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:

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 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:

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:

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

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]:

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

1837

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:

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:

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]:

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

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

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].

Influenza having continued epidemic for a few weeks in the beginning of 1848, ceased thereafter to attract popular notice in Britain during a period of more than forty years. But a certain number of “influenza” deaths continued to appear steadily year after year in the registration tables. In 1851 this number was nearly doubled, in 1855 it was more than trebled; and those two years were undoubtedly seasons (about January and February) of real influenza epidemics in Europe, recorded by several but not by English writers. A slight epidemic was described for Scotland in 1857, and one for Norfolk in 1878, neither of which seems to have influenced the registration returns in an obvious degree. After the undoubted influenza of 1855, the annual total of deaths in England set down to that cause steadily declined from four figures, to three figures, and then to two figures, standing at 55 in the bill of mortality for 1889. It is improbable that those small annual totals of deaths in all England and Wales were caused by the real influenza; the name at that time was synonymous with a feverish cold, and would have been given here or there to fatalities from some such ordinary cause. An epidemic ague was reported from Somerset in 1858[746].

The Influenzas of 1889-94.

More than a generation had passed with little or no word of epidemic influenza in this country, when in the early winter of 1889 the newspapers began to publish long telegrams on the influenza in Moscow, St Petersburg, Berlin, Paris, Madrid and other foreign capitals. This epidemic wave, like those immediately preceding it in the Eastern hemisphere, in 1833, 1837 and 1847, and like one or more, but by no means all, of the earlier influenzas, had an obvious course from Asiatic and European Russia towards Western Europe[747]. In due time it reached London, and produced a decided effect upon the bills of mortality for the first and second weeks of January, 1890, but a moderate effect compared with that of 1847, which was the first to be recorded under the same system of registration. It spread all over England, Scotland and Ireland in the months of January and February, 1890, proving itself everywhere a short and sharp influenza of the old kind, but with catarrhal symptoms on the whole a less constant feature than in the epidemics of most recent memory. At the end of February it looked as if Great Britain and Ireland had got off lightly from the visitation which had caused high mortalities in many countries of Continental Europe. But this epidemic in the beginning of 1890 was only the first of four, and less severe than the second and third. It returned in the spring and early summer of 1891, in the first weeks of 1892, and in the winter of 1893-94. To understand this influenza prevalence as a whole, its four great seasons should be compared. The following tables show its incidence upon London on each occasion:

Four epidemics of Influenza in London, 1890-94.

1890

1891

1891-92

1893-94

It will be seen that the third epidemic, that of Jan.-Feb. 1892, had the highest maximum weekly mortality from influenza (506) as well as the highest maxima from bronchitis and pneumonia not specially associated in the certificates with influenza; that the second epidemic, of 1891, had the next highest maxima, and that the first and last of the four outbreaks were both milder than the two intermediate ones. All but the second, which fell in early summer, are strictly comparable as regards season (mid-winter). But although the second, in 1891, had the advantage of falling in some of the healthiest weeks of the year, it was more protracted than the original outbreak, much more fatal than it in the article influenza, more fatal also in the article pneumonia, and less fatal only in the article bronchitis. The third outbreak was not only more protracted than the first, in the same season of the year, but much more fatal in all the associated articles. As to the deaths referred to influenza (whether as primary or secondary cause), the numbers are not strictly comparable in all the outbreaks; they are probably too few in the first table, more nearly exact in the second, third, and fourth, the diagnosis having at length become familiar and the fashion of nomenclature established. It is undoubted that many of the deaths from bronchitis and pneumonia in January, 1890, were due to the epidemic; for, “while the ordinary rise of mortality in cold seasons is mainly among the very aged, the increased mortality in this fatal month was mainly among persons between 20 and 60 years” (Ogle).

While the first epidemic of the series was universal and of short duration all over the kingdom, the second and third were more partial in their incidence and more desultory or prolonged. The second, which began in Hull (and at the same time on the borders of Wales), produced the following highest weekly death-rates per annum from all causes among 1000 persons living:

Highest Weekly Death-rates in the Second Influenza.

1891

The third was heard of first in the west of Cornwall and in the east of Scotland, in the last quarter of 1891. It was in the following English towns that it produced the maximum weekly death-rates per annum from all causes:

Highest Weekly Death-rates in the Third Influenza.

1892

These highest death-rates in the third successive season of influenza were all in the southern or eastern counties; in the latter, Colchester also had a maximum death-rate during one week of about 80 per 1000 per annum. Liverpool, among the northern great towns, appears to have had most of the third influenza. The fourth outbreak, in the end of 1893, was noticed first in the Midlands (Birmingham especially), and was afterwards heard of in the mining and manufacturing districts of Staffordshire, South Wales, Lancashire, Yorkshire and Durham, as well as in Scotland and Ireland, London, as in the table, having a share of it. The tables given of the London mortality in each of the four outbreaks, from influenza and the chest-complaints which were its most usual secondary effects, are a fair index both of the period and of the severity of the disease all over the kingdom in each of its successive appearances[748]. Everywhere the first and the fourth were the mildest, the second and third the most fatal. Deaths from “influenza” were reported from all the counties of England and Wales in the first and second epidemics, the highest rates of mortality per 1000 inhabitants in the corresponding calendar years having been in the following counties, while in all the counties the greater fatality of the second epidemic is equally marked:

In London the entry of influenza is in the weekly bills of mortality throughout the whole period, with the exception of a few weeks; but the deaths were often reduced to unity, and there was perhaps only one occasion, besides the four great outbursts, namely the months of March and April, 1893, when cases were so numerous or so close together in households or neighbourhoods as to constitute a minor epidemic.

The type of the influenza of 1890-93 was not quite the same as on the last historical occasions. When it was announced as approaching from the Continent, everyone looked for “influenza colds”; but the catarrhal symptoms, although not wanting, were soon found to be unimportant beside the nameless misery, prostration and ensuing weakness. Some, indeed, contended that the disease was not influenza but dengue, so pronounced were the symptoms of break-bone fever[749]. Many cases had a decided aguish or intermittent character. The name of ague itself was once more heard in newspaper paragraphs, and more freely used in private talk; but, as we have long ceased to write of epidemic agues, equally as of marsh intermittents, in this country, it is not probable that there will remain any record of agues in Britain accompanying the influenzas of the years 1890-94. On the other hand the complications and after-effects of our latest influenza, more especially as affecting the nervous system, have been very fully studied[750].

That which chiefly distinguishes the influenza of the end of the 19th century from all other invasions of the disease is the revival of the epidemic in three successive seasons, the first recurrence having been more fatal than the original outbreak, and the second recurrence more fatal (in London at least) than the first. The closest scrutiny of the old records, including the series of weekly bills of mortality issued by the Parish Clerks of London for nearly two hundred years, discovers no such recurrences of influenza on the great scale in successive seasons. It is true that several of the old influenzas came in the midst of sickly periods of two or more years’ duration, such as the years 1557-58, 1580-82, 1657-59, 1678-80, 1727-29 and 1780-85. But in those periods the bulk of the sickness was aguish, the somewhat definite episodes of catarrhal fever having been distinguished from the epidemic agues by Willis in 1658, by Sydenham in 1679, by several in 1729, and by Baker, among others, in 1782. It is probable, indeed, that there were two strictly catarrhal epidemics in successive years in the periods 1657-59 and 1727-29, just as we know that, in New England, there was a catarrhal epidemic in the autumn of 1789 and an equally severe influenza, less catarrhal in type, in the spring of 1790[751]. But history does not appear to supply a parallel case to the four successive influenzas in the period 1889-94, unless we count the seasonal epidemic agues of former “constitutions” as equivalent to influenzas for the purpose of making out a series.

The Theory of Influenza.

Influenza is not an infection which lends itself to a simple theory of its nature or a neat formula of its cause. All that one can do is to indicate the direction in which the truth lies. Something broad, comprehensive, steady from age to age, telluric if not cosmic, must be sought for. Some have thought that the legendary or representative universal sickness at the siege of Troy was influenza, because it began upon the horses and dogs, as so many historical influenzas have done. But it will be sufficient to show that influenza was the same in the Middle Ages as now; for what circumstances make a broader contrast than medieval and modern? The first writer in England to mention influenza—of course not under that name—was a dean of St Paul’s in the reign of Henry II., Radulphus de Diceto[752]. He is narrating the journey to Rome of the archbishop-elect of Canterbury: his election in England was in June, 1173, he had got as far as Placentia by Christmas, whence he turned aside to Genoa, and at length reached Rome, to have his election confirmed by the pope in the nones of April, 1174. It is in the midst of this account of the archbishop’s journey, that reference is made to an influenza, otherwise known, from German and Italian chronicles, to have happened in December, 1173: “In those days the whole world was infected by a nebulous corruption of the air, causing catarrh of the stomach and a general cough, to the detriment of all and the death of many”—universus orbis infectus ex aeris nebulosa corruptione. What kind of infection can that be which has befallen men on both sides of the Alps within the same short time in the 12th century as in the 19th? And what kind of infection is it which has outlived so many changes in the great pestilences of mankind, has seen the extinction of plague and the rise of cholera, and all other variations, most of them for the better, in the reigning types of epidemic sickness? To have lasted unchanged through so many mutations of things, from medieval to modern, and from modern to ultra-modern, and to have become more inveterate or protracted at the end of the 19th century than it had ever been, is unique in this history. Influenza appears to correspond with something broadly the same in human life at all times. Or is it rather a thing telluric, of the crust of the earth or the bowels of the earth? Or is it perhaps cosmic, affecting men as the vintage is affected by a comet, or as if it came from the upper spheres? My belief is that we need not transcend the globe to look for its source, and that, upon the earth, we need not go deeper than the surface, nor beyond the inhabited spots. I shall come back to this from giving the history of English opinion upon it.

The best known influenzas of the 16th century all came in summer, as some of the later ones have done, so that no one thought of them as exaggerated common colds. But it happened that the influenzas observed by Willis in 1658, and by Sydenham in 1675 and 1679, came in spring or winter and in such weather as to suggest to each of those physicians that the catarrhal symptoms corresponded to the season. Robert Boyle, their great philosophical contemporary, was also a witness of one or more of these influenzas, and it appeared to him that there was more than season and weather in them.