The Day My Great Uncles Died

This blog entry has received minor edits since its first publication.

On one day in the summer of 1873, two of my great uncles died in Holyoke, Massachusetts.  John Knightley, age 8 ½, and his brother Patrick, age 10 months, died of whooping cough on July 15. John had been born in Ireland, Patrick in Holyoke.

I learned this in the course of genealogical research. I wondered if there was some significance to that day or that week or that time in 1873, if there had been some sort of epidemic. As it happens, determining if there was an epidemic is more than problematic. There was a smallpox epidemic in progress in Boston and, at a lesser level, in Holyoke, but knowing that didn’t help since John and Patrick didn’t die of that disease.

My genealogical research often turns up medical information, usually about causes of death, which I record for several reasons, not the least of which is my long interest in medical and science history. By the 19^th century doctors, coroners and other such parties were trying to understand the causes of disease. The discovery of and general understanding of the actual agents of causation were slow in coming but gathered steam in the latter half of the 1800s. However, prevailing wisdom even in the 1870s assigned causes we today consider quaint, but which had long standing.

When I encounter a cause of death in that period, I know from long study that by our lights such causes were suppositions based often on the coincidence of assumed “bad” local factors found (or expected to be found) nearby. In fact, causes of death were often reported by neighbors, passers-by, relatives, and others who might have heard reports of illness from family members or visitors. Frequently these causes were duly recorded in death certificates without review.

Whether “whooping cough,” which we know today as pertussis, was the actual cause of the deaths of my great-uncles is open to question. As I’ve said, the germ theory of disease had not yet hatched, so clinical evidence was limited to symptoms. In the case of such diseases as measles, mumps, smallpox and whooping cough, symptoms were clear enough to allow for a reasonably certain diagnosis. We now know that pertussis is caused by the bacterium Bordetella pertussis. In that era,though, the assumed causes were almost entirely environmental, residing in bad pools of water and bad air, mainly. For example, in the annual report of the State Board of Health of Massachusetts for 1873, the health officer of Chicopee, the city next door to Holyoke, said:

“During June and July spinal-meningitis prevailed, apparently epidemic, in one section of this village. This was alluded to in a reply to a previous circular.

This disease appeared to me to have some connection, as a probable consequence, with foul vapors arising from a stagnant pool of water from the sewage of several houses crowded with tenants, although some isolated cases occurred in other parts of the village where I could not detect any malarial influence. The symptoms seemed somewhat rheumatic in character in most cases, though some were peculiar to that disease.

The chief apparent cause might have been remedied by a little more energetic action of our board of health, a month earlier, so far as the stagnant pool was concerned.” (1)

A brief digression (which is material to the discussion). The curious use of the term “rheumatic” in this passage speaks to long standing accepted wisdom about disease causation. The word is likely derived from an ancient belief,  first propounded by the Greek physician Galen ( 131-201 A.D), regarded as the founder of experimental physiology. According to Lawrence C. Parish in his monograph “An Historical Approach to the Nomenclature of Rheumatoid Arthritis” (Arthritis and Rheumatism, Vol. 6, No. 2, April, 1963), Galen “was one of the early Roman [Empire] physicians to use the word ‘rheumatismus.’ He applied the theory of humoral pathology to arthritis and felt that gout and arthritic conditions were caused by a collection of some humor in the affected part. ‘Rheumatismus’ was probably chosen to indicate the flow of the humors into the joints.” (2)

More on humoral theory later.

It is fascinating to look at the recorded causes of death in this period. The City (then called the “Town”) of Holyoke’s death register for the period July 14 through July 31, 1873 lists 51 deaths. Fully 47 of the 51 deceased individuals were under age 20. The causes of death were:

• Cholera infantum (16)
• Typhoid fever (2)
• Brain disease/fever (3)
• Whooping Cough (2)
• Canker (1)
• Small Pox (15)
• Teething (2)
• Inflamed bowels (1)
• Measles (1)
• Consumption (2)
• Heart disease (1)
• Sore Foot (1)

Smallpox in the period before its actual causative agent was discovered was distinguished entirely by symptoms. Fans of Shakespeare and other writers prior to the 20^th century will recognize the word “pox” as a reference to syphilis, which was also known as “great pox.” The smaller pustules of what was also called “variola” (derived from the “speckled” character of the small lesions) distinguished smallpox from great pox. The term “variola,” first used as a name for smallpox in the late 18^th century, carried over into modern times with the naming of the viruses that cause the two forms of smallpox, Variola major and Variola minor. In any case, the name of the disease was attached to the visual appearance of the disease.

Whooping cough was so named because of a characteristic “whoop” in the constant coughing of its sufferers, generally in the sound made during an inhaling breath. It was likely that though other diseases might sometimes cause a similar sounding cough, the diagnosis was reasonably correct.

This was not the case with “cholera infantum.” The term was a catch-all for diseases of the abdominal tract that caused severe diarrhea, vomiting and, ultimately, dehydration. Today we might determine such symptoms to be caused by norovirus, rotavirus, salmonella, an E. coli infection, or any of several other enteroviruses and bacteria – even of the specific disease “cholera” caused by the bacterium Vibrio cholerae. The term “cholera” derives from “choler.” A short essay by Michelle Ziegler in her blog “Contagions” says:

“Since antiquity, cholera could refer to any diarrhea or dysentery. The term cholera comes from the Greek word cholē meaning bile. Cholera then was a flushing of bile from the body in an attempt to rebalance Galen’s four humors of the body (blood, bile, black bile [choler], and phlegm).

In 19th century American medical records it is common to see three types of cholera reported: cholera morbus, cholera infantum, and Asiatic cholera. Cholera morbus and cholera infantum were both terms for non-specific diarrhea and/or dysentery in adults and children under age five respectively.  Cholera morbus was sometimes called the summer complaint and was usually found in older children and adults from July to September. It was caused by a variety of gastrointestinal pathogens with a significant contribution from contaminated food. Cholera infantum was given as the primary cause of death in children under age five in 19th century Illinois . Physicians specifically associated it with the ages of teething and finger foods. Even given its non-specific definition, it was still probably over-diagnosed due to paradigms of childhood illness. For example, early Illinois physicians did not believe that children could contract malaria, then endemic in Illinois.” (3)

It becomes clear that the assigning of diagnoses in these times retained the ideas of the theory of humors (and their associated temperaments), which began, as noted above, with Galen in the 2^nd century.

The idea that most diseases derived from “miasmas” and “bad air” was very strong at this time. Note the reference in the Chicopee annual medical report above to “foul vapors arising from a stagnant pool of water from the sewage of several houses crowded with tenants.” The same 1873 Chicopee report to the State Board of Health of Massachusetts says:

“Cholera infantum always prevails here during July and August. More children die with some form of morbid discharge from the primæ viæ [intestinal tract], than from anything else during summer and early autumn. The causes seem to be mainly these: hot, impure air, sympathetic irritation from teething, and improper diet. A very large majority of the cases occur among our foreign population, and the causes can be removed by a development higher [sic] intelligence among mothers, the enforcement of stricter sanitary measures by our corporations and health officers.” (4)

Miasmas and “bad air” or malaria were the reasons many cities had breathing parks, which were refuges from environments deemed dangerous, including crowded apartments, filthy basements, and other inimical locations. The open space of park areas provided what we still call “fresh air,” a phrase that seems innocuous enough but that partakes of the old idea of escaping from the supposed noxious effects of bad air and foul vapors. Ironically, we know today that diseases can, indeed, be transmitted through the air, though it isn’t the air itself that is at fault: it’s the viruses and bacteria effused into the air by ill people who are coughing and sneezing. Florence Nightingale is often credited with saving lives during the Crimean War by opening windows in military hospitals, exposing injured soldiers to fresh air. Nightingale was, in a sense, prescient, though she was, in fact, a “miasmist,” informed by the prevailing beliefs of her day. She was right, but not for the right reasons.

Unfortunately, the Chicopee health officer’s report also abounds in the bias of his day against immigrants and the assumed lack of intelligence in women, which weirdly and distressingly reflects bigotry in our time. He also states: “Scarlatina, whooping-cough and measles have each had their turn among the children; but neither was extensively prevalent or fatal.” (5) Perhaps this was true in that community in general, but note that whooping cough was very often fatal in that time and appears to have been extensively fatal to my great-uncles.

Farther along in the Chicopee report we see this:

“Typhoid fever has disturbed us less than usual, and much less than it has adjoining towns. This disease occurs much oftener near certain streets here than in other localities, and I have little doubt that badly arranged privy-vaults, imperfect sewerage, damp cellars and too heavily shaded streets, are responsible for almost all these cases. In passing near the large corporation blocks, along the rear alleys, one cannot help receiving emphatic, sensible evidence of the foul odors of decomposing organic and excrementitious matters, during any of the warm months. It cannot be easily helped with our present amount of sewerage, except by using a large quantity of disinfecting material, and by putting up high ventilating pipes connecting with every vault, and keeping the vault tight.

Our local health authorities are the ‘selectmen,’ fair business-men, of average intelligence, none of them physicians, druggists or chemists, I think. I do not think that they are as vigilant to detect, or energetic to remove, causes detrimental to public health, as would be highly desirable in so crowded a village; but tax-payers are generally ready to cry out against any but the most obvious and pressing needs of reform, and without more liberal public sympathy to back them, I suppose they could effect but little more than they do, without great personal sacrifice.” (5)

The report (while bringing us the wonderful term “excrementitious”) does not note any incidence of smallpox, which is odd considering the number of fatal cases in the city next door to Chicopee. The note about “typhoid fever” brings us back to the discussion of accuracy of diagnosis. We know today that proximity is an actual strong contributing factor in the transmission of true “typhoid fever,” which is caused specifically by the bacterium Salmonella typhi. But proximity also seriously contributes to many similar diseases caused by other agents, so “typhoid fever” was a catch-all cause for numerous 19^th century ailments. This is shown by the many alternative names for what was assumed to be one disease: bilious fever, camp fever, jail fever, hospital fever, putrid fever, ship fever or spotted fever. “Bilious” fever was, for those times, caused by an exudation of excess bile. “Camp”, “jail,” “hospital” and “ship” fever labels speak to the clear dangers of close contact. “Putrid” fever speaks for itself. The “typhoid fever” our correspondent identifies was likely a combination of viral and bacterial diseases causing severe diarrhea and dehydration. What is sad, by the way, is that in our own time we know that constant hydration and dosing with salt for people suffering from enteric diseases is life-saving. So many lives could have been saved by simply getting the sick to drink water and take salt.

In our time, of course, we vaccinate and inoculate. DPT (diphtheria, pertussis, tetanus), TDaP (tetanus, diphtheria, acellular pertussis) and MMR (measles, mumps, rubella) immunizations have (except in areas of marked stupidity) essentially eliminated many of the potentially deadly childhood diseases.

But those measures were unavailable to my great uncles. Such deaths were common in that period. They were expected as a grim fact of life, which, along with the lack of birth control methods, accounts for the large numbers of children in many families over the centuries. In one family in my genealogical line, a mother bore 12 children, only 4 of whom lived to adulthood. More than once I’ve seen instances of children given a name at baptism but dying within days; within the year, another child would be born and given the same name. In our first-world lives we are not familiar with such common heartbreak.

In a certain sense our lives are charmed, compared to those of our ancestors.At least “humor” for us is about laughing, not about what causes disease. But don’t laugh yet. My immediate forebears still referred to ailments such as “catarrh”and “lumbago” and said that nervy people “have a lot of gall.” (6)

Today some folks believe you can “get your death” or “come down” with something by being exposed suddenly (or even gradually) to cold temperatures. We even call our most common disease a “cold,” possibly because a cold usually presents without fever, but also because of its association with cold weather. This despite our knowing that colds are caused by viruses. Of course, those viruses move about when we’re in close proximity to each other – when it’s cold. So there we are again.

NOTES

Thanks to Burton Andersen, MD for his reading and edits of this essay. Dr. Andersen is an infectious diseases specialist and a retired Professor of Medicine and Chief of Infectious Diseases at University of Illinois at Chicago School of Medicine and Hospital.

(1) Annual report of the State Board of Health of Massachusetts. … v.5 1873/74.
From https://babel.hathitrust.org/cgi/pt?id=coo.31924060901158;view=1up;seq=546
For this report place page number 518 in the “jump to” box.

(2)  Lawrence C. Parish, “An Historical Approach to the Nomenclature of Rheumatoid Arthritis” (Arthritis and Rheumatism, Vol. 6, No. 2, April, 1963)
https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780060206

(3) Michelle Ziegler, “Historic Meanings of Cholera.”    From https://contagions.wordpress.com/2011/11/01/historic-meanings-of-cholera/#more-4906 in her Blog “Contagions.”

(4) (5) Annual report of the State Board of Health of Massachusetts. … v.5 1873/74.

(6) Another derivative of Galen’s ideas is the pop-psychology Meyers-Briggs Personality Inventory, which partakes of the theory of the four temperaments as does its proximate inspiration, Carl Jung’s theory of types, which expanded the four temperaments to eight personality types. The MBTI has many adherents in today’s world and is used in organizational workshops frequently, despite its having been relegated to non-science by the larger psychology community.

© Edmund J. McDevitt
December, 2018