Chapter III: Influenzas and Epidemic Agues (4)

Reynolds, another London physician, in a letter to Sir George Baker confirms all that the latter says of these singular epidemic agues: “No two cases resembled each other except in very few circumstances[670]”--the remark commonly made about the influenza itself. If these descriptions of the epidemic ague had not been given by physicians living as late as 1782, and altogether modern in their methods, we might have supposed that they were confusing influenzas with agues, or using the latter term inexactly. “The ague with a hundred names” is the striking phrase of Abraham Holland, in his poem on the plague of 1625. Whitmore, describing the fatal epidemic ague (with an episode of influenza) in 1658-59, does not say that it had a hundred names, but that it assumed a hundred shapes, “which render it such a hocus-pocus to the amazed and perplexed people, they being held after most strange and diverse ways with it.... So prodigious in its alterations that it seems to outvie even Proteus himself[671].”

As farther showing the anomalous character of these epidemic agues, or their difference from the endemic, Baker adds:--

“It is a remarkable fact, and well attested, that in many places,
whilst the inhabitants of the high grounds were harassed by this
fever, in its worst form, those of the subjacent valleys were not
affected by it. The people of Boston and of the neighbouring villages
in the midst of the Fens were in general healthy at a time when fever
was epidemic in the more elevated situations of Lincolnshire.” Women
were nearly exempt, but few male labourers in the fields escaped it.

Baker heard from all parts that the same constitution continued through 1781 and 1782; and that since that time, though it seemingly abated, yet agues had been much more prevalent than usual, and had even been frequent in places where before that period they were uncommon. They were very noticeable in London from 1781 to 1785, not least so during the very severe cold of the winter and spring of 1783-84. We hear of great numbers attacked at Hampstead with common intermittents in February and the following months of 1781, during which time even the measles, in the greater number of cases, “ended in very troublesome intermittents[672]”--just as they were apt to end often in troublesome coughs.

The annals of Barker, of Coleshill, are full of references to agues, among other fevers, from 1780 onwards. Under 1781 he writes:--

“This spring that very peculiar, irregular, dangerous and obstinate
disease, the burning, or as the people in Kent properly enough called
it, the Plague-ague, made its appearance, became very epidemical in
the eastern part of the kingdom, and raged in Leicestershire, the
lower part of Northamptonshire, Bedfordshire, and in the fens
throughout the year.... This strongly pestilential disease had such
an effect upon them that the complexion of their faces continued for a
time as white as paper, and they went abroad more like walking corpses
than living subjects.”

As many as five persons in an evening were buried from it in some large towns in Northamptonshire; and about Boston it was so general and grievous that out of forty labourers hired for work in harvest, half of them, it was said, would be laid up in three days[673]. In 1783 the “pestilential agues” were as bad in Northamptonshire and eastern parts as the year before. A Liverpool writer says:

“In the autumn of 1782 the quartan ague was very prevalent on the
opposite shore of the river in Cheshire: it was universal in the
neighbourhood of Hoylake, where many died of it. Yet it was scarcely
heard of in Liverpool, although from the uncommon wetness of the
season it prevailed throughout the kingdom[674].”

On October 25, 1783, a correspondent of the _Gentleman’s Magazine_ offered an explanation of the “present epidemic disorder, which has so long ravaged this country, and that in the most healthy situations of it,” namely, “the putrescent air caused by the number of enclosures, and the many inland cuts made for navigation[675].” Next year, 1784, appears to have been the principal season of epidemic agues on both sides of the Severn valley, one practitioner at Bridgenorth making them the subject of a special essay[676].

It was at this time that Fowler brought into use his solution of arsenic as a substitute for bark in agues, the latter having notably failed in the epidemics since 1780.

Baker says: “The distinguishing character of this fever was its obstinate resistance to the Peruvian bark; nor, indeed, was the prevalence of the disease more observable than the inefficacy of the remedy:” in that respect the epidemic agues had belied the experience with bark in ordinary agues. Again, it is singular that bark had failed most, and arsenic been especially useful in those parts of England where ordinary malarious agues were never seen. One practitioner in Dorset laid in a large stock of arsenic, wherewith he “hardly ever failed to stop the fits soon[677].” Another, at Painswick, in Gloucestershire, used it successfully in two hundred cases of epidemic agues from 1784 onwards. He gives the following account of these unusual agues at Painswick:

“This town, which is situated on the side of a hill, and is remarkable
for the purity of its air, is very populous. In the year 1784 the
epidemic ague, that prevailed in many parts of the kingdom, made its
appearance in this place, and has continued till the present time
[Nov. 1787], although previously to that period the disease was hardly
ever seen here, unless a stranger came with it for the recovery of his
health, on account of the healthy situation of the place. It affected
whole families, and appeared to be most violent in spring and autumn.
In the summer of 1786 it was followed by a fever of the kind called
typhus, or low nervous fever, which not unfrequently degenerated into
a putrid fever and proved very fatal[678].” In May, 1785, at a general
inoculation of smallpox, “many had been afflicted with intermittents
of several months’ duration attended with anasarcous swellings[679].”

It will be seen from the following table of cases treated at the Newcastle Dispensary, under the direction of Dr John Clark, during twelve years from 1 October, 1777, to 1 September, 1789, that influenza makes the smallest show among them, being far surpassed by the intermittent fevers and dysenteries, while all three together are greatly exceeded by the perennial typhus fever:

Cases treated

Putrid fever 1920
Intermitting fever 313
Epidemic dysentery in 1783 and 1785 329
Influenza of 1782 53

In Scotland, also, agues became epidemic about the year 1780. There is no reason to suppose that their prevalence in these years was less exceptional there than in England and Ireland. It will be seen, indeed, from the following table compiled from the books of the Kelso Dispensary that the only years of their considerable prevalence were the same as the years of epidemic ague in England.

_Kelso Dispensary_[680].

All Cases
Year Cases of Ague

1777 302 17
1778 306 33
1779 460 70
1780 675 161
1781 510 103
1782 440 61
1783 510 73
1784 459 40
1785 573 62
1786 563 48
1787 525 24
1788 577 25
1789 546 48
1790 640 18
1791 715 13
1792 570 16
1793 666 19
1794 447 9
1795 513 23
1796 355 12
1797 318 9
1798 415 7
1799 558 2
1800 665 4
1801 433 9
1802 377 5
1803 308 2
1804 422 5
1805 469 0
1806 318 1

It was doubtless the recollection of these epidemic agues that led the parish ministers who wrote in the ‘Statistical Account of Scotland’ from 1791 to 1799 to remark upon a supposed progressive decline of endemic ague, which they set down to drainage of the land[681]. It is probable, however, that each tradition of ague in Scotland dated from one of its epidemic periods; it has been shown, indeed, in the foregoing that Scotland in the end of the 17th century was reputed tolerably free from ague, and that the severe agues previous to 1728, which belonged to the epidemical kind, were thought to be something new.

The Influenza of 1788.

According to Barker, of Coleshill, who kept systematic notes of the epidemic maladies from year to year, there were several recurrences of the influenza of 1782[682]. But there is only one of these seasons, the summer of 1788, that other English writers have singled out as a time of influenza. It was undoubtedly of a very mild type, producing hardly any effect upon the bills of mortality; but it attracted the notice of several. Dr Simmons, the editor of the _London Medical Journal_, became the recorder of it, collecting reports from various parts, as others had done in 1782. He himself treated 160 cases at the Westminster General Dispensary, and 65 more elsewhere. It was most prevalent in London from the second to the fourth week of July, but the mortalities for those weeks show no abrupt rise. It was at Chatham, Dover, Plymouth and Bath about the same time, at Manchester in the beginning of August, in Cornwall in the middle of August, and at Montrose about the end of August, or perhaps most certainly in October. On 5 August, a physician at York wrote: “We have not had the slightest appearance of a catarrh in our city or neighbourhood during the year.” The epidemic was undoubtedly a partial one in Britain, and so slight as to have made little impression where it did occur. It is said to have been very general at Warsaw in April or May, at Vienna in April (20,000 cases before the 20th), at Munich in June, at Paris in the end of August and still continuing on the 24th October, at Geneva on the 10th October. Its most constant symptom in England was pain in the fore-part of the head, with vertigo; next most constant was a pain at the pit of the stomach and along the breast-bone; cough was wanting in perhaps a third of the cases and was always slight, diarrhoea was somewhat general, running from the eyes exceptional, sore-throat in perhaps one-sixth of the cases[683]. At Plymouth where it was seen earliest and clearest among the regiment of artillery and in the guardships, the symptoms were pain in the head and limbs, soreness of the throat, pain in the breast, a feeling of coldness all over the skin, and these followed by cough, a great discharge from the nose and eyes, and slight nausea. It was much less noticeable among the townspeople than among the troops and sailors[684]. It occurred chiefly among soldiers or sailors also at Dover and Chatham. At Bath it was marked by chills, headache, swelling of the throat, difficult swallowing, quick pulse, hot, dry skin (but not pungent as in malignant fever), ending in a sweat; no delirium, but broken sleep or vigil; the eyes scarcely affected, cough in some, but not vehement; in some, sublingual swellings which suppurated[685]. At Manchester it looked as if it had been brought in by travellers who had acquired it in London[686].

At Portsmouth a singular thing happened two or three months after the epidemic had passed. The frigate ‘Rose’ arrived on 4 November from Newfoundland; within a short time all the dogs on board were seized with cough and catarrh, and soon after the whole ship’s company were affected in the same way[687]. Simmons says of the epidemic of 1788 in general: “During the progress of the influenza, a complaint which was evidently an inflammatory affection of the mucous membrane of the fauces, etc. was frequently observed among horses and other cattle, and was generally as violent among them as it was mild among their rational neighbours”--many dying after four or six days.

The very slight and partial influenza of July and August, 1788, happened at a time when there was much fever of a more serious kind in the country. The history of the latter belongs to another chapter; but there was in Cornwall, in the same season as the influenza, an epidemic fever which might in former times have been described as a part, and the most fatal part, of the “new disease,” and may be taken in this context rather than in the chapter on typhus. The same physician, Dr William May, of Truro, gave an account of the influenza first[688] and of the other fever afterwards[689].

The latter began at Truro in the end of April, 1788, and was also at
St Ives and other small towns in various parts of the county. A
malignant fever had for near two years before been exceedingly rife
among the poor (owing to distress from loss of pilchard fishing), and
had carried off a great number of them; but this was something new.
Yet it was “truly a fever of the typhus type,” one of its symptoms
being constant wakefulness. It passed through whole families,
affecting all ages and constitutions. It ended on the 17th day,
whereas the influenza (says May in his other paper) ended with a sweat
on the fourth or fifth day. In one small neighbourhood this epidemic
fever affected chiefly the aged, who were blooded owing to dyspnoea:
out of ten or eleven so affected, not one recovered, an experience
that reminded May of what Willis said of the village elders being
swept off by the “new fever” of 1658. Surgeons at St Austel, East Looe
and Falmouth are cited as having seen much of the same fever. In like
manner the Manchester chronicler of the influenza of 1788 says:
“Fevers of different kinds, but chiefly of the type now distinguished
by the appellation of typhus, were exceedingly prevalent after the
epidemic catarrh had in great measure ceased to be general; but from
which, by tracing the symptoms, the fever might usually be found to
have originated[690].”

For a good many years after the period last dealt with, nothing is heard in Britain either of epidemic agues or of influenza[691]. Writing in 1800, Willan said that intermittents had not, to his knowledge, been epidemic in London at any time within twenty years. He explains this by “the practice of draining, and the improved modes of cultivating land in Essex, Kent, and some other adjoining counties, from which either agues were formerly imported, or the effluvia causing them were conveyed by particular winds”--the latter being the doctrine of Lancisi for the country round Rome. But he forgets that their appearance nearly twenty years before was a strange phenomenon to the practitioners of that generation, and that Sydenham, whom he cites to prove agues in London in former times, had also remarked their absence, except in occasional cases, for as long a period as thirteen years. Of such occasional agues acquired in London, Willan and Bateman had each one or two examples in the autumn of 1794, and the spring of 1805.

As in the case of epidemic agues, so also in the case of influenzas, there was immunity in Britain for a good many years after 1788; and, as the slight epidemic catarrh of 1788 was something less than universal, the clear interval may almost be reckoned from the summer of 1782, a space of over twenty years. Willan’s monthly reports of the weather and diseases in London from March, 1796, to December, 1800, twice mention epidemic catarrhs,--in February and March, 1797, and in February, 1800, the latter chiefly among children. But to neither of them will he concede the name of “influenza,” as the complaint was merely epidemical from a particular state of the atmosphere, and not propagated by contagion, nor quite general.

The symptoms, however, were headache, sometimes attended with vertigo,
a thin acrid discharge from the nostrils, slight inflammation of the
throat, a sense of constriction in the chest, with a frequent dry
cough, pains in the limbs, a white tongue, a quick and small pulse,
with a sensation of languor and general debility. These symptoms,
fairly complete for influenza of the correct type, lasted about eight
days and ended in a gentle sweat or in a diarrhoea. Coughs had been
remarkably severe and obstinate; they were frequently attended with
painful stitches and spitting of blood[692].

The Influenza of 1803.

The number of the _Medical and Physical Journal_ for March, 1803, announced that “a cold attended by symptoms of a very alarming nature has been general in the city of Paris for some time”; but it said nothing of the alarming disorder being in London. It is in the next number, under the date of Soho Square, March 11th, that a correspondent identifies the Paris epidemic with “the complaint now general in this metropolis, and called by some the Influenza.” In a report upon the diseases “in an Eastern District of London from February 20 to March 20, 1803,” the “catarrhal fever” is thus described:

“This disease has been so general as to claim the title of the
reigning epidemic, and is very similar to one which prevailed a few
years ago, and was denominated Influenza. It has generally been
introduced by chilliness and shivering, which have been succeeded by
violent pains in the head, with some discharge from the eyes and
nostrils, as in a common catarrh, together with hoarseness and cough.
The pains in the head have in some cases been the first symptoms and
have been succeeded by giddiness, sickness and vomiting” &c. There
were also rheumatic pains in the limbs, intercostals &c.

Meanwhile the information from various sources showed that the old influenza was once more really in this country. Two collective inquiries were made on the influenza of 1803: one by Dr Beddoes of Bristol, who issued a circular of five queries, and received answers to them (with other information) from one hundred and twenty-four correspondents[693]; the other by the Medical Society of London[694]. The _Medical and Physical Journal_ and Duncan’s _Annals_ each received a few independent papers on it; and several pamphlets were issued, mostly devoted to treatment--two in London[695], one at Edinburgh[696], one at Bath[697], and one at Bristol[698].

In these abundant data there is little novelty and not much variety.

The attack began with chills and severe pain in the head, along with
slight running of the eyes and nose, as typhus fever might have begun.
After the slightly catarrhal onset the malady was mostly a fever, with
dry cough, dry and hot skin, pain in the forehead and about the
eyeballs, pains in the limbs, “spontaneous” weariness and extreme
prostration--a group of symptoms which led Hooper to find a rheumatic
character in the malady. Among other symptoms were vertigo, nausea,
vomiting and diarrhoea. Much sweating is not reported; but there was
often a gentle sweat in recovering after about a week, less or more.
There was the usual range from mildness to severity. Pneumonia and
pleurisy were not rare, and were commonly the cause of fatalities.

The deaths were for the most part among the phthisical, the asthmatic and the aged; but these were not many, certainly not so many as in 1729, 1733 and 1743, and probably in about the same proportion as in 1762, 1775 and 1782. In the London bills the weekly deaths rose in March, to an average of 537 from an average of 429 in February, and of 375 in January, falling to an average of 417 in April. In Ireland the epidemic is said to have been seen among the troops in garrisons as early as December, 1802; it became universal in spring and summer. In Edinburgh the rise in the burials at Greyfriars churchyard was in the weeks ending 5th and 12th April, making them about a half more than usual for the brief period. When the wave of influenza was past, the public health in nearly all places became unusually good, as had happened immediately after the influenza of 1782.

The question most to the front in the influenza of 1803 was its manner of spreading. Beddoes, who believed in personal contagion, had this in view in his five queries:

1. When did the influenza appear and disappear with you?

2. Was its date different in remote places within your reach?

3. After being general, did it occur for some time in single
instances?

4. Did it ever seem to pass from person to person?

5. If so, is it likely that clothes or fomites conveyed it in any
case?

The dates of commencement were earlier or later according to no rule of direction or of distance from London. In some large towns of Yorkshire it appeared to be unusually late, in Chester unusually early; Edinburgh, certainly, was as long behind London as London was behind Paris. Haygarth, who took the most narrow view of contagion, made out the incidence thus: London first, then the towns which have the greatest intercourse with London, such as Bath and Chester, then smaller towns, and last of all the villages around each of the more populous centres. Several towns had the brunt of the epidemic in the same weeks (of March) as London; in very few was it later than the first weeks of April. In some towns it attracted little notice. In North Devon, it was said to have been at Hartland and Clovelly a fortnight before it was seen in Bideford; the first of it seen by one of the doctors of that town was in a solitary potter’s house four miles to the eastward, on a peninsula made by the confluence of a small stream with the Torridge, all the inmates of the house being attacked; in the town itself from first to last he saw but few cases, whereas there were many in the adjacent country[699].

The general rule seems to have been that the more sparse populations had it later, the nearer they were to the extremities of the kingdom, as in Cornwall, the north of Scotland, and in Ireland. Opinion was divided as to the part played by persons in carrying contagion from place to place, some holding that the facts of diffusion could be explained on no other hypothesis, while most held that the influenza was in the air. Beddoes got as many answers favouring the doctrine of personal contagion as made a respectable show for it; but when these had all been set forth to the best advantage, a practitioner wrote to say that, after all, nine-tenths of professional opinion was against the contagiousness of influenza. The practical question for Haygarth, Beddoes, and other contagionists was whether influenza was not a disease, like smallpox or scarlet fever, which could be kept from spreading by means of isolation, disinfection (with the fumes of mineral acids) and other precautions.

Some curious facts came out, showing the effect of influenza upon other epidemic diseases, or the effect of other epidemic diseases upon influenza. One writer applied to influenza what used to be said of the plague or pestilential fever, that these Leviathan constitutions swallowed up all other reigning epidemics. Holywell, a town in Flintshire, with a large cotton-weaving industry, had not been free from a bad kind of typhus for two years. “On the appearance of the influenza the typhus entirely ceased, and only one case of fever has occurred since. I have not for many years known this country so healthy as since the influenza disappeared[700].” The influenza was said also to have superseded typhus fever at Navan, in Meath[701]. At St Neots typhus was peculiarly prevalent for three months before the influenza, but ceased thereafter[702]. Another relation to typhus was seen at Clifton: “In the low, confined, and ill-ventilated houses in the Hot Well road, where typhus often abounds, the influenza was very unfrequent; while in the exposed high-lying buildings on Clifton Hill it was almost universal[703].” As to ague, which had often before stood in a remarkable relation to epidemics of catarrhal fever, there is one possibly relevant fact related from the Lincolnshire fens. A Wisbech physician writes:

“The influenza which ceased here about the middle of April made its
appearance again in May; the leading symptoms were the same as in the
first attack. About the same time also a most malignant fever, having
some symptoms in common with the influenza, began to rage in that part
of Lincolnshire contiguous to us, which has proved fatal to
hundreds[704].”

From 1803 to 1831, nothing is heard in England of a universal influenza, although there was one such in the end of 1805 and beginning of 1806 in Russia, Germany, France and Italy; and there were four great influenzas in the Western Hemisphere (1807, 1815-16, 1824-25, and 1826). Catarrhs were perhaps commoner than usual in England and Scotland in the winter of 1807-8, but they cannot be reckoned an epidemic of influenza[705]. The summer following (1808) was unusually hot and agues became more epidemic in the fens than at any time since the great aguish period of 1780 and following years[706]. Agues were again unusually rife in England in 1826, 1827 and 1828, at the same time as the remarkable epidemics of them, from inundations and subsequent drought, in Holland and along the German coast of the North Sea. Dr John Elliotson, of London, met with cases of agues in his practice in those years in the following scale:

Year Cases

1823 8
1824 14
1825 15
1826 44
1827 53
1828 27
1829 8

They had increased, he says, throughout the country as well as in London, owing, as he thought, in agreement with Macmichael, to the higher mean temperature of the respective years; and he would apply the same law of increase to the epidemic periods of ague in Britain in former times[707]. Christison saw his first case of ague at Edinburgh in the autumn of 1827, in a labourer who had caught it working at the harvest in the fen-country of Lincolnshire.

The Influenza of 1831.

The next influenza in Britain fell in the early summer of 1831. It was a mild epidemic of the catarrhal type, which attracted hardly any notice in England. In one of the London medical journals there is no other notice of it but this, dated 2 July, 1831[708]: “In consequence of the sudden variations of temperature which have prevailed since the last fortnight of May an epidemic bronchitis has shown itself in Paris.” Another London journal[709], on the very same day, wrote: “Influenza in a severe form is at present prevailing in London and some of the provincial towns. It commences like a common cold, but is soon discovered to be more serious, &c.” The physician to the public dispensary in Chancery Lane found that more than half of the seventy applicants on 23 June came with the symptoms of influenza--severe, harsh, dry cough, in paroxysms, pain behind the sternum, a fixed pain in one side, congested state of the throat, nose and eyes, heaviness of the head, languor, debility, hot skin, foul tongue, impaired sense of taste. The symptoms went off after three or four days with a sweat in the night and a discharge from the nostrils[710].

This epidemic hardly affected the London bills of mortality, according to the following figures:

Four weeks, 25 May to 21 June, 1579 births, 1430 deaths.
Five weeks, 22 June to 26 July, 2153 births, 2010 deaths.
Four weeks, 27 July to 23 Aug., 1997 births, 1652 deaths.

The rise in the last four weeks was due to summer diarrhoea, or choleraic diarrhoea, which was unusually common in 1831. This slight influenza was also reported from Plymouth by a surgeon who had seen the disease, and suffered from it, at Manilla in September, 1830[711], and by a Plymouth practitioner, who wrote, on 14 July, that it had been extensively prevalent there and in the neighbouring towns and villages[712]. It is recorded also from the Isle of Man, Glasgow[713], and Ayr[714], and it is supposed to have been in Aberdeen[715]. But, while there are many accounts of this epidemic in Germany in May and June, and undoubted evidence of it in France and Italy, as well as in Sweden, and in Poland and Russia earlier in the year, the accounts of it in Britain are so meagre and casual as to make one doubt whether it really was an influenza worth reckoning.

The Influenza of 1833.

The next year, 1832, which was the first great season of Asiatic cholera in Britain, is absolutely free from records of influenza in all Europe. It was in the spring of the year following, 1833, that the really serious influenza came. The continental literature of the epidemic of 1833 is immense, the English literature of it is all but non-existent: and yet it was a very severe influenza with us, just as with other European peoples. There was no collective inquiry in Britain on this occasion, such as had been made first by Fothergill in 1775, by the College of Physicians and another Society in 1782, by Simmons in 1788, and by Beddoes and the Medical Society of London in 1803, or such as was made in the next influenza, that of 1837, by a committee of the Provincial Medical Association. But enough is known of it to place it among the severer influenzas. In London the bills of mortality, which relate only to a part of London, showed the characteristic sudden rise and fall:

Baptisms Burials

Four weeks, 20 Feb. to 16 March 2310 2352
Five " 17 March to 23 April 1955 2105
Four " 24 April to 21 May 2016 3350
Four " 22 May to 18 June 2070 1685

For a whole month the burials in London were nearly doubled, and for the two worst weeks they were nearly quadrupled. This mortality, by all accounts, fell most on the richer classes, to whom it was a much more serious calamity than the Asiatic cholera of the year before. The president of the Medical Society said, on the 22nd April, that he had “heard of nine lords or ladies who had been carried off by it or by its indirect agency, in the course of last week[716].” Its type in the month of May was worse than in April[717]. When it was first seen it was a somewhat short catarrhal attack, ending in a sweat after two, three or four days, with the usual head-pains, soreness of the ribs and limbs, languor and prostration. Later, it became a more “adynamic” illness, beginning indeed with slight catarrhal symptoms, but soon passing into subacute nervous fever which might last for three weeks, involving much risk to life[718]. Hence arose the warnings, just as in 1890-92, that the influenza was a much more serious thing than it had been thought when the epidemic began, and hence the delay, as it were, in the bills of mortality to show the effects of the epidemic until it had been two or three weeks prevalent. It is to the month of April, before the highest death-rate was reached in London, that the following, in the _Gentleman’s Magazine_, applies[719]:

“During the month a severe form of catarrhal epidemic, generally
termed influenza, has been extremely prevalent in London. It has laid
up at once all the members of many large households, and has attacked
great numbers in several public offices, particularly the Bank of
England and some divisions of the new police. The performers at the
theatres have much suffered, and their houses have been closed for
several nights. It commences suddenly with headache and feeling of
general discomfort, attended or soon followed by cough, hoarseness, or
loss of voice; oppression, and sometimes severe pain in the chest,
tenderness about the ribs, and sense of having been bruised about the
limbs or muscles.... The disease is generally attributed to the
constant north-east winds; but by some of the learned is regarded as
the epidemic influenza which has lately prevailed in the eastern parts
of Europe, and that is travelling, like many of its predecessors, to
the west.”

It would have been in this earlier stage of the epidemic, when it was laying up whole households, thinning workshops and closing theatres, that a practitioner was heard to say (as reported by the _Lancet_): “Best thing I ever had! Quite a godsend! Everybody ill, nobody dying!” The seriousness of the disease was, however, at length recognized, so that the members of the Medical Society debated the subject at three successive meetings. One of the questions was, whether the malady called for blooding--a question that had divided opinion as long ago as 1658[720]. On 13 May, the following passed at the Medical Society:

Mr Williams remembered the similar influenza of 1803, and said that
depletion was then regarded as an injurious plan of treatment.

Mr Proctor:--Yes, but the Brunonian doctrines were then in full fling,
and practitioners had not learned the full use of the lancet.

Graves states very fairly the reasons that induced them to take blood in the influenza of 1833, as well as the results of the practice[721]:

“The sudden manner in which the disease came on, the great heat of
skin, acceleration of pulse, and the intolerable violence of the
headache,--together with the oppression of the chest, cough, and
wheezing--all encouraged us to the employment of the most active modes
of depletion; and yet the result was but little answerable to our
expectations; for these means were found to induce an awful
prostration of strength, with little or no alleviation of the
symptoms.”

The prostration, be it said, was probably as great and as frequent in the epidemics of 1890-93, when bleeding had gone out altogether; still it was not understood that all these signs of sthenic action in the attack were really paradoxical, as Whitmore, in the passage cited in the note, saw clearly two centuries before.

The epidemic became rapidly prevalent all over England, Scotland and Ireland in April and May, following no very definite order of progression. The Liverpool newspapers asserted that ten thousand were down with it in that town in one week. A doctor at Lincoln wrote, on 13 May, that few families there had escaped it[722]. Other towns in which it is said to have been “more or less” prevalent were Portsmouth, Sheffield, Birmingham, Leeds, York, Halifax, Glasgow, Edinburgh[723], Dublin and Armagh; so that we may fairly assume, although we are without the detailed evidence available for earlier epidemics, that it was ubiquitous in town and country.

At Birmingham[724], among the outpatients of the Infirmary, the cases of influenza were as follows, the 25th and 26th April being the days when cases came first in rapid succession, while the middle of May was practically the limit:

Cases of
Influenza Males Females

April 151 52 99
May 464 159 305
June 28 9 19
--- --- ---
643 220 423

The great excess of females is remarkable, but was probably due to some local circumstances. Of the 643 cases, 122 were under ten years of age. Of the females, 9 died, of the males 3. But the deaths in Birmingham caused by the epidemic directly or indirectly were many; the burial registers of four churches and chapels showed a marked increase of burials above those of the corresponding months of 1832:

1832 1833

April 205 245
May 211 434
June 193 230
--- ---
609 909

Medical opinion in 1833 was decidedly adverse to the contagiousness of influenza. The common remark was that it was just as little contagious as the cholera of the year before had proved to be. As in 1837 and 1847, when the doctrine of contagiousness was equally out of favour, the disease was observed to spread rapidly, in no very definite line, affecting most parts of the country in the same two or three weeks, affecting the population within a considerable radius almost at once, and the inmates of houses all together. These, it was said, are not the marks of a disease that persons hand on one to another, _quasi cursores_.

The Influenza of 1837.

Between the influenza of April-May, 1833, and that of January-February, 1837, it seems probable that there were minor catarrhal outbreaks, distinguishable from ordinary colds. One writer on the influenza of 1837 refers to those “who had it in 1834 or in the intervening period between the two epidemics.” The table of diseases of the outpatients at the Birmingham Infirmary for the year 1836 contains a large total of catarrhs, and, in another line, 24 cases of “epidemic catarrh” in the summer months. The _Gentleman’s Magazine_ begins its notice of the epidemic of 1837 by calling it “an influenza of a peculiar character,” which shows that influenza of the ordinary kind was a familiar thing. Probably the name was a good deal misapplied in the years following every great epidemic from 1782 onwards: thus in ‘St Ronan’s Well,’ which was written in 1823, or twenty years from the last general influenza, a tradesman’s widow in easy circumstances and given to good living comes to the Spa on account of a supposed malady which she calls the _influenzy_. But our recent experiences of four great influenza seasons in succession from 1889-90 to 1893, although it is without precedent in the history, will incline us the more to credit what is recorded of influenza cases in the intervals between the years of great historical epidemics[725]. However that may be for the years following 1833, the influenza of January, 1837, was sudden, simultaneous, universal.

The first cases, which Watson compares to the first drops of a thunder-shower, were seen earlier in some places than in others; but from all parts of England it was reported that the influenza was at its height from the middle of January to the end of the first week of February. Possibly it was a few days earlier in London than in most other towns, inasmuch as the great increase of the deaths that is shown in the following table, in the second and third weeks of January, would imply a prevalence of the epidemic for at least a fortnight before.

_Weekly Mortalities in London (by the old Bills)._

1837

Week ending Influenza All causes

Jan. 10 0 284
17 13 477
24 106 871
31 99 860
Feb. 7 63 589
14 35 558
21 20 350
28 8 321
March 7 4 262

This sudden rise in the deaths from all causes is a characteristic influenza bill, comparable with those already given from 1580 onwards. But the bill is far from showing the whole of the mortality in London in 1837. The London bills of mortality compiled by the Parish Clerks’ Company had fallen into the last stage of inadequacy, and were on the eve of being superseded by the general system of registration for all England and Wales[726].

The London bills, so long as they existed, never took in the great parishes of St Pancras, Marylebone, Kensington and Chelsea. The area “within the bills of mortality” was that of London about the middle of the 18th century. But, instead of becoming more and more crowded as time went on, it had actually become much less populous, especially in the old City and Liberties, owing to the erection of warehouses, workshops, counting-houses and other non-residential buildings where dwelling houses used to be; so that the decrease of mortality “within the bills” in the 19th century is in part due to the decrease of population within the same area. This has to be kept in mind when the above table is compared with one of those for former influenzas, such as that of 1737, exactly a hundred years before.

It was thought that the 1837 influenza in London was worse than that of 1833, but the figures show the contrary as regards the number of deaths from all causes[727]. Both of them, however, were in the first rank of severity, finding their nearest parallels in the three great influenzas of the 18th century, in 1733, 1737 and 1743, when the deaths from all causes during the influenza rose, indeed, to a much larger total within the bills, but rose from a much higher mean level.

In Dublin the great increase of burials from the influenza of 1837 fell at the same time as in London, according to the following comparison with the year before for Glasnevin Cemetery[728]:

1835-36

Dec. 1835 355
Jan. 1836 392
Feb. " 362
Mar. " 392
----
1501

1836-37

Dec. 1836 413
Jan. 1837 821
Feb. " 537
Mar. " 477
----
2248

At Glasgow the deaths from influenza were as follows[729]:

1837

Males Females Total

January 111 118 229
February 37 62 99
March 9 20 29
--- --- ---
157 200 357

But the heading of “influenza” did not nearly show the full effects of the epidemic upon the mortality, which was enormous in Glasgow in January, as compared with the same month of 1836:

---------------------------------------------------------------
|| All causes||Catarrh| Aged| Asthma| Fever| Decline
----------||-----------||-------|-----|-------|------|---------
Jan. 1836 || 790 || 4 | 73 | 31 | 45 | 124
Jan. 1837 || 1972 || 229 | 274 | 185 | 201 | 247

There was also a great increase in the deaths of infants by bowel complaint. The only period of life which did not show a great rise of mortality was from five to twenty; the greatest rise was between the ages of forty and seventy, corresponding to the London experience in the epidemic of 1847.

At Bolton, Lancashire, the great rise in the deaths, as compared with the average of five years before, was in February:

Average of
five years
1831-36 1837

January 111·2 115
February 79·0 205
March 97·8 100
----- ---
288·0 420

At Exeter, the burials in the two chief graveyards were 227 in January and February, 1837, as compared with 125 in the same months of 1836. These mortalities, although large, were but a small ratio of the attacks. In 2347 cases enumerated in the collective inquiry, there were 54 deaths, a ratio of two deaths in a hundred cases being considered a full average. The attacks were mostly in middle life, and the deaths nearly all among the asthmatic, the consumptive and the aged. The ages of one hundred persons attacked at Birmingham were as follows[730]:

Ages 1- 5- 10- 20- 30- 40- 50- 60- 70- 80-90

Cases 3 2 12 23 21 19 12 7 0 1

At Evesham only five out of 93 were under five years. At Leamington, in a list of 170 cases, there were 26 under fourteen years, 119 from fourteen to sixty-five years, and 25 above the age of sixty-five[731]. In some places males seemed to be most attacked, just as at Birmingham in 1833 there was a great excess of female cases; but the collective inquiry showed that the sexes shared about equally all over. The type of the malady was on the whole catarrhal, as in 1833. Nearly all the cases had symptoms of sneezing, coughing, and defluxions; many cases had nothing more than the symptoms of a severe feverish cold; the more dangerous cases had dyspnoea, pneumonia and the like; while all had the languor, weariness, and soreness in the bones which mark every influenza, whether it incline more to the moist type of catarrhal fever or to the dry type of the old “hot ague.”

The influenza of 1837 having been remarkably simultaneous, sudden and brief, the doctrine of personal contagiousness found little favour, just as in 1833. The 12th query sent out by the committee of the Provincial Medical Association was: “Are you in possession of any proof of its having been communicated from one person to another?” The answers are said to have been nearly all negative; namely, that there was “no proof of the existence of any contagious principles by which it was propagated from one individual to another.” Shapter, a learned physician at Exeter, inclined to a certain modified doctrine of contagion by persons. Blakiston, of Birmingham, an exact mathematician, declared that the question as ordinarily stated did not admit of an answer.

At Liverpool there was an interesting observation made, exactly parallel with those made at Gravesend in 1782 and Portsmouth in 1788. The influenza of 1837 was practically over by the first or second week of March; but “that the atmosphere of Liverpool was still contaminated by the epidemic influence up to the middle and latter end of April was apparent from the fact that many of the officers and men of the American ships, and generally the most robust, were violently attacked shortly after their arrival in port,”--the same being the case also with black sailors on ships arriving from the Brazils and the West Coast of Africa[732]. At the naval stations of Sheerness, Portsmouth, Plymouth and Falmouth, every one of the ships of war had been attacked in January, the ships cruising on the south coast of Spain, or lying at Barcelona, in February, the ships at Gibraltar in April, and those at Malta in May. The ‘Thunderer,’ on the passage from Malta to Plymouth, had the first cases of influenza at sea on the 3rd of January, four days before reaching Plymouth[733], as if she had sailed into an atmosphere of it somewhere near the coast of Brittany.

* * * * *

For fully ten years, from March or April 1837 to November 1847, there was no great and universal influenza in England. But there were several undoubted minor, and perhaps localized, outbreaks of an epidemic malady which was in each case judged to be truly the influenza, and not a common cold. The earliest of these was in the spring of 1841. It was recognized by the Registrar-General to have been in London from 20 February to 24 April, the mortality having been little affected by it. It was also recognized in Dublin in March, and remarked upon by two physicians to the Cork Street Fever Hospital; it was characterized by the usual languor, weariness, and pains in the head, by defluxions of the eyes, nose and throat, but not by any affection of the lungs, and was in all respects mild[734]. Exactly a year after, in March, 1842, influenza was described as epidemic at York[735]: it was noted also in London in March[736], and is mentioned as having been again in Ireland in 1842[737]. The next undoubted influenza is reported from a rural part of Cheshire (Holme Chapel) in January, 1844, in the wake of an epidemic of scarlatina; it continued in all kinds of weather until June, and had a remarkable intercurrent episode, for some weeks from the middle of March, in the form of an epidemic of pneumonia among young children, which passed into mild bronchitis in the cases last attacked[738]. Coincidently with the influenza in Cheshire, there is a report of a series of catarrhal cases in Dublin about the beginning of January, 1844, in which the sense of constriction and suffocation under the sternum and the paroxysmal character of the attacks seemed to point to influenza[739]. Two years after, a Dublin physician in extensive practice among the rich wrote, at the request of a medical editor, an account of an epidemic of influenza in January and February, 1847; he had sixty cases among children under fourteen in his private practice, usually several children in one house, and sometimes the adults in the house[740]. This was in the midst of the great epidemic of relapsing fever in Dublin and all over Ireland, due to the potato famine. The same prevalence of influenza to a slight extent is recorded also for London at the end of 1846 and beginning of 1847[741]. It is easy to object that these “influenzas” between 1837 and 1847 were but the ordinary catarrhal maladies of the seasons. But the physicians who took the trouble to record them--probably more might have done so--were, of course, aware of the distinction that had to be made between many common feverish colds concurring in the ordinary way, and a truly epidemic influenza, however slight.

The Influenza of 1847-48.

The great influenza of 1847 began in London about the 16th or 18th of November, was at its height from the 22nd to the 30th, had “ceased to be very prevalent” by the 6th or 8th of December, but affected the bills of mortality for some time longer, as in the following table:

_Weekly Mortalities in London._

1847

Week ending All causes Influenza Pneumonia Bronchitis Asthma Typhus

Nov. 20 1086 4 95 61 12 86
27 1677 36 170 196 77 87
Dec. 4 2454 198 306 343 86 132
11 2416 374 294 299 78 136
18 1946 270 189 234 52 131
25 1247 142 131 107 14 83
Jan. 1 1599 127 148 138 26 74

In the thirteen weeks of the first quarter of 1848 the influenza deaths declined as follows: 102, 102, 89, 56, 59, 47, 27, 33, 18, 11, 10, 16, 8.

This was the first great epidemic of influenza under the new system of registration. According to the Superintendent of Statistics, it caused an excess of 5000 deaths during the six weeks that it lasted, of which about a fourth part only were set down to influenza, and the rest to pneumonia, bronchitis, asthma, etc. During the three worst weeks it raised the deaths in the age of childhood 83 per cent., in the age of manhood 104 per cent., in old age 247 per cent., whereas the deaths between fifteen years and twenty-five were but little raised by it, and those between ten and fifteen hardly at all. It raised the deaths during six weeks in St George’s-in-the East to a rate per annum of 73 per 1000 living: in some other parishes it increased the death-rate very little. But it had the usual effect of lengthening enormously the obituary columns of the newspapers, which shows that it fell, as usual, to a large extent upon the richer classes. It went all over England in a short time, the month of December being the time of excessive mortality in the towns, according to the following sample totals of deaths from all causes:

1847

Manchester Sheffield York Places in
(Ancoats) (West) (Walmgate) Scotland

October 169 27 61 521
November 135 27 52 728
December 270 85 99 1001

In some parts of England, as in Kendal, a district of Anglesea and in the Isle of Wight, the mortality of the last quarter of 1847 was actually lower than that of the year before. From St Albans the sub-registrar reported that there had been “no epidemic.” In most parts of the country, including the medium-sized towns, the mortality directly or indirectly due to influenza was lower than in London. The principal returns did not come in from the country until after the new year, the effects of the epidemic having been, as usual, later in rural districts. Hence, while London had 1253 deaths put down to “influenza” in 1847 (nearly all in December), and 659 in 1848 (nearly all in the first quarter), the rest of England had 4881 influenza deaths before the New Year, and 7963 after it[742]. This influenza in the mid-winter of 1847-8 made a great impression everywhere[743]. As regards its range and its fatality, it was like those of 1833 and 1837; and it had once more so much of the catarrhal type, that the name of influenza became still more firmly joined to the idea of a feverish cold or defluxion.

* * * * *

By the year 1847, agues had almost ceased to be written of in England, although they still occurred in the Fens. But Peacock begins his account of the influenza of that winter with an enumeration of prevailing diseases, which reads somewhat like an old “constitution” by Sydenham or Huxham. The summers and autumns of 1846 and 1847, he says, were both highly choleraic, and dysentery (as well as enteric fever) was unusually common in the former year. Fatal cases of “ague and remittent fever” were also more numerous than usual. Then came much enteric fever, “not unfrequently complicated with catarrhal symptoms.” Throughout the spring and early summer of the influenza year, 1847, “intermittent fevers were common, and in March, April and May, purpura was frequently met with, either as a primary or secondary disease. Scurvy also, owing to the deficiency of fresh vegetables, and from the general failure of the potato crop in the previous year was occasionally seen.” Then follows much concerning a fever called remittent, which reads more like relapsing fever than anything else[744]. “The remittent form of fever was frequent in the course of the epidemic [of influenza], though seldom registered as the cause of death.” Peacock says truly that the rather unusual concurrence of so many sicknesses was “not peculiar to the recent influenza alone;” and he can “scarcely refrain from acknowledging that these several affections are not merely coetaneous but correlative, and types and modifications of one disease, with which they have a common origin. Assuming this inference to be admitted, we may advance to the solution of the further question of what is the essential nature or proximate cause of the disease.” But the inquiry led him to no result: the precise cause he leaves “involved in the obscurity that veils the origin of epidemics generally”--which are surely not all equally obscure[745].

* * * * *