A short history of respiratory illness epidemics (2)

*This blog post first appeared in Dutch on NL-lab.net. *

Last week, I discussed that from antiquity until well into the nineteenth century, the idea that contagious diseases were caused by the influence of celestial bodies, the weather, and climate, was common. We still see these ideas in our language: think of catching a cold. This explains why until the twentieth century, quarantines and isolations were not used to battle epidemic respiratory illnesses. After all, if an illness is caused by the weather, isolating patients has little use. The best option, usually only available to the wealthy, was to stay inside, warmly wrapped up.

Quarantining was an existing practice, but it was mostly used in other diseases. During a plague epidemic in Italy in the fourteenth century for example, the crew of mooring vessels was kept on the boat for forty days (quarantaine) to prevent infections.[1] So even though the contagious nature of some diseases and the fact that their spread can be stopped by isolating (suspected) patients have been understood for centuries, isolating patients with respiratory illnesses is a much more recent phenomenon. Only in 1898 did Dutch microbiologist Martinus Beijerinck coin the term ‘virus’ to describe what, up till that point, had been considered extremely small bacteria. And only in 1901 an influenza virus was first isolated, in poultry. The Spanish flu epidemic of 1918 was, in all likelihood, the first flu epidemic in which quarantine was used widely to manage the disease.

Detail of Jan Luyken, The Apothecary (1694), ets. Rijksmuseum RP-P-OB-44.502

Of course, people did try to manage and cure respiratory illness before the late nineteenth century too. Until the 1850s, most people depended on selfcare: ‘cures’ bought at the pharmacist, from herbal healers, or made from supplies from their own garden or pantry. Those who could afford it asked a doctor for advice, who would visit the patient at home and might give them a recipe for the apothecary. Hospitals were places where poor people would go if they were at the end of their tether, and no one could take care of them at home. Most people who went into a hospital had little hopes of coming out alive.[2]

Physicians like the Amsterdam medical doctor Steven Blankaart (1650-1704) advised rest and warm coverings in case of coughing and colds, very much in line with Hippocratic understandings of colds as caused by the weather. He also prescribed cures prepared by pharmacists, which could contain ingredients that we still use in cough medicine today, such as ginger and aniseed, but also plants and substances that have been nearly forgotten now. Blankaart warned that using sugary syrups and pastilles was useless, and that so-called plasters, swaths of fabric drenched in extracts, were no good either. The only possible exception were plasters containing substances like camphor, because the smell – much like Vicks VapoRub today – could ease the patient: “Some place plasters on the chest, but I cannot see what use they have, because this means should penetrate the lungs through the breastbone, which would be absurd, therefore these means are of no importance, unless they reek of Musk, Saffron, or Camphor, &C. And that smell by breathing it in could do something useful in our blood.”[3]

Sweets and substances that are quite similar to modern liquorice were popular though, something we see reflected in books like ‘The Perfect Dutch Kitchen Maid’ (De Volmaakte Hollandsche Keuken-Meid, 1752). Here ‘chest sugar’, sugar pastilles with expensive exotic spices like saffron or cloves, and ‘tablets of liquorice’, made from liquorice extract, aniseed, Arabic gum, and rosewater were recommended for colds and coughs respectively.[4]  Less prosperous citizens had to make do with drinks made of cucumber juice or marjoram, or brews with aniseed, fennel seed, liquorice, honey, or hyssop.[5]

Cures for colds and coughs, Steven Blankaart, Verhandelinge van de Opvoedinge En Ziekten Der Kinderen (Amsterdam: Hieronymus Swierts, 1684), p. 176.

Although such preparations, either made by the apothecary or at home from the pantry, were probably easing colds, they of course did not cure respiratory illnesses – although that is not that different today. In premodern descriptions of epidemics of respiratory illness, it is often noted in a rather off-hand way that it were mostly the elderly who died from them. ‘Elderly’ is relative of course, and in the past people grieved the loss of their loved ones too. But such remarks do suggest that death was much more present in everyday life than it is today; and that would not change until the second half of the nineteenth century.

Finally, we have seen over the past few weeks that scientists are trying to find a vaccine against covid-19. The first rudimentary vaccines in Europe, against smallpox, date back to the eighteenth century. In China and Asia, such immunisation practices had existed much longer.[6] Bacterial pneumonia could increasingly be treated successfully from the start of twentieth century, especially when penicillin became commercially available.  The Spanish flu epidemic of 1918 led to a search for new treatments for flu. This would eventually result in the first flu shots during World War II, developed by the American army.

The history of our understanding of and ways of dealing with epidemic respiratory illnesses thus shows that we have come to understand the causes, spreading, and effects of respiratory infections in completely new ways over the past 150 years. However, there is still a lot of confusion among the general public about the differences between flu, colds, and infections like covid-19. We have become much more successful in treating severe cases of lower respiratory tract infections, but the treatment of upper respiratory tract infections has not changed significantly since the seventeenth century. We have relatively little experience in the prevention, curtailing, and ‘flattening’ of epidemics of respiratory infections, which partly explains the wide variety of current measures.

[1] See e.g. Monica Green (ed.) “Pandemic Disease in the Medieval World”, special issue of The Medieval Globe, vol. 1, 2014.

[2] See e.g. Ruth Richardson, Death, Dissection, and the Destitute (Chicago: University of Chicago Press, 2001).

[3] Steven Blankaart, Verhandelinge van de Opvoedinge En Ziekten Der Kinderen (Amsterdam: Hieronymus Swierts, 1684), p. 173-180: “Op de borst leggen sommige Pleisters, maar ik kan niet sien wat groote nut zy konnen uitrichten, want dit Middel zoude moeten door het Borst-been tot in de Longe doordringen, het welke absurd soude zijn, derhalven zijn die Middelen mede al van geen belang, ten zy ze riekende zijn van Moschus, Saffraan, Campher, &c. En die reuk door het inademen onse sappen en bloed eenig nut aanbracht.”

[4] De Volmaakte Hollandsche Keuken-Meid… Als Meede Eenige Huismiddelen. Voor de Verkoudheid (Amsterdam: Steven van Esveldt, 1752)

[5] Evert Jan Thomassen a Thuessink, Prysverhandeling over de Vraag, Voorgesteld Door Het Geneeskundig Genootschap […] Servandis Civibus, in Hoe Verre Zou Men, by Gebrek van de Apotheek, Uit Kelder En Keuken de Vereischte Geneesmiddelen […] Kunnen Bekomen. (Amsterdam: Petrus Conradi, 1789), p. 11, 192. Heyman Jacobaus, Schat Der Armen, of Huismedicyn Boekje, 1606, p. 49, 197.

[6] See e.g. Anne Eriksen, “Cure or Protection? the Meaning of Smallpox Inoculation, ca. 1750—1775”, Medical History 57(4):516-36 (2013).

A short history of respiratory illness epidemics (1)

*This blog post first appeared in Dutch on the NL-Lab website on 31 March 2020*

The Netherlands are in lockdown to curb the covid-19 epidemic since prime minister Mark Rutte announced social distancing rules on 13 and 15 March. Since that time, various people have asked me, as a medical historian, ‘how we handled this kind of thing in the past’. By this they mean: how did people, both in the Netherlands and abroad, deal with epidemic respiratory infections in the past? The short answer would be: very different. The long answer could fill a book, but a blog post (or two) is written and read faster. This week part 1, on the history of our understanding of respiratory illnesses. Next week part 2, on treatments and management of respiratory illnesses.

Gabriël Metsu, The Sick Child, ca. 1664 – ca. 1666. Oil on canvas, h 32,2cm × b 27,2cm. Rijksmuseum.

We now understand respiratory infections as an infection of the mucous membranes of the airways, caused by pathogens such as bacteria and viruses. On the website of the Dutch National Institute of Public Health (RIVM), we read: “Infections of the upper respiratory tract, such as colds and sore throats, are usually caused by a virus and normally pass without treatment. Infections of the lower respiratory tract or for example pneumonia and bronchitis. These can be caused by both viruses and bacteria and can lead to severe illness. Pneumonia is an important cause of death in the Netherlands.”[1]

Confusingly, respiratory infections which can present with very similar symptoms, such as the common cold, flu, and covid-19, are caused by completely different viruses, which do not belong to the same taxonomic and morphological families. Cold virus (Rhinovirus) is part if the  Picornaviridae family; the four influenza viruses (A,B,C,D) are part of the Orthomyxoviridae family, and corona viruses such as are part of the Orthocoronavirinae family. Comparing covid-19 to ‘a flu’ hence is incorrect, not only clinically, but also taxonomically speaking.

Yet this is all very recent knowledge from a historical perspective. Although it has been known since antiquity that certain diseases are very contagious, and that their transmission can be stopped by isolating the ill from healthy people, that line of thought in general was not applied to respiratory infections or illnesses. The reason for that is that only in the late nineteenth century the role of viruses and bacteria in respiratory infections became clear, and that respiratory infections therefore can be contagious. Epidemic respiratory infections with flu-like symptoms have been described with some regularity since antiquity though. In Hypocrates’ Book of Epidemics, written around 410 BCE for example, we already find a description of a very contagious disease in the north of Greece, which sounds a lot like flu. Until the Middle Ages, throughout Europe a wide variety of epidemics is described. Nearly all of these epidemics, including those that appear to have been respiratory infections, were described as ‘plague’ or ‘pest’.

In Florence in 1357 an epidemic of ‘influenza’ was first documented.[2] The word influenza literally means ‘inlfuence’ in Italian. From antiquity until late in the nineteenth century people thought that many contagious diseases were actually caused by the influence of celestial bodies, weather, or climates – a believe still reflected in contemporary language, think of ‘flu’, the ‘common cold’, or catching ‘a cold’.[3] The influenza epidemic in Florence of 1375 was indeed most likely an ‘influenza di freddo’, a ‘cold influence’ or influenza epidemic. But until the eighteenth century, the word influenza, like plague, meant a (contagious) disease more generally. It appears that the term also did not spread throughout Europe until the eighteenth century. For example, Lord Chesterfield wrote in a letter to this son in 1767: ““a little fever that kills nobody but elderly people that is now called by a beautiful name: influenza”. [4]

Titel page of Hennert’s treatise, 1785

In the Netherlands, the word influenza first appeared by the end of the eighteenth century, as a synonym for the common cold, but used metaphorically rather than medically. The Utrecht professor of philosophy and mathematics J.F. Hennert for example in 1785 published a pamphlet with the title Special Effects of the Influenza, and the Cures Against that Contagious Disease.[5] It’s actually not a text on the symptoms and treatment of colds or flu, but a squib aimed a critic who tried to slander his work. Something similar is going on in The Lighter: Being an Elaborated Treatise on the Influenza, that is Public Cold, published in 1800 by army physician Pieter van Woensel.[6] On closer inspection, it’s not about physical colds at all, but about the spreading of dangerous political ideology.

The word ‘griep’ did not appear in Dutch until around 1800, when the French armies brought their grippe, which is most likely etymologically related to the German grippen (‘to catch’). Before that time, respiratory afflictions in Dutch were described using a wide variety of terms, such as verkoudheid, longontsteking, pneumonia, peripneumonia, consumptie, zydewee, pleuris, tering or Phthisis. Lacking a microbiolological understanding of respiratory illnesses, the categories in which they were divided were also much more fluid.[7] We should also be aware of the fact that such terms, even if they seem identical to modern words, had a different meaning for the people who used them in the eighteenth century. Understandings of illness are always simultaneously clinical and social, and separating those two dimensions is nearly impossible. Therefore, we cannot simply say that eighteenth-century consumption sufferers ‘actually’ had tuberculosis – after all, TBC did not exist in social, biological, and medical reality before 1882, the year in which the tuberculosis bacteria was first identified. Hence it is not useful either to assume that the ‘zydewee’ (‘side ache’) described by a seventeenth-century doctor was the same disease as modern pleurisy.

This of course does not mean that medical people did not think critically about the causes of various respiratory illnesses. According to the Amsterdam physician Steven Blankaart (1650-1704) for example, coughing in colds was caused either by ‘a salty and sharp substance excreted by the glands that cover the inside of the lungs’ or because of the fact that ‘the air sometimes contains more sour particles than other times, which are breathed in, sharpening the blood, and dismay the lung to coughing’.[8] But how were respiratory illnesses treated before the late nineteenth century? More next week!

[1] https://www.rivm.nl/luchtweginfecties, last consulted on 27-3-2020

[2] Bruno Lina, “History of Influenza Pandemics,” in Paleomicrobiology, by D. Raoult and M. Drancourt (Berlin: Springer, 2008), 199–211, https://doi.org/10.1007/978-3-540-75855-6_12.

[3] A similar etymology is found in malaria: mal’aria literally means ‘bad air’ in Italian

[4] Lina 2008, p. 202.

[5] Johann Friedrich Hennert, Bijzondere Uitwerkzelen van de Influenza, En de Geneesmiddelen Tegen Die Besmettelijke Ziekte(Utrecht: A. van Paddenburg, Akademie drukker, 1785).

[6] Pieter Van Woensel, De Bij-Lichter, Zijnde Eene Uitgewerkte Verhandeling over de Influenza, Dat Is Publieke Verkoudheid(Amsterdam: In ’t Nieuwe Licht, 1800).

[7] E.g. Vanessa Harding, “Housing and Health in Early Modern London,” in Environment, Health and History, by Virginia Berridge and Martin Gorsky (Basingstoke: Palgrave Macmillan, 2012), 23–44, pp. 38.

[8] Steven Blankaart, De Kartesiaanse Academie Ofte, Institutie Der Medicyne (Amsterdam: Johannes ten Hoorn, 1683), p. 285. “een siltige en scherpe [stof] door de kliertjes die de longe-pijps rok van binnen bekleeden, uitsypert” (…) “de locht d’eene tijd meerder suure deeltjens by sich heeft als d’andere tijd, welk dan ingeademt wordende, het bloed scherper maakt, en de long tot hoesten ontstelt”.