Sydenham’s epidemic Constitutions.

Sydenham adopted the epidemic constitutions from Hippocrates, as he did much else in his method and practice. In the first and third books of the ‘Epidemics,’ Hippocrates describes three successive seasons and their reigning diseases in the island of Thasos, as well as a fourth plague-constitution which agrees exactly with the facts of the plague of Athens as described by Thucydides. The Greek term translated “constitution” is κατάστασις, which means literally a settling, appointing; ordaining, and in the epidemiological sense means the type of reigning disease as settled by the season. The method of Hippocrates is first to give an account of the weather—the winds, the rains, the temperature and the like,—and then to describe the diseases of the seasons[17]. Sydenham followed his model with remarkable closeness. The great plague of London has almost the same place in his series of years that the plague-constitution, the fourth in order, has in that of Hippocrates. It looks, indeed, as if Sydenham had begun with the year 1661, more for the purpose of having several constitutions preceding that of the plague than because he had any full observations of his own to record previous to 1665. He is also much influenced by the example of Hippocrates in giving prominence to the intermittent type of fevers. It was remarked by one of our best 18th century epidemiologists, Rogers of Cork, and with special reference to Sydenham’s “intermittent constitutions,” that fevers proper to the climate of Thasos were not likely to be identified in or near London excepted by a forced construction.

Sydenham’s Constitutions.

	Constitutions	Total deaths in London	Plague	Fever and Spotted Fever	Smallpox	Measles	Griping in the Guts
1661	“Intermittent” constitution: with a continued fever throughout.	16,665	20	3,490	1,246	188	1,061
1662		13,664	12	2,601	768	20	835
1663		12,741	9	2,107	411	42	866
1664		15,453	5	2,258	1,233	311	1,146
1665	Constitution of plague and pestilential fever.	97,306	68,596	5,257	655	7	1,288
1666	Constitution of plague and pestilential fever.	12,738	1,998	741	38	3	676
1667	Constitution of smallpox, with a continued “variolous” fever.	15,842	35	916	1,196	83	2,108
1668		17,278	14	1,247	1,987	200	2,415
1669		19,432	3	1,499	951	15	4,385
1669	Constitution of dysentery and cholera nostras, with a continued fever.	19,432	3	1,499	951	15	4,385
1670		20,198	0	1,729	1,465	295	3,690
1671		15,729	5	1,343	696	17	2,537
1672	Measles in 1670.	18,230	5	1,615	1,116	118	2,645
1673	Constitution of “comatose” fevers. Influenza in 1675.	17,504	5	1,804	853	15	2,624
1674		21,201	3	2,164	2,507	795	1,777
1675		17,244	1	2,154	997	1	3,321
1676		18,732	2	2,112	359	83	2,083
1677	Not recorded.	19,067	2	1,749	1,678	87	2,602
1678	Return of the “intermittent” constitution, absent since 1661-64.	20,678	5	2,376	1,798	93	3,150
1679		21,730	2	2,763	1,967	117	2,996
1680		21,053	0	3,324	689	49	3,271
1681	“Depuratory” fevers, or dregs of the intermittents.	23,951	0	3,174	2,982	121	2,827
1682		20,691	0	2,696	1,408	50	2,631
1683		20,587	0	2,250	2,096	39	2,438
1684		23,202	0	2,836	1,560	6	2,981
1685	Constitution of a “new” continued fever.	23,222	0	3,832	2,496	197	2,203
1686	Constitution of a “new” continued fever.	22,609	0	4,185	1,062	25	2,605

The foregoing is a Table of Sydenham’s epidemic constitutions from 1661 to 1686, compiled from his various writings, with the corresponding statistics from the London Bills of Mortality.

I give this Table both as a convenient outline and in deference to the great name of Sydenham. But we should be much at fault in interpreting the figures of the London Bills, or the history of epidemic diseases in the country at large, if we had no other sources of information than his writings. Only some of the figures in the Table concern us in this chapter; plague has been finished in the previous volume, smallpox, measles and “griping in the guts” are reserved each for a separate chapter, as well as the influenzas and epidemic agues which formed the chief part of the “strange” or “new” fevers. If this work had been the Annals of Epidemics in Britain, it would have been at once proper and easy to follow Sydenham’s constitutions exactly, and to group under each year the information collected from all sources about all epidemic maladies. But as the work is a history, it proceeds, as other histories do, in sections, observing the chronological order and the mutual relations of epidemic types as far as possible; and in this section of it we have to cull out and reduce to order the facts relating to fevers, beginning with those of 1661.

Cases of fever, says Sydenham, began to be epidemic about the beginning of July 1661, being mostly tertians of a bad type, and became so frequent day by day that in August they were raging everywhere, and in many places made a great slaughter of people, whole families being seized. This was not an ordinary tertian intermittent; indeed no one but Sydenham calls it an intermittent at all, and he qualifies the intermittence as follows:

“Autumnal intermittents do not at once assume the genuine type, but in all respects so imitate continued fevers that unless you examine the two respectively with the closest scrutiny, they cannot be distinguished. But, when by degrees the impetus of the ‘constitution’ is repelled and its strength reined in, the fevers change into a regular type; and as autumn goes out, they openly confess themselves, by casting their slough (larva abjecta) to be the intermittents that they really were from the first, whether quartans or tertians. If we do not attend to this diligently” etc. And again, in a paragraph which does not occur in the earlier editions, he writes as follows in the context of the “Intermittent Fevers of the years 1661-1664:”

“It is also to be noted that in the beginning of intermittent fevers, especially those that are epidemic in autumn, it is not altogether easy to distinguish the type correctly within the first few days of their accession, since they arise at first with continued fever superadded. Nor is it always easy, unless you are intent upon it, to detect anything else than a slight remission of the disease, which, however, declines by degrees into a perfect intermission, with its type (third-day or fourth-day) corresponding fitly to the season of the year.”

The intermittent character of these fevers seems to have struck Sydenham himself in a later work as forced and unreal. Writing in 1680, when the same kind of fevers were prevalent, after the epidemic agues of 1678 and 1679, he calls them “depuratory,” and says that “doubtless those depuratory fevers which reigned in 1661-64 were as if the dregs of the intermittents which raged sometime before during a series of years,” i.e. the agues of 1657-59[18].

Theory or names apart, Sydenham’s account of the fatal epidemic fever of the summer and autumn of 1661, comes to nearly the same as Willis’s. Without saying expressly, as Willis does, that the victims were mostly children or young people, he speaks in one place of those of more mature years lying much longer in the fever, even to three months, and he specially mentions the same sequelae of the fever in children that Willis mentions, and that Roger North remembered in his own case—namely that they sometimes became hectic, with bellies distended and hard, and often acquired a cough and other consumptive symptoms, “which clearly put one in mind of rickets.” He refers also to pain and swelling of the tonsils and to difficulty of swallowing, which, if followed by hoarseness, hollow eyes, and the facies Hippocratica, portended speedy death. Among the numerous other accidentia of the fever, was a certain kind of mania. Among the symptoms were phrensy, and coma-vigil; diarrhœa occurred in some owing, as he thought, to the omission of an emetic at the outset; hiccup and bleeding at the nose were occasional.

But, although Sydenham must have had the same phenomena of fever before him that Willis had, the epidemic being general, according to the statements of both, one would hardly guess from his way of presenting the facts, that the fever was what Willis took it to be—a slow nervous fever, with convulsive and ataxic symptoms, specially affecting children and the young. Both Willis and Sydenham recognised something new in it; the common people called it, once more, the “new disease,” and Pepys calls it a “sort of fever,” and “strange and fatal fevers.”

As Sydenham maintains that the same epidemic constitution continued until 1664 (although the fever-deaths in London are much fewer in 1662-3-4 than in the year 1661, which was the first of it), we may take in the same connexion Pepys’s account of the Queen’s attack of fever in 1663. The young princess Katharine of Portugal, married to Charles II. in 1662, had the beginning of a fever at Whitehall about the middle of October, 1663; Pepys enters on the 19th that her pulse beat twenty to eleven of the king’s, that her head was shaved, and pigeons put to her feet, that extreme unction was given her (the priests so long about it that the doctors were angry). On the 20th he hears that the queen’s sickness is a spotted fever, that she was as full of the spots as a leopard: “which is very strange that it should be no more known, but perhaps it is not so.” On the 22nd the queen is worse, 23rd she slept, 24th she is in a good way to recovery, Sir Francis Prujean’s cordial having given her rest; on the 26th “the delirium in her head continues still; she talks idle, not by fits, but always, which in some lasts a week after so high a fever, in some more, and in some for ever.” On the 27th she still raves and talks, especially about her imagined children; on the 30th she continues “light-headed, but in hopes to recover.” On 7th December, she is pretty well, and goes out of her chamber to her little chapel in the house; on the 31st “the queen after a long and sore sickness is become well again.”