by Mark Honigsbaum
In June, 1895, The Strand Magazine, a periodical best known for its stories about a certain pipe-smoking Baker Street detective, published a tale about a London physician, Clifford Halifax, and his encounter with a promising young medical colleague named Arthur Feveral. The story opens in the winter of 1893 with Halifax returning home to find Feveral waiting in his hallway. His practice is in the grip of an influenza epidemic and Feveral appears to have suffered “some sort of collapse”. It soon emerges that his baby daughter has died of influenza and that he has also suffered an attack of the “awful plague”. But it is not this that has brought him to Halifax’s door. “The influenza has left an extraordinary sequel behind”, he explains. “I have an inexpressible dread over me. By no means in my power can I drive it away.”
Feveral’s dread is linked to his fear that he may have suffered a memory lapse and administered a fatal poison to a patient, thereby failing in his professional duty, and is now being pursued by the police. Rather than dismissing Feveral as a madman, Halifax tells him his symptoms are perfectly normal—the result of what Halifax calls a “double shock” to his nervous system caused by the death of his child followed by influenza. Although the story is fictional, The Strand claimed that, like other tales that appeared in its “Storiesfrom the Diary of a Doctor” series, it was “founded on fact”and had been written “in collaboration with a medical manof large experience”. In fact, Halifax was the pseudonym of Dr Edgar Beaumont, a physician who practised in London’sHarley Street, and although to modern ears Feveral’s tale isoutlandish, in the mid-1890s British medical journals werefull of tales of Victorian professionals driven to the brink ofmadness and beyond by the nervous sequelae of influenza.
As with Feveral, these patients were often male and had previously been in robust physical and mental condition. However, after successive waves of the so-called Russian influenza—the epidemic first broke out in St Petersburg in 1889—this had changed and there were reports of patients with influenza succumbing to nervous disturbances, which ranged from neuralgia to neurasthenia, insomnia ,and depression. In the most extreme cases of all, Russian influenza was thought to trigger peculiar psychoses attended by suicidal thoughts and homicidal urges. In such cases, wrote Julius Althaus, a Harley Street neurologist and frequent correspondent to The Lancet, it was not uncommon for patients to experience “dark forebodings of impending disaster” or to become convinced they had committed a “fearful crime” for which they were about to be punished. Indeed, so marked were these psychoses that one correspondent to The Lancet thought the Russian influenza ought to be renamed “influenza nervosa”.
From a present-day perspective this characterization looks decidedly odd. Today, influenza is regarded primarily as a respiratory disease. Although it is known that A strains of the virus can trigger CNS complications, the pathogenic mechanisms behind such complications are poorly understood. Moreover, few modern psychiatrists regard influenza as a trigger for psychosis. Yet for some 30 years, from the first epidemics of Russian influenza in the 1890s through to the “Spanish” influenza of 1918–19, the “psychoses of influenza” were a widely recognised psychiatric phenomenon. Unfortunately, unlike the H1N1 “Spanish” influenza, the genes of which have now been retrieved from archival autopsy specimens and sequenced in the laboratory, viral material from the Russian epidemic was not preserved, meaning that the precise genetic identity of the virus and its effects on the nervous system may never be known. Nevertheless, contemporary accounts left by Victorian nerve doctors provide a rich store of clinical information.
Re-reading these accounts, one is reminded that in the 1890s the nosological identity of influenza was far from fixed. Instead, the disease was regarded as a protean somatopsychic infection that, in the words of the Victorian throat specialist Sir Morell Mackenzie, had a propensity to “run up and down the nervous keyboard stirring up disorder and pain in different parts of the body with what almost seems malicious caprice”. In particular, doctors noted how patients with influenza frequently presented with very similar symptoms to neurasthenics: namely, anxiety accompanied by insomnia, fatigue, and depression. No doubt this reflected the fact that many of the clients of Harley Street practices were middle-class professionals—the very same group that George Miller Beard had identified as being prone to neurasthenia because of their stressful urban lifestyles.
Whatever was the case, it was not long before Victorian nerve specialists were on the lookout for influenza convalescents to swell their practices and enhance their reputations. One of these was Thomas Stretch Dowse, a consulting physician to the Hospital for Epilepsy and Paralysis in Regent’s Park who practised in Welbeck Street. In his popular book, On Brain and Nerve Exhaustion (Neurasthenia) and on the Nervous Sequelae of Influenza, which went into four editions, Dowse argued that, like neurasthenia, influenza was an “exhaustion” disease with a “wizard-like” effect on the nervous system. “Patients tells us that they cannot sleep, that they become depressed and despondent, that they are rarely free from pain, and that they fail in energy, and that they get done up in a manner quite unaccountable”, he wrote. In particular, Dowse speculated that the marked “emotional depression” that followed attacks of influenza arose from the depletion of nervous force cause by an “overstrained brain”.
By contrast, Althaus was rather more sceptical of the parallels with neurasthenia. Instead, he regarded influenza as a focal infection and speculated that the nervous sequelae were the result of the “grippal toxine” combining with other diseases, such as syphilis, that may have been dormant in the nervous system for years. This made sense given the association between syphilis and “general paralysis of the insane”, a common cause of admission to Victorian asylums at the time. However, as Althaus observed, and as asylum attendants like T. S. Clouston, the editor of the Journal of Mental Science, had also noted, the nervous sequelae that followed the Russian influenza were far in excess of those seen during previous influenza epidemics or after outbreaks of such infectious diseases as diphtheria, typhoid, and measles.
How did these psychoses manifest themselves and how accurate was the portrayal of Feveral’s symptoms? Judging by Althaus’s case notes, the answer is very accurate indeed. A good example came in May, 1891, when a 26-year-old clerk presented at Althaus’s surgery suffering from “delirium of inanition”. Like Feveral, the clerk had recently suffered a bout of influenza but had ignored his doctor’s advice to convalesce. Back at work, his colleagues noted, he had “dawdled over his work [and] did not seem to know what he was about”. Next, he accused his colleagues of theft and, like Feveral, became convinced he had committed a crime and was about to be charged with perjury. He also had great difficulty sleeping. Indeed, the night before arriving at Althaus’s surgery the clerk had risen from his bed at 2am and had run to his office where he created a “great disturbance”. Although this behavior made him a candidate for the asylum, Althaus was careful to avoid stigmatising his patients. Ascribing their behaviour to a nervous “idiosyncrasy”, he recommended strong morphine-based sedatives, coupled with nourishing food and rest.
Althaus was not the only physician eager to sidestep the issue of patients’ deeper psychological pathologies. In the winter of 1895, for instance, the Prime Minister Lord Rosebery suffered a debilitating attack of insomnia after a brief bout of influenza. The attack, which came at a difficult time for his government and coincided with dissensions within his Cabinet, saw Rosebery confined to his country house at Epsom for 6 weeks, during which time his friends became convinced he was suffering a nervous breakdown. But while Rosebery’s insomnia provided rich fodder for satirists in the comic weeklies (figure), his physician Sir William Broadbent blamed his condition on a “stomachic derangement” caused by his habit of reading while eating meals alone, “with the result that the nervous power had gone from the stomach to the brain”. It was only years later that Rosebery acknowledged how profoundly ill he had been, writing that his insomnia was “an experience which no sane man with a conscience would repeat” and that influenza had left him feeling like a “disembodied spirit”. Similar symptoms of insomnia accompanied by “troublesome dreams” were also experienced by Dowse’s patients. Indeed, reading these case histories today one cannot help but be struck by how, as in The Strand story, Russian influenza provoked profound feelings of doom and “dread”. “I have seen men, within twenty-four hours of taking the influenza, sob like children for hours together as though their hearts would break”, he wrote, adding that “the sacredness of life is seen only through a flimsy veil of conflicting emotions of doubt, of dread, and of determination to burst these bonds by one fell swoop of severance from the mortal to immortality.”
Today the “psychoses of influenza”, like neurasthenia, no longer warrant an entry in manuals of psychiatric medicine, having long ago being subsumed into the mood and personality disorders. The result is that few psychiatrists pay attention any longer to mental disturbances associated with influenza and fewer still take the trouble to record patients’ phenomenological experiences of the disease. That is a pity, for as The Strand story illustrates—and as Althaus and Dowse’s books underline—such narrative accounts are a valuable resource for medical historians, ones that both enrich our understanding of influenza and serve to remind us of the contingency of current psychiatric constructions.
(Mark Honigsbaum wrote this from Institute and Museum of Medical History, University of Zurich, in Perspectives, Lancet Vol. 381 March 23, 2013)