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Miliary Fever, or the Sweating Sickness.
MILIARY
1374
FEVER,
OR THE SWEATING SICKNESS
for the stone, to attend a woman in labour, or to command the Channel Fleet; the willingness arising from the fact that, not being a surgeon, an accoucheur, or of all a sailor, and equally ignorant of the business three, he was ignorant also of the dangers against which
closely similar malady, was known As far as England is con. as 11 trousse galant." of 1551 appears to be the last the cerned, epidemic This epidemic is of interest in the to have occurred. fact that the disease was described and recorded by Dr. were JOHANNES CAius in two papers-one in English, the other in those following any of the callings question expected to provide. Such is the type of scores of in Latin. A sweating disease of similar character was uneducated persons who would tranquilly instruct a observed in Germany in 1652, 1802, and 1864, while outphysician about an epidemic or correct an astronomer breaks with closely similar clinical features, though less A recent illustration of severe, have occurred in certain parts of Germany and about the heavenly bodies. this tone and mode of thought has been furnished France, being known as " la suette des Picards " or by press comments upon the composition of the Royal " the miliary sweat of Poitou." A severe epidemic man
France
it,
or
a
Vivisection and upon its decision to hear of this character occurred in the central provinces evidence in private ; comments in which it is declared of France in 1887 and was carefully studied by M. that the "public"are "the only possible judges of BROUARDEL. In an annotation in THE LANCET of the issue at stake." The issue at stake is, we conceive, Oct. 1st, 1887, p. 671, a careful account of the clinical - simply that of the conditions in which experiments upon features of the disease will be found. In the district living animals are for the future to be conducted (the pro- of Montmorellon, out of a population of 13,000 there were hibition of them in a civilised country being unthinkable) ; 1700 attacked, with an average mortality of 12 per cent., and the only persons capable of "judging"upon such an though in some villages it reached as much as 33 per issue are those who possess, or are capable of acquiring, cent. of the persons attacked, while convalescence some knowledge concerning the present state of physio. in most cases was liable to be slow. M. BROUARDEL logical inquiry in relation to the prevention and the treatment organised a special medical service to disinfect the of disease and to the problems which are still pressing for cottages and the clothes in infected areas. An outbreak - solution. Persons ignorant on these points, assuming that of this disease has occurred in May and June of they were empowered " to decide," would still be absolutely this year in the districts of Les Charentes and we unable "to judge." If it be immoral, as some will publish in our Paris letter an abstract of a report on have it, to occasion suffering to the lower animals, the subject presented to the Académie de Medecine by M. it is at least equally immoral to leave human suffer- CHANTEMESSE, working in conjunction with M. MARCHOUX ing unrelieved ; and the balance of judgment must and M. HAVRY. During the space of six weeks 6000 necessarily incline towards the mitigation of that which is persons were attacked, exclusively in the villages, the towns shown, by complete inquiry, to be the greater and more escaping. Bacteriological investigations failed to reveal. widely extended evil of the two. In the meanwhile we may the existence of any organism that could be inoculated or mention that Mr. STEPHEN PAGET has just published a new cultivated. It was found that the epidemic was limited edition of his useful book about "Experiments on Animals,,. and did not spread across the Charente except in the and that it contains, among much else that is worth reading, neighbourhood of the bridges. The study of the incidence an interesting account of the " press methods " of the several of the disease showed that women were more frequently antivivisection societies whose common character is to seek attacked than men and that the houses at the periphery money from the public for their maintenance. of the villages were first invaded, especially the residents Commission
on
ground level of houses without wooden floors. CHANTEMESSE makes the suggestion that the field M. mice, or rather the fleas infesting them, may be the agents carrying the infection, since the districts con. cerned have been overrun for the past two years by field mice, while in many of the patients suffering from the disease he observed flea-bites. The suggestion is a purely on
the Sickness.
Miliary Fever, RECENT events
or
Sweating
are making miliary fever Among the plagues of the
a
subject
of
Middle Ages few are more remarkable than that of the sweating sickness, or as it was at one time generally named sudor Anglicus, the English sweat. The earliest recorded outbreak occurred in August of the year 1485, in the districts occupied by the mercenary troops employed by HENRY OF RICHMOND at the battle of Bosworth Field. The disease reached Oxford at the end of the month and London on Sept. 21st. Other epidemics occurred and Outbreaks also occurred 1551. in 1506, 1517, 1528, in Calais, chiefly limited to the English inhabitants. The
topical interest.
the
theoretical one but deserves careful examination, although in the absence of any knowledge of the infective agent it must be difficult to substantiate. A question of interest in regard to the history and origin of contagious and infectious diseases is the relation of the modern miliary fever to the mediasval sweating sickness. This aspect of the disease has been carefully and critically studied by Dr. J. F. PAYNEand recently by Dr. W. H. HAMER2 in his Milroy lectures, It is of interest in this connexion to compare the clinical characters of the two diseases. Among the most careful accounts of the sweat of Picardy are those given by M. EMILE PARMENTIER3 and by
character of the disease, its sudden onset, and frequent fatal issue earned for it a variety of names ; for example, in the parish register of Loughborough it is 1 St. Thomas’s Hospital Reports for 1887. Article "Sweating Sickreferred to as " the swet called new acquaintance, ness," Encyclopæedia Britannica. 2 THE LANCET, March 3rd, 1906, p. 572. alias stoupe knave and know thy master," while in 3 Revue de Médecine, September, 1887, p. 725. severe
THE POSITION OF THE ROYAL NAVY
MEDICAL
SERVICE.
1375
M. BROUARDEL. The disease appears to be sudden in its developments as had occurred contemporaneously with the onset with some ill-defined forerunners, such as fever, developments of antiseptic surgery and modern operative malaise, and weakness. On the second day profuse sweating procedure, but appended to a speech which in other ways conformed to the established model of inaugural eloquence occurs and is associated with the appearance of the rash’ be to The was a forcible indictment of the present conditions in the the fourth may postponed tongue day. though-this is furred and there is usually constipation, cough rapidly medical service of the Royal Navy. Sir LAMBERT ORMSBY’s develops, and epistaxis is frequent. Some nervous sym. strictures, which we publish this week in our Service ptoms are also the rule, such as restlessness, delirium, and columns, have been passed at a time when the medical proparoxysmal dyspnoea. The eruption presents two chief fession as a whole is encouraged to believe that the Royal features-viz., an outbreak of miliary papules subsequently Navy Medical Service is in a good and improving condition, becoming vesicular, and a polymorphous erythema which and as that is the view which, with certain reserva. may become purpuric. The erythema is sometimes sugges- tions, we have taken in our columns we consider that tive of measles, the more so that it first appears on the face. we owe it to our readers to deal categorically with Sir The sweat is in some cases feetid, but this is stated by M. LAMBERT ORMSBY’S complaints and in so doing we PARMENTIER to be due to lack of cleanliness. Desquamation may say at once that, while allowing the considerable occurs from about the tenth to the twelfth day or sometimes cogency and truth of much of what the distinguished earlier; on the second day of desquamation a critical polyuria surgeon has said, we hope to remove the sweepingly bad is observed. Convalescence is slow, while anemia and some impression which he has conveyed. Things are neither so tremors of the face and tongue are not uncommon during this bad as he would have us believe nor really in other than a period. The medieval sweating sickness was characterised, healthy and improving state. There are grievances some of I which could be removed with ease and some with as described by Dr. CAIUS, by the extreme suddenness of its difficulty, onset and the rapidity of its course which was sometimes while some perhaps will have to be endured ; but the only a few hours. It was also very fatal. Dr. PAYNE points medical officer in the navy is not the bitter victim of a black out also that in the accounts extant of that disease there is fate whose picture is now presented to us. In our comments, no mention of the miliary eruption, but he is of opinion that as a matter of convenience, we have adopted the numbering the two diseases are similar if not identical. He offers the of the paragraphs employed by Sir LAMBERT ORMSBY, so ingenious suggestion that supposing the disease to have that the reader may find it necessary to consult the report of been brought to England by the French mercenaries of his speech upon p. 1396 of this issue. RICHMOND’S army as was generally believed, the reason of We must all agree that there are defects in the Royal its severity was the previous freedom of the English from Navy Medical Service. The rules as to medical guard to the disease, on the analogy of the severity of the outbreak which Sir LAMBERT ORMSBY refers in his fifth paragraph of measles in the Fame Islands.
He also refers to the over the greater part of
should be
distinctly laid down in the
EixG’s
Regulations and great epidemic spread Admiralty Again, paragraph he Europe north of the Alps, and states that France escpaed. points out how wrong it is that an Inspector-General ranking He therefore regards France as the home of the mediaeval with a Rear-Admiral or a Major-General in the Army should disease as of the modern form. Dr. HAMER in his interesting act as adviser to a Commander in the Navy who ranks with lectures discusses the various sweating sicknesses which have a Lieutenant-Colonel. We are of opinion that a board of occurred in this country and surmises that the English medical officers could do all that is necessary in the matter sweating sickness came originally from the Baltic. He of medical service and the presence of an executive officer is shows that RICHMOND’S mercenaries were probably not the not only quite unnecessary but may lead to a great waste of As a matter of fact, we have never heard of any source of the disease, since there is no record of their time. suffering from any illness when they arrived, and there is executive officer attempting to overrule the decisions of his medical colleagues on a medical question and the force of Sir some ground for believing that the disease started before they came. Again, in the epidemic of 1528, when France LAMBERT ORMSBY’S complaint rather depends on how often is said to have escaped the English disease, an epidemic of a case may occur in practice. Again, in the matter of "trousse galant carried off a fourth part of the population the control of the sick berth staff (paragraph 4) we are in that and the following years. The origin of the disease in agreement with much of what Sir LAMBERT ORMSBY is therefore still a matter of conjecture and its relation to sajs. We are all aware of differences of opinion among the present disease remains difficult to determine, the more naval medical officers of experience on this matter, but in so because of the long interval between 1551 and the first our view the principal medical officer of a naval hosof the outbreaks in Germany and France. pital should be empowered to award minor punishments for breaches of discipline on the part of the sick berth staff. The existing system whereby an Inspector-General of The Position of the Royal Navy Hospitals, befcre he can award a well-earned punishment, of 1528 which
in his next
Instructions.
"
Medical Service. SIR LAMBERT
Meath
ORMSBY,
who is senior surgeon to the
has to
report
the offender to
an
executive officer at
a
local
depot is attended with vast unnecessary friction and waste of time. We do not, however, think that naval medical
Hospital, Dublin, and a past president of the Hoyal College of Surgeons in Ireland, delivered recently a very officers, however high in the Service, would much relish the interesting introductory address at the opening of the winter increase of responsibility that would accrue to them if they session of that hospital. In the course of his address he had to award major punishments where imprisonment is of sketched the history the hospital and such of its recent necessary, but the matter is one upon which it is difficult for
1374
FEVER,
OR THE SWEATING SICKNESS
for the stone, to attend a woman in labour, or to command the Channel Fleet; the willingness arising from the fact that, not being a surgeon, an accoucheur, or of all a sailor, and equally ignorant of the business three, he was ignorant also of the dangers against which
closely similar malady, was known As far as England is con. as 11 trousse galant." of 1551 appears to be the last the cerned, epidemic This epidemic is of interest in the to have occurred. fact that the disease was described and recorded by Dr. were JOHANNES CAius in two papers-one in English, the other in those following any of the callings question expected to provide. Such is the type of scores of in Latin. A sweating disease of similar character was uneducated persons who would tranquilly instruct a observed in Germany in 1652, 1802, and 1864, while outphysician about an epidemic or correct an astronomer breaks with closely similar clinical features, though less A recent illustration of severe, have occurred in certain parts of Germany and about the heavenly bodies. this tone and mode of thought has been furnished France, being known as " la suette des Picards " or by press comments upon the composition of the Royal " the miliary sweat of Poitou." A severe epidemic man
France
it,
or
a
Vivisection and upon its decision to hear of this character occurred in the central provinces evidence in private ; comments in which it is declared of France in 1887 and was carefully studied by M. that the "public"are "the only possible judges of BROUARDEL. In an annotation in THE LANCET of the issue at stake." The issue at stake is, we conceive, Oct. 1st, 1887, p. 671, a careful account of the clinical - simply that of the conditions in which experiments upon features of the disease will be found. In the district living animals are for the future to be conducted (the pro- of Montmorellon, out of a population of 13,000 there were hibition of them in a civilised country being unthinkable) ; 1700 attacked, with an average mortality of 12 per cent., and the only persons capable of "judging"upon such an though in some villages it reached as much as 33 per issue are those who possess, or are capable of acquiring, cent. of the persons attacked, while convalescence some knowledge concerning the present state of physio. in most cases was liable to be slow. M. BROUARDEL logical inquiry in relation to the prevention and the treatment organised a special medical service to disinfect the of disease and to the problems which are still pressing for cottages and the clothes in infected areas. An outbreak - solution. Persons ignorant on these points, assuming that of this disease has occurred in May and June of they were empowered " to decide," would still be absolutely this year in the districts of Les Charentes and we unable "to judge." If it be immoral, as some will publish in our Paris letter an abstract of a report on have it, to occasion suffering to the lower animals, the subject presented to the Académie de Medecine by M. it is at least equally immoral to leave human suffer- CHANTEMESSE, working in conjunction with M. MARCHOUX ing unrelieved ; and the balance of judgment must and M. HAVRY. During the space of six weeks 6000 necessarily incline towards the mitigation of that which is persons were attacked, exclusively in the villages, the towns shown, by complete inquiry, to be the greater and more escaping. Bacteriological investigations failed to reveal. widely extended evil of the two. In the meanwhile we may the existence of any organism that could be inoculated or mention that Mr. STEPHEN PAGET has just published a new cultivated. It was found that the epidemic was limited edition of his useful book about "Experiments on Animals,,. and did not spread across the Charente except in the and that it contains, among much else that is worth reading, neighbourhood of the bridges. The study of the incidence an interesting account of the " press methods " of the several of the disease showed that women were more frequently antivivisection societies whose common character is to seek attacked than men and that the houses at the periphery money from the public for their maintenance. of the villages were first invaded, especially the residents Commission
on
ground level of houses without wooden floors. CHANTEMESSE makes the suggestion that the field M. mice, or rather the fleas infesting them, may be the agents carrying the infection, since the districts con. cerned have been overrun for the past two years by field mice, while in many of the patients suffering from the disease he observed flea-bites. The suggestion is a purely on
the Sickness.
Miliary Fever, RECENT events
or
Sweating
are making miliary fever Among the plagues of the
a
subject
of
Middle Ages few are more remarkable than that of the sweating sickness, or as it was at one time generally named sudor Anglicus, the English sweat. The earliest recorded outbreak occurred in August of the year 1485, in the districts occupied by the mercenary troops employed by HENRY OF RICHMOND at the battle of Bosworth Field. The disease reached Oxford at the end of the month and London on Sept. 21st. Other epidemics occurred and Outbreaks also occurred 1551. in 1506, 1517, 1528, in Calais, chiefly limited to the English inhabitants. The
topical interest.
the
theoretical one but deserves careful examination, although in the absence of any knowledge of the infective agent it must be difficult to substantiate. A question of interest in regard to the history and origin of contagious and infectious diseases is the relation of the modern miliary fever to the mediasval sweating sickness. This aspect of the disease has been carefully and critically studied by Dr. J. F. PAYNEand recently by Dr. W. H. HAMER2 in his Milroy lectures, It is of interest in this connexion to compare the clinical characters of the two diseases. Among the most careful accounts of the sweat of Picardy are those given by M. EMILE PARMENTIER3 and by
character of the disease, its sudden onset, and frequent fatal issue earned for it a variety of names ; for example, in the parish register of Loughborough it is 1 St. Thomas’s Hospital Reports for 1887. Article "Sweating Sickreferred to as " the swet called new acquaintance, ness," Encyclopæedia Britannica. 2 THE LANCET, March 3rd, 1906, p. 572. alias stoupe knave and know thy master," while in 3 Revue de Médecine, September, 1887, p. 725. severe
THE POSITION OF THE ROYAL NAVY
MEDICAL
SERVICE.
1375
M. BROUARDEL. The disease appears to be sudden in its developments as had occurred contemporaneously with the onset with some ill-defined forerunners, such as fever, developments of antiseptic surgery and modern operative malaise, and weakness. On the second day profuse sweating procedure, but appended to a speech which in other ways conformed to the established model of inaugural eloquence occurs and is associated with the appearance of the rash’ be to The was a forcible indictment of the present conditions in the the fourth may postponed tongue day. though-this is furred and there is usually constipation, cough rapidly medical service of the Royal Navy. Sir LAMBERT ORMSBY’s develops, and epistaxis is frequent. Some nervous sym. strictures, which we publish this week in our Service ptoms are also the rule, such as restlessness, delirium, and columns, have been passed at a time when the medical proparoxysmal dyspnoea. The eruption presents two chief fession as a whole is encouraged to believe that the Royal features-viz., an outbreak of miliary papules subsequently Navy Medical Service is in a good and improving condition, becoming vesicular, and a polymorphous erythema which and as that is the view which, with certain reserva. may become purpuric. The erythema is sometimes sugges- tions, we have taken in our columns we consider that tive of measles, the more so that it first appears on the face. we owe it to our readers to deal categorically with Sir The sweat is in some cases feetid, but this is stated by M. LAMBERT ORMSBY’S complaints and in so doing we PARMENTIER to be due to lack of cleanliness. Desquamation may say at once that, while allowing the considerable occurs from about the tenth to the twelfth day or sometimes cogency and truth of much of what the distinguished earlier; on the second day of desquamation a critical polyuria surgeon has said, we hope to remove the sweepingly bad is observed. Convalescence is slow, while anemia and some impression which he has conveyed. Things are neither so tremors of the face and tongue are not uncommon during this bad as he would have us believe nor really in other than a period. The medieval sweating sickness was characterised, healthy and improving state. There are grievances some of I which could be removed with ease and some with as described by Dr. CAIUS, by the extreme suddenness of its difficulty, onset and the rapidity of its course which was sometimes while some perhaps will have to be endured ; but the only a few hours. It was also very fatal. Dr. PAYNE points medical officer in the navy is not the bitter victim of a black out also that in the accounts extant of that disease there is fate whose picture is now presented to us. In our comments, no mention of the miliary eruption, but he is of opinion that as a matter of convenience, we have adopted the numbering the two diseases are similar if not identical. He offers the of the paragraphs employed by Sir LAMBERT ORMSBY, so ingenious suggestion that supposing the disease to have that the reader may find it necessary to consult the report of been brought to England by the French mercenaries of his speech upon p. 1396 of this issue. RICHMOND’S army as was generally believed, the reason of We must all agree that there are defects in the Royal its severity was the previous freedom of the English from Navy Medical Service. The rules as to medical guard to the disease, on the analogy of the severity of the outbreak which Sir LAMBERT ORMSBY refers in his fifth paragraph of measles in the Fame Islands.
He also refers to the over the greater part of
should be
distinctly laid down in the
EixG’s
Regulations and great epidemic spread Admiralty Again, paragraph he Europe north of the Alps, and states that France escpaed. points out how wrong it is that an Inspector-General ranking He therefore regards France as the home of the mediaeval with a Rear-Admiral or a Major-General in the Army should disease as of the modern form. Dr. HAMER in his interesting act as adviser to a Commander in the Navy who ranks with lectures discusses the various sweating sicknesses which have a Lieutenant-Colonel. We are of opinion that a board of occurred in this country and surmises that the English medical officers could do all that is necessary in the matter sweating sickness came originally from the Baltic. He of medical service and the presence of an executive officer is shows that RICHMOND’S mercenaries were probably not the not only quite unnecessary but may lead to a great waste of As a matter of fact, we have never heard of any source of the disease, since there is no record of their time. suffering from any illness when they arrived, and there is executive officer attempting to overrule the decisions of his medical colleagues on a medical question and the force of Sir some ground for believing that the disease started before they came. Again, in the epidemic of 1528, when France LAMBERT ORMSBY’S complaint rather depends on how often is said to have escaped the English disease, an epidemic of a case may occur in practice. Again, in the matter of "trousse galant carried off a fourth part of the population the control of the sick berth staff (paragraph 4) we are in that and the following years. The origin of the disease in agreement with much of what Sir LAMBERT ORMSBY is therefore still a matter of conjecture and its relation to sajs. We are all aware of differences of opinion among the present disease remains difficult to determine, the more naval medical officers of experience on this matter, but in so because of the long interval between 1551 and the first our view the principal medical officer of a naval hosof the outbreaks in Germany and France. pital should be empowered to award minor punishments for breaches of discipline on the part of the sick berth staff. The existing system whereby an Inspector-General of The Position of the Royal Navy Hospitals, befcre he can award a well-earned punishment, of 1528 which
in his next
Instructions.
"
Medical Service. SIR LAMBERT
Meath
ORMSBY,
who is senior surgeon to the
has to
report
the offender to
an
executive officer at
a
local
depot is attended with vast unnecessary friction and waste of time. We do not, however, think that naval medical
Hospital, Dublin, and a past president of the Hoyal College of Surgeons in Ireland, delivered recently a very officers, however high in the Service, would much relish the interesting introductory address at the opening of the winter increase of responsibility that would accrue to them if they session of that hospital. In the course of his address he had to award major punishments where imprisonment is of sketched the history the hospital and such of its recent necessary, but the matter is one upon which it is difficult for