A Reversal of Seasons

Mortality rates by month in Chicago in the 1870s and 1922. Isaac Rawlings et al, The Rise and Fall of Disease in Illinois, State Department of Health, 1927.

In the last post I mentioned that the federal mortality census can inform us of the seasonality of disease in the mid-nineteenth century. This chart illustrates the seasonality of death in Chicago during the 1870s and in 1922. The solid line represents the average deaths per month during the 1870s, while the lower dotted line represents deaths in 1922.  As you can see, Chicago experienced a nearly complete reversal of seasonal mortality. In the 1870s, deaths peaked in July and slowly declined through the autumn. By 1922 the summer months are the safest months of the year with the lowest death rates. Seasonality largely exists because the primary cause of death in the 19th century was infectious disease, and the major diseases displayed a marked seasonality. So malaria and gastrointestinal diseases like typhoid fever are more common in the summer and autumn, while all  infectious respiratory diseases are more common in the winter.

From what we know of common nineteenth century diseases summer had almost certainly been the deadliest season for most if not all of the nineteenth century. Statewide, the 1870 Illinois federal mortality census records cholera infantum, pneumonia, scarlet fever, typhoid, meningitis, dysentery and diarrhea as the most common causes of death (p. 98).   Yet these causes of death amount to only one third of all deaths. In the same year, children under 5 years were 50.3% of all deaths with children under age 1 accounting for 27.3% of the 33,672 deaths reported that year. Looking at Chicago alone, children under age 5 accounted for 62.8% of all deaths in 1870, but it dropped to 17.8% in 1925.

Consumption  or tuberculosis is a dark horse lurking in data. Deaths by consumption are not listed in the summary of the 1870 federal mortality census, but somehow they came up a death rate of 145.6 per 100,000 people in 1870. In 1922, they record 5,620 deaths or 83.3 deaths per 100,000 people (p. 364). For the topic at hand though, data for tuberculosis cases and deaths shows no seasonality to either.

The state health department credited the reversal of seasons to “the disappearance of malaria, the near disappearance of typhoid and the great decrease in diarrhoeal diseases and other causes more or less related to the work of the health departments” (Rawlings et al, p. 90).  The winter peak began to appear in the 1870s and continued to grow until the 1920s. The state department credited this rise almost entirely to pneumonia and influenza (Rawlings et al, 1927). We have to remember that there were major pandemics of influenza in 1892 and 1918. In the final chapter of The Rise and Fall of Disease in Illinois the health department summarizes their success against all the major diseases. For influenza they list just one line: “There has been no success in combating influenza.” (p. 404)

Source:  Isaac Rawlings et al, The Rise and Fall of Disease in Illinois. The Health Department, 1927.

Federal Mortality Census, 1850-1880

Sometime in the next few weeks we will all fill out our federal census forms (skimpy as they are this year). The United States has the longest tradition of government censuses, made necessary by our method of determining representation in the House of Representatives. While we have had a federal census since 1790, they have changed greatly over the years. Until the mid-20th century a census taker with a big spread sheet showed up at your door to record all inhabitants at the residence. From 1850 to 1880, the census taker asked if anyone died at the residence in the last year and recorded any on a second spreadsheet called the Federal Mortality Census. You think they asked a lot if questions about the living, less than about the dead.

In theory it should be a snapshot of mortality in every county of the United States for the previous year. Keep in mind that the United States was a growing nation in the 19th century, so not all modern states are represented in the mortality censuses and county boundaries have changed in many states. They asked interesting data. The mortality census covers name, age, color (white, black, mulatto), marital status, state of birth, month of death, occupation, cause of death and length of illness. These schedules are the forerunners of death certificates. The Federal Mortality Schedules can be searched here and local mortality schedules may be available at local libraries. If your local library does not have them, then look for the library that hosts the county genealogical society. Better genealogy society libraries will have the data for most or all of the state.

For epidemiological purposes these schedules have limited usefulness because of under-reporting and misdiagnosis. Cause of death is usually reported by the family, though doctors in the earlier years often didn’t do much better. Many early doctors in the first half of the 19th century had little or no official medical training and/or used a limited set of diagnoses. Nineteenth century medicine had a series of, well, just plain odd thoughts. One of my personal favorites was the notion that children could not contract malaria! Not only can they contract malaria, but they have a higher mortality rate than adults. They also listed causes of death like “teething” in children. Some diagnoses like cholera morbus no longer exist. Cholera morbus was a collection of gastrointestinal diseases that caused diarrhea. Most cases of cholera morbus were probably related to food contamination (food poisoning).

Under-reporting is apparent if you just look at the schedules. I looked at the Illinois schedules and it is obvious that not all census takers were equally vigorous in collecting mortality data. Even in areas where the census taker asked, he was reliant upon surviving family members or boarding house keepers for data. Single people could easily be missed because there was no one left to report. The same could be said for travelers who died in a district (and in some trading or market areas there were a lot transients). When one or both parents died, families were often broken up and scattered. This could lead to some deaths being overlooked. During the worst epidemics, sometimes entire families died. With no one left to report on them, they were overlooked. In 1850 Illinois census takers complain that they know they are missing many of the dead from the cholera epidemic that year because entire families have died with no one left to report. Even where there are people left to report, it seems likely there is still under-reporting. The number of children reported does not match physician’s estimates of childhood mortality. There are very few infants reported when we know that without premature infant care, C-sections, or antibiotics, infant mortality must have been relatively high.

So with all these problems, is there anything that can be taken from the federal mortality census? Yes, there is within reason. It is naturally useful to genealogists interested in particular family histories. With the life expectancies of the 19th century and incomplete recording, it is not uncommon for people to be listed on only one census, dead or alive. They are also of some use for the study of public health. The federal mortality censuses can show seasonality and a rough estimate of mortality. Trends can be observed and epidemics identified. Diagnoses can tell us a lot about paradigms of 19th century disease and life-stage.

Lincoln’s Illness at Gettysburg

Abraham Lincoln, photo taken by Alexander Gardner on 8 November 1863,  11 days before the Gettysburg Address.

The Gettysburg address is one of the best known speeches ever delivered by an American president. Few Americans know how close Lincoln came to not delivering it, or that its brevity may owe something to how poorly Lincoln was feeling as he wrote and delivered the address.

The battle of Gettysburg was fought in July of 1863 but the cemetery wasn’t dedicated until November. Lincoln was a late addition to the program, asked only 17 days before the event. In the days between agreeing to give the address and leaving for Gettysburg, Lincoln’s young son Tad lay ill with a high fever and rash. Details of Tad’s illness are vague and are really based on his father’s diagnosis. Lincoln was understandably distracted, two of  sons had previously died from what is believed to have been typhoid fever. When the president left for Gettysburg, Mary Todd Lincoln stayed behind with Tad. The president took his valet William H Johnson, a free black man who came to Washington from Illinois with the Lincoln family, with him to Gettysburg. What follows is based on a case study compiled by Goldman and Schmalsteig (2007).

On the train to Gettysburg Lincoln began to tell his staff that he was feeling weak, but he finished editing his address and continued on to Gettysburg. When the arrived Lincoln rode to the cemetery on horseback and viewed the area and plans. When the program began Lincoln sat on the platform for over two hours while classical scholar Edward Everett spoke and during a short musical piece. Lincoln was feeling weaker all the while and observers called his color ‘ghastly’. When the President finally got up, he stunned the crowd with his short address; most were caught so unawares that they missed it. Lincoln judged the crowds silence as disappointment and left Gettysburg himself disappointed. On the train back to Washington Lincoln grew feverish and weaker still. His valet William Johnson sat up with the President wiping his face with a wet cloth to cool him.

By the time Lincoln returned to Washington, his weakness had progressed and he had become feverish with severe headaches and back pain. By the fourth day of symptoms, a red rash appeared that developed into scattered blisters by the next day. A good description of the rash and its development are lacking.  The president’s personal physician Dr Robert King Stone first diagnosed him with a cold, then ‘bilious fever’ (an early name for malaria), and then scarletina (scarlet fever). Both scarlet fever and malaria were common in early 19th century America including in Lincoln’s home state of Illinois.  Goldman and Schmalsteig reviewed Dr Stone’s records; oddly, he apparently never mentions this illness though he attended the president through the entire period. As the rash progressed, Dr Washington Chew Van Bibber was called in for a consultation. After examining the President, he diagnosed a mild case of smallpox (varioloid). Much later Dr Van Bibber’s version of a conversation with the President was recorded in the autobiography of another surgeon:

‘Mr President, if I were to give a name to your malady, I should say that you have a touch of varioloid.’ [the old fashioned name for smallpox]. ‘Then am I to understand that I have the smallpox?’ Lincoln asked, to which the doctor assented. ‘How interesting’, said Mr Lincoln. ‘I find that every now and then unpleasant situations in life may have certain compensation. As you came in just now, did you pass through the waiting room?’ He replied, ‘I passed through a room full of people’. ‘Yes, that’s the waiting room, and its always full of people. Do you have any idea what they are there for?’ ‘Well’, said the Doctor, ‘perhaps I could guess.’ ‘Yes,’ said Mr Lincoln, ‘they are there, every mother’s son of them, for one purpose only; namely to, to get something from me. For once in my life as President, I find myself in a position to give everybody something!’ (Goldman & Schmalsteig, 2007, p. 106).

By day 10 of symptoms, the fever was decreasing and the rash was beginning to itch and peel. The weakness persists the longest, preventing him from returning to work for official business for 25 days. Visitors report that he was beginning to walk briefly by December 7 (day 19 of symptoms) and that marks of the rash were visible but few if any remained as facial scars. On Dec 15 he was able to work for a few hours and went to a play at Ford’s theater. A month later on January 12 he was reported as having regained most of his old vigor, though still underweight.

The diagnosis is primarily based on three factors: the appearance of a rash, a three week illness, and contemporary physicians diagnosis of smallpox. In Goldman and Schmalsteig’s analysis, the diagnosis appears correct from the available information and they note that a three week illness is too long for most other possibilities. Additionally, we know that his son Tad had been ill with a fever for two weeks before Gettysburg, though his disease less well recorded than his fathers and no photos of father or son ever showed visible pox scars. Given that two of Lincoln’s sons had previously died of what is believed to have been typhoid fever it must be considered. However, as his physicians never diagnosed him with typhoid and they should have been very familiar with that disease, so we can rule it out. Typhoid can produce a rash but not blisters.

The last clue comes from Lincoln’s valet William H Johnson, who did develop smallpox and died of it before January 12. In an interview with the Chicago Tribune on that day, Lincoln told the reporter than he didn’t believe that he gave smallpox to Johnson. Goldman and Schmalsteig believe that a mid-January death for the valet Johnson is the right timing for a disease contracted while caring for Lincoln in late November given the incubation period of about two weeks and then Johnson’s own illness to run its  fatal course. Further, when Johnson died Lincoln secured a place for him in Arlington National Cemetery under a grave stone marked “citizen”, all paid for by President Lincoln.  However, from 1863 there was also a Freedman’s Village where  former slaves lived on the Arlington estate and many were buried there.  Lincoln’s choice of the Arlington cemetery may not have been unusual for the times and need not imply that the President felt any guilt over Johnson’s smallpox. Although they imply that Lincoln’s actions suggest he contracted it from the President, Goldman and Schmalsteig point out themselves, that we don’t know how much smallpox was circulating in Washington at the time. If it was circulating around residents and staff at the White House, it is possible that Johnson contracted it from someone else.

Goldman and Schmalsteig’s recent analysis was not only to determine if Lincoln really had smallpox, but also to determine whether he had a full blown case or  a mild case due to previous vaccination (or variolization). Modern vaccinations following Jenner’s original protocol use the related vaccinia virus (cowpox) to illicit immunity that will protect against smallpox. Variolization takes material from an active smallpox lesion and inoculates a healthy person through a cut in the skin. Variolization is riskier than vaccination because it can produce a full blown case of smallpox. Yet, smallpox was so devestating, with such a high mortality rate (about 30%), that people were willing to undergo variolization and the mild case of smallpox it usually created, to increase their chances of surviving smallpox. Jenner’s method grew in popularity after its introduction because it was so much safer but its unclear how completely Jenner’s process was accepted during Lincoln’s youth. Regardless, Goldman and Schmalsteig could not find any evidence that Lincoln had been immunized against smallpox by either method.

Abraham Lincoln taken January 8, 1864. (Library of Congress), click to enlarge

There was great concern among the public over the President’s illness. At one point rumors circulated around Washington that the President was dying (Goldman and Schmalsteig, 2007). Despite his contagious condition causal references from his visitors seem to suggest that the President had frequent visitors during his illness including an old ally Rep. Owen Lovejoy of Illinois. He went to the Ford theater on December 15, perhaps to show himself to the public. We can only imagine the effect that these rumors could have had on the war effort in the winter of 1863-4 if they had spread widely. Two photos on were taken one and two months after his recovery respectively (shown here). We have several photographic portraits of Lincoln but for two of them to have come so closely after his illness is remarkable. It has often been said that the weight of the Presidency aged Lincoln, and no doubt it did, as it does every President, but smallpox may have taken its toll too.

Abraham Lincoln, taken February 1864 (Wikipedia Commons)

Goldman and Schmalsteig assert that Lincoln’s physicians tried to pass off his disease as the mild (immune-modified) form of smallpox but they really don’t outline any evidence of anything more than respecting the President’s privacy. They seem to be placing a lot of emphasis on the physicians use of the term varioloid, that in the 20th century meant a mild case in a vaccinated person, but as they admit was a common term for all smallpox in the 19th century. They conclude that the President did have a full immune-unmodified case of smallpox based on the length of his illness. With a 30% fatality rate, the public had a right to be concerned over the President’s health.  Approximately 1 out of 3 cases didn’t make it: the President and Tad survived, his valet William Johnson didn’t. We can only imagine the effect of the President’s death in December 1863 could have had on the war.

References:

Goldman AS, & Schmalstieg FC Jr (2007). Abraham Lincoln’s Gettysburg illness. Journal of medical biography, 15 (2), 104-10 PMID: 17551612

Arlington National Cemetery: Historical Information

William H Johnson, Find a Grave

William H. Johnson, Wikipedia.