fatal, the deaths being due to secondary disease, or, I may add, to present. the treatment. The epidemic of 1833 Mort alit y and Inci de nce was thought by contemporary writers As has been said, influenza is a to owe its high mortality to complica- disease with an enormous morbidity tions and sequelae and not to the and a relatively small mortality.19 disease.4 But in 1847-48 the capillary There have been exceptions to this, bronchitis was very fatal, and in 1918 as in 1918; and in 1647, when in the the mauve or heliotrope cyanosis was particularly indicative of a fatal ter- 9. Dona lds on , R. The Bacteriology of mination, even though the other symp- Influenza: With Special Reference to toms then present did not appear Pfeiffer’s Bacillus. serious. This symptom and its prog- 10. Abraham s , A. Influenza: Some Clinical nostic value were referred to by and Therapeutic Considerations. 11. Jellif fe , S. E. The Nervous Syndromes Peacock as early as 1847.10 of Influenza. Ref ere nce s 12. Mc Houl , J. Ocular Affections in In- 1. Crook sha nk , F. G. [Ed.] Influenza, fluenza. Essays by several authors. London, 13. Boyd , S. The Surgical Aspect of Influenza. Heinemann, 1922. (The numbers 2-18 14. Whal e , H. L. Influenza: The Complica- inclusive refer to the essays and their tions affecting the Throat, Nose and authors.) Ear. 2. Crook shan k , F. G. Method and 15. Bourne , A. W. Influenza: Pregnancy, Thought. Labour, the Puerperium and Diseases 3. Crook shan k , F. G. First Principles of of Women. . 16. Davi s , H. The Skin Lesions of Influenza. 4. Croo ks ha nk , F. G. Some Historical 17. Crooks hank , F. G. The Theory of Conceptions of Influenza. Influenza. 5. Croo ks ha nk , F. G. The Name and 18. Croo ks han k , F. G. In Brief. Names of Influenza. 19. Hopki rk , A. F. Influenza: History, 6. Crook shan k , F. G. The History of Epidemic Encephalomyelitis. Nature, Causes and Treatments. Lon- 7. Hamer , W. H. The Phases of Influenza. don, Scott, 1913. 8. Lewi s , D. M. Some Epidemiological Con- 20. Johnson , R. An Inaugural Dissertation siderations concerning the Prevention on the Influenza. Phila., Bradford, of Influenza. 1806.

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