the vast majority of cases were treated at their own homes, and, being of slighter character, presumably recovered: and even these 4 cases do not appear altogether free from ambiguity. One of them was in a women formerly of intemperate habits, and attacked first with vomiting and jaundice before the bronchitis; another was a girl who had previously suffered from cough and debility; and in both these cases there was no post-mortem examination. In the other 2 cases there was a heart-disease. It follows, therefore, that, although the actual mortality of pure influenza cannot be laid down, according to Dr. Peacock's experience, it must have been very small; and it is very important to remember, for reasons to which we shall presently allude, that the previous health of the subjects bore a close relation to the mortality. So that, in judging of the severity of an epidemic by the number of deaths among a given population, two distinct elements enter into the calculation, viz. the actual power of the morbific cause, and the previous condition of health of those on whom it acted.

The treatment of the capillary bronchitis attending influenza is most judiciously given by Dr. Peacock. In accordance with general experience, he found bloodletting of little use, except in the early stage; it increased prostration, without benefiting in any commensurate degree the pulmonary disease. Leeches were sometimes useful, and counter-irritation of various kinds. At the commencement of the attack an antimonial emetic was generally given, and in some cases antimonials were persevered in, but Dr. Peacock thinks with less success than in common sthenic pneumonia. In other instances, mercury, to gentle salivation with opium was given. In a later stage, anodynes, antispasmodic, and diffusible stimuli were necessary. Dr. Peacock points out the importance of early treatment; although the disease, depending upon a specific poison, necessarily runs a course, yet this may be much mitigated by appropriate measures; if, however, the disease proceed to copious effusion into the smaller bronchial tubes, it is obviously in a state very unfavourable for treatment. During convalescence, in addition to general tonic measures, the sulphate of zinc was found to be very servicable when the expectoration was thin and spumous; and, on the other hand, when it was very viscid, glairy, or "vitreous," alkalies, combined with expectorants and anodynes, were useful.

In the pneumonic complication, which, as already said, was very amenable to treatment, antimonials were of greater use; depletion was used in only one case, mercury, in two, and some form of counter-irritation in all. In the other chest affections, pleurisy, or old or recent heart disease, the treatment was of the usual kind.

We must now pass on to the chapter on the "abdominal complications" of influenza. We confess we were curious to know what Dr. Peacock had to say upon this point. We were aware that in many epidemics, in 1676, 1729, 1732, 1737, 1761-2, and others, and even in 1803, 1833, 1837, the occurrence of bilious purging, vomiting, and evident derangement of the digestive organs, had been more or less carefully noted. In the earlier epidemics the bilious diarrhoea is usually described as coming on towards the termination of the complaint, on the fourth, fifth, or sixth day, and it is often regarded in the light of a critical discharge, like the profuse prespirations which have been in many epidemics such marked accompa

niments of the later stage of the disease. Even in the epidemic of 1817, we had ourselves occasionally noticed a manifest implication of the liver and the digestive mucous membrane; and it did not seem improbable to suppose that these phenomena, secondary and consecutive in all cases to the primary impression of the poison on the laryngo-pulmonary mucous membrane, might yet occasionally acquire an unusual development and importance. We considered indeed these phenomena, as well as those of the skin and kidneys, to be of great interest, as testifying to the general action of the cause, whose elective choice of locality, so to speak, was nevertheless on that particular mucous membrane, whose deranged actions constitute the pathognomonic symptoms of the disease. We had never ourselves worked out the exact relation of bilious diarrhoea, or vomiting, to the primary symptoms, nor were we aware that it had been done by others; we were therefore all the more anxious to know what an acute observer like Dr. Peacock had to say on this interesting point. But, after a careful consideration of this chapter, and of the light which is thrown on it by the general opinion of the writer as testified throughout the whole work, we are compelled reluctantly to differ altogether from Dr. Peacock, and to record our dissent from his opinions of the nature of the abdominal complications of influenza, and of the connexion between this affection and other epidemic diseases prevailing at the same time.

In order, however, to do full justice to Dr. Peacock, and to enunciate clearly the grounds on which we differ from him, we shall briefly state the point of view from which we are disposed to observe influenza and all affections of the same class, and then contrast with it the opinion of Dr. Peacock.

The first aim of the practical physician of the present day, is the discrimination and diagnosis of diseases. He does not, it is true, make the multiplicity of divisions and varieties which some of our old nosological writers delighted to enumerate, and under which the typical form of the disease was often buried and concealed; but he seeks to determine the essential and primitive elements of each disease, as the foundation of all treatment, of all enquiry into laws, and of all preventive measures. This is especially the case with diseases which originate from the introduction of foreign agents and forces into the system, from whatever sources they may be derived. Those diseases which severally spring from special and uninterchangeable poisons, are themselves equally distinct and uninterchangeable. They may intermix; they never pass into each other. No one ever saw smallpox deviate into measles, or scarlet fever into cholera. No one in the present day believes that our English typhus can become the bubo plague of the Levant, or the marsh fever of Batavia the typhoid fever of Paris. And, in respect to the continued fevers of this country, and of northern Europe generally, the researches of the last twenty years seem gradually, but certainly, tending to the opinion, that, under the term "continued fever," several perfectly distinct diseases have been included. From the heterogeneous and contradictory accounts of the systematic writers of the last generation, it is clear that they had no idea of this separation. But already three, if not more, distinct forms of disease have been designated, which are distinguished by differences in course, differences in symptoms and treatment, and differences as to the influences exerted upon them by locality and general or special atmospheric conditions. It

is certainly not yet absolutely proved, that there is a continued fever with a special eruption, with a certain duration, and with particular anatomical signs, derived from certain abdominal organs, and particularly from changes in the patches of Peyer; that there is another disease, with a totally distinct eruption, an entirely different course, and which never presents the same anatomical signs, but which still has been included in the term "continued fever;" that there is a third, characterised by a most remarkable feature, viz. a tendency to relapse on particular days, and unmarked by eruptions, or a course at all analogous to the two former affections; and yet, although not proved, there is the highest probability that these distinctions are real ones, and that, in another ten years, practitioners will look upon the way in which they have been confounded together with the surprise with which we remember the singular confusion, formerly prevalent in the minds of the most eminent physicians, as to the differences between measles and scarlatina. As another disease of this class, having laws of its own, a special mode of spread, pathognomonic symptoms, and a certain course, influenza is, by the supporters of this opinion, as much distinguished from typhoid, maculated typhus, or relapsing fever, as any of these are from each other, or all from smallpox. It may combine with them, modify their symptoms, alter their treatment, or increase their mortality; but it still preserves intact its own individuality. And this holds good, even if we adopt the opinion, that, the continued fevers of this country are but modifications of one stock.

The best way of describing Dr. Peacock's opinion will be to say, that, as far as continued fevers and influenza are concerned, it is exactly the reverse of the one above stated. He admits influenza into the class of fevers, and calls it "catarrhal fever ;" and this term is not used in the simple sense of the older writers, to distinguish influenza from common catarrh, but has a deeper meaning, and expreses a relation to the continued fevers. Dr. Peacock appears to consider, that all the forms of this class of fevers are the modifications which one great entity undergoes, from the influences to which it is subjected by the prevailing epidemic constitution He does not, certainly, in so many words, formally adopt this opinion, but he does vitally profess it, with more or less precision, in various parts of his work. This will more evidently appear when we have proceeded a little further with the analysis. At page 17, Dr. Peacock writes thus: "It is my intention to treat of the several varieties of the disease under the heads of

"Ist. Simple catarrhal fever.

"2d. Catarrhal fever with pulmonary complication.

"3d. Catarrhal fever with predominant disorder of the abdominal organs.

"Of these the first and second comprise those to which the term influenza is commonly applied. The third class I shall further subdivide into:-1st, Cases of simple enteric fever; 2d, Cases with bilious disorder, and characterised by a tendency to relapse, or assume a remittent form; and 3d, Gastro-enteritic and bilious fever, complicated with rheumatism."

In the chapter on abdominal complications, these views are worked out. We will quote the description of the more severe cases of the "catarrhal fever with gastro-enteric disease :"

"The cases usually commenced very gradually, so that it was difficult to as certain the precise period of invasion. The symptoms at first of a mild character,

after the disease had continued to advance for a week or ten days, began to assume a more threatening aspect; the pulse became feeble and quick, rising to 120, 130, or 140 in the minute; the tongue became dry, acquired a thick, brown coating, and was morbidly red at the tip and edges, and often chapped and painful. The teeth were covered with yellowish-brown sordes: the skin was hot, dry, and harsh, and continued free from moisture when its temperature had declined. From an early period there was much restlessness and inability to sleep, often combined with torpor, so that the patient was with difficulty aroused, and subsequently delirium made its appearance, generally of the low muttering form, but in several cases so active as to require restraint. With the progress of attack the usual comatose tendency appeared, and in one case death was preceded by convulsions. The abdomen was generally at first somewhat tympanitic, and afterwards became tense and tender to the touch, and frequently a gurgling sound and feeling of fluctuation were caused by pressure in the ilio-cæcal region. In the early stages, the bowels were not unfrequently confined, though usually more relaxed than in a state of health, and at a later period there were frequent liquid stools, with occasionally some blood in them. A slight jaundiced tinge was usually present. Some degree of pulmonary disorder, characterised by hurried respiration, cough, and the usual sign of febrile bronchitis, was also very generally observed. (pp. 56-60.)

The duration of this form, we are told in the next paragraph, may be estimated at from 20 to 25 or 30 days.

Now, we think all our readers will at once say, this is a good description of typhoid fever; but how comes it to be called influenza? It commences insidiously, it has a long course, it is attended with the abdominal and the pulmonary symptoms of typhoid fever; but wants altogether the signs of influenza.

On turning to the chapter on the mortality (p. 75), we find this view confirmed. There were five fatal cases of what Dr. Peacock terms "epidemic catarrhal fever with abdominal complication;" and yet, immediately after this, we read: "Of the five fatal cases, four were examples of continued fever with intestinal disease." (p. 75.) Of these, one was in a man who had been found lying ill in the streets, and was dying when admitted. The second case died on the twenty-sixth day of the disease; the third on the thirtieth; and the fourth on the twenty-seventh day of the disease. In all these cases, the usual post-mortem appearances of typhoid fever were found, viz. ulceration and sloughing, following deposit into the patches of Peyer and the solitary glands; but the account (pp. 76-7) is too long for us to extract. These were undoubtedly, then, cases of common typhoid fever; that is to say, of the disease so well described by Louis and Chomel. Nay, even Dr. Peacock recognises them as such; he is far too good an observer to confound them with the common form of influenza; only, in the spirit of his system, as they occurred during the prevalence of catarrhal fever, he considers them as allied to this disease. He seems to attach some importance to the fact, that "they had not the usual form of typhoid eruption;" and, indeed, only in one case any eruption at all.

In the following section, which is entitled "Catarrhal fever characterised by tendency to relapse," we find also known forms of disease described, which practitioners generally are not at all disposed to regard as influenza. There are several undoubted cases of the fever which, during the last five years, has attracted so much attention in Edinburgh and elsewhere, from its tendency to relapse between the eleventh and fourteenth day after seizure, and when convalescence had apparently set in. Cases apparently 7-IV.

9*

of more or less regular remittent fever are also described. Our space will not allow us to extract these sketches, but on reference to the book (pp. 61-2), it will be seen that Dr. Peacock has drawn them very accurately. In the third section, which is headed "Catarrhal fever, with affection of the gastro-enteric mucous membrane and liver, complicated with rheumatism," we have several distinct diseases brought together, which we are not certain that we can refer to any head, except that it does not appear to us that their connexion with influenza is clearly made out. Many of them (pp. 63-5) seem to have had an intermittent or remittent character, and to have been attended with severe rheumatic pains and profuse perspiration.

The way in which Dr. Peacock is disposed to blend all these febrile states, and to consider them but modifications of the same disease, is shown still more clearly by a general exposition of his views of fever and influenza, which occurs at page 104; here he distinctly refers to fever as a single affection, undergoing alteration in symptoms and post-mortem appearances from the influence of localities and seasons. He then says, "these views, if applicable to the more intense forms of febrile disease, no less apply to those of a slighter description," that is, we presume, to influenza.

Although in this passage Dr. Peacock seems to include all fevers in one general term, he has previously expressed an opinion somewhat at variance with this; thus, at page 9, he writes, in reference to the increase of typhus during the epidemic," the deaths registered as from typhus should not be relied on, as showing the prevalence of true typhus characterised by the roseolous eruption on the skin, but be viewed rather as cases of typhoid fever with intestinal and other complications, or as examples of the remittent form of fever."

Dr. Peacock advances as evidence of the correctness of his description of the abdominal complications, the two following statements: 1. That in his practice the cases merged one into the other. In reply to this, we can only say that although we should have expected that influenza might attack fever patients, yet Dr. Peacock has described the cases so well, that we have no difficulty in distinguishing them. 2. That the complications had certainly a near relation to the epidemic disease. Thus he writes:

"When therefore we consider the remarkable coincidence in the period of accession, general prevalence, and decline of the several forms of pulmonary, enteric, hepatic, and rheumatic affections; the very common occurrence of symptoms referable to the stomach, intestines, and liver, in the cases with predominant affections of the lungs, and of those of bronchitis and pneumonia in the abdominal form of the disease; and when we further find that these symptoms were features not peculiar to the recent influenza, but have characterised all its former appearances (?), we can scarcely refrain from acknowledging that these several affections are not merely coetaneous, but correlative, and types and modifications of one disease, with which they have a common origin." (p. 103.)

Now certainly it does appear that, during the prevalence of influenza in London, the deaths from typhus rose from a weekly average of 70 or 80 to 130 and 136, but the same increase occurred in the deaths from hooping-cough (which rose from 12 and 25 to 65 and 71), and from measles (which rose from 43 to 96).* An increase likewise occurred in *Registrar-General's Report, p. 3.