iq|[inJj pjgfrui3frm3fp^ i i i 1 1 1 1 i i i THE LIBRARIES COLUMBIA UNIVERSITY HEALTH SCIENCES LIBRARY i 1 1 1 1 1 1 1 1 i E uugifuonuTJirinifFugnugfrOTjf^ influenz;a INFLUENZA OR EPIDEMIC CATARRHAL FEVER AN HISTORICAL SURVEY OF PAST EPIDEMICS IN GREAT BRITAIN FROM 1510 TO 1890 BEING A NEW AND REVISED EDITION OF 'ANNALS OF INFLUENZA' BY THEOPHILUS THOMPSON, M.D., F.R.C.P., F.R.S. BY E. SYMES THOMPSON, M.D., F.R.C.P. GKESHAM PROFESSOR OP MEDICINE AND CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, BROMPTON PERCIVAL AND CO. KING STREET, GOVENT GARDEN ILontion 1890 PKEFACE The disorder which it is the object of this work to illustrate has spared no part of the world in its circuit, visiting the British Isles with great severity, and has of late returned. A complete chronological history of its visitations was regarded by the Council of the Sydenham Society as calculated to be of value, in various ways, to medical practitioners ; enabling them to compare the disorder, on any occasion of its recurrence, with those previous epidemics which it may most resemble, and suggesting particulars requiring further investigation, whenever such an opportunity is renewed. The information extant on the subject was not readily accessible, being sometimes, as it were, concealed in volumes devoted chiefly to other topics, or otherwise scattered through the pages of periodicals long since discontinued. My father, in endeavouring to fulfil the difficult but honourable task with which he had been entrusted by the Council, spared no pains in the search, or care in the selection, of materials ; and he shared with the Council a desire to present the facts which are recorded, as far as possible, in the words of the original observers, although, especially as respects the visitation of 1803, the miscellaneous character of the com- munications has rendered such an attempt by no means easy. He had much satisfaction in being the first to put into an English form the classical production of Sir George Baker. The epidemic of 1889-90 is too recent — indeed, it cannot yet be considered to have entirely left us — to allow of so com- vi PREFACE preliensive a description as we could desire. It lias been ray aim to collect data and give the detailed information on a similar plan to that adopted in the earlier part of the work. Dr. Peacock's book on the epidemic of 1847-48, and the Registrar-General's valuable Report, have furnished the chief sources of information with regard to that very extensive and severe epidemic. E. S. T. London, W., J^iine 1890. INTEODUCTION The laws which regulate epidemic diseases are well entitled to careful investigation. The variations of the same disease on different occasions of its epidemic prevalence are so con- siderable as to have elicited from the observant and judicious Sydenham the remark, that on each fresh visit of such disease he had to work out for himself a fresh knowledge of the appropriate plan of treatment. But the advantages which the inquiry presents extend further than its practical relation to individual instances of such disease. They spread through- out the whole compass of etiology, and tend to illustrate the causes which affect human life in the aggregate. Influenza possesses, in this point of view, a special interest, being of all epidemics the most extensively diffused, and apparently the least liable to essential modification, either by appreciable atmospheric changes, or by hygienic conditions under the control of man. It is not, like smallpox, communicable by inoculation ; and, however its fatality may be influenced by de- fective drainage, it is not, like typhus, traceable to this neglect as its cause. Unlike cholera, it often outstrips in its course the speed of human intercourse. It does not, like plague, desert for ages a country which it has once afflicted, nor is it accustomed, like the sweating-sickness, in any marked manner to limit its attack to particular nations or races of mankind, or, like dengue fever, to confine itself to tropical or sub-tropical regions. There is a grandeur in its constancy and immuta- viii INTRODUCTION bility superior to the influence of national habits. The changes in our national system of diet during the period which this volume embraces, have been of a nature to effect remarkable modifications in the condition of the people in reference to disease, yet, as respects influenza, they are not proved to have exerted any manifest influence. The disease, moreover, exhibits in the well-ordered mansions of modern days, phenomena similar to those which it presented in the time when rushes strewed the ground in the presence-chamber of our monarchs, and decaying animal and vegetable matter obstructed the porticoes of palaces. The importance of the subject cannot be estimated simply by the number of deaths recorded as directly attributable to the disease ; indeed we frequently find visitations of Influenza represented as by no means fatal. It is necessary to extend our consideration to the fact, that during the prevalence of epidemic catarrhal fever the mortality is usually increased, often to a very remarkable degree ; the cause of influenza, inde- pendently of its agency in producing characteristic symptoms, appearing to exert a power to modify any pre-existing disease with which it may coincide ; to impair extensively the vital energy, so as to increase, in the population of an affected district, the liability to contract other diseases ; and also to lessen the ability to resist any degree of fatal tendency which such concurrent diseases may possess. Even when complete re- covery takes place, the period of convalescence is often pro- longed for three or four months. The analogies traceable between influenza and other dis- orders, and its seeming relation to them in the way of transition or succession, are so remarkable as to encourage the hope that the study of this malady may help us to distinguish between the essential circumstances and the modifying influences con- cerned in producing the phenomena of epidemic disease in general. It is by explaining the laws obeyed by the most simple affections of this class, that we may most reasonably INTRODUCTION ix expect to elucidate those which are apparently dependent on more complicated conditions. No single generation of medical practitioners can be ex- pected to possess a sufficient range of observation, or to accumulate adequate materials of information on the subject, to enable them to detect the clue by which to thread the intricacies of this inquiry. The past must be scrutinised, and its reflected light brought to our aid ; old and new facts when collated, by the harmony which they exhibit, become mutually illustrative, and acquire a value previously unknown. It is true that medical records abound in fallacious and imperfect observations, transmitted from one generation to another, and that popular prejudices have exercised an in- fluence in disseminating error which the obstinacy engendered by the evidence of imperfectly observed facts has tended to confirm and perpetuate ; but it is possible to manifest too indiscriminate a contempt for statements which partake of popular superstition. Popular opinion is not always or neces- sarily incorrect, because inconsistent with the views of con- temporary philosophers. The " fiery tears " recorded in old Church Calendars as having fallen from meteors owed their ap- pearance to something more than the superstitious fancies of the narrators, and the days of their recorded appearance harmonise in an interesting manner with those on which the observations of modern astronomers would lead us to expect them. It would be presumptuous to set aside as absurd, frivolous, or erroneous, observations given in this volume on the testimony of honest observers, merely because such observations may not be consistent with our preconceived opinions, or explicable by our schemes of philosophy. Signacula, " blood rains," " bloody springs," wheat similarly coloured, and such like phenomena, noticed in recent history, and in the annals of the sixteenth century, although in the intermediate period rarely recorded, perhaps from the fear of seeming superstitious, are brought by modern research within the limits of explanation and belief. X - INTRODUCTION The copiousness and variety of observation admitted into this treatise will not be without value, if, as respects theoreti- cal opinion, they serve only to establish such negative conclu- sions as often prove the first and most secure steps in true philosophy, and convince the most confident theorists that they still have something to unlearn. The Editor of this volume has endeavoured to present the picture of influenza exactly as it was delineated by the original observers, for he is convinced that it is expedient to avoid the colouring which the existence of any bias in his own mind might impart, since narratives free from all preconceived impressions contribute far more effectually than commentaries to the formation of clear and independent opinion. Authentic information has been incorporated regarding epidemic disease among the lower animals, occurring contem- poraneously with the prevalence of Influenza amongst man, presenting analogous appearances. In the First Edition of this work many observations were made upon the relations which epidemics among the lower animals bear to disease among man. This inquiry still needs more full elucidation. Many suggestive hints were thrown out as to the influence exerted by insects in the development of disease. The relation which various fungi and mildews bore to diseases among plants, as well as annuals, was sketched out as having a possible bearing upon epidemic prevalence. The knowledge of the life history of very many of the micro- scopic fungi, and especially of bacteria, has been so greatly extended, and the fact that some diseases are caused by or associated with the presence of such organisms is so conclusively proved, that the spirit of speculation as to the possible influences at work to cause Influenza, which found their place very appro- priately in 1852, has not now the same cause for expression. It is improbable that the diseases of plants have anything in common with Influenza, except that similar atmospheric INTRODUCTION xi conditions may affect them. There is no conclusive evidence to show that there has been any widespread or extensive disease among plants during the recent epidemic of 1889-90. Mr. 6. T. Brown, of the Board of Agriculture, writes (10th February 1890): "I have made inquiry, and find that there are no reports of any special disease of food plants, the usual parasitic affections of cereals, e.g. ergot, smut, and ravages of insects, were not noticed to any great extent, except in the case of ergot, which was very abundant in some districts." The parasitic diseases of plants have been so fully in- vestigated in recent years that it would not be possible to do justice to the subject here. This is indeed a tempting field of inquiry, the more so as the life history of the parasites of plants is better understood than that of the parasitic diseases of man. A parasite, whose natural function is to flourish only in the presence of decay and death, may gain access to the tissues of living plants, if those plants are aquatic in their habits and waterlogged in texture. It is not so much the diseased plants that are access- ible to the parasite as the plants that, by living in water, have diluted their juices and lessened their powers of resist- ance. Such observations as these have a direct bearing on the accessibility of the body to the action of the micro-organisms in consequence, not of disease, but of modification in the environ- ment. Who shall say whether the greater accessibility to tuber- culous diseases known to prevail among the residents in humid or undrained districts may not bear an analogous interpretation ? If our own countrymen had followed up the hints given in the First Edition of this work — the suggestion, for instance, that epidemics are produced by vegetable germs borne on the wings of the wind — they might have been credited with many xn INTRODUCTION of the more important discoveries with the microscope which have been recently made by German investigators. The diseases of plants have now a literature of their own, which is becoming every year more full and more interesting, and which it would be impossible as well as out of place to attempt to summarise here.^ The comprehensive accumulation of facts now presented to the profession, by affording materials to those who would aim to interpret their meaning, may be held to render unnecessary any attempt on the part of the author to describe at large his own opinion regarding the essential nature of the malady. He would venture to invite attention to the evidence which these Annals afford, that the disease is dependent on the in- troduction of a micro-organism into the system, the febrile symptoms thus induced being modified by the amount and virulence of the poison, as well as by the power of reaction, and by the constitutional peculiarities of the individual attacked. ^ The following works may be studied by those who are anxious to pursue the investigation: 'Timber, and some of its Diseases,' by Marshall Ward, 1889 'On Diseases of Field and Garden Crops,' by G. Worthington Smith, 1884 'British Uredinea and Ustilaginea,' by C. B. Plowright, F.R.S., M.R.C.S., 1889 ' Comparative Morphology and Biology of Fungi, Mycetozoa, and Bacteria,' by De Bary ; 'British Discomycetes, ' by W. Phillips; 'Microscopic Fungi,' by M. C. Cooke ; also works by R. Hartig, Nordlinger, Gamble, Frank, Soraner, Willkomm, Hesse, etc. Of Bacteria, which are probably answerable for many diseases of plants, the literature is even more extensive, including works by Klein, Crookshank, etc. CONTENTS PAGE Preface ••..... v Introduction .... vii History of Epidemics of 1510-1581 1 Dr. Short's History 3 Erasmus 4 Epidemic of 1658 11 Dr. Willis's Description 11 Epidemic of 1675 17 Sydenham's Account . 17 Epidemic of 1688 23 Epidemic of 1693 23 Dr. Molyneux 23 Dr. Short's History 25 Epidemic of 1709 25 Epidemic of 1729 27 Huxham's Observations 27 Dr. Arbuthnot's Essay . . / 32 Medical Observations in Edinbiirgli 35 Epidemic op 1737 . . . 41 Huxliam .... 41 Epidemic of 1743 .... 45 Huxhani 45 Epidemic of 1758 49 Dr. Whytt .... 49 Dr. Alves .... 54 Dr. Millar .... 55 Epidemic of 1762 56 Sir George Baker 56 Dr. Watson .... 64 Dr. Rutty .... 67 XIV CONTENTS Epidemic of 1767 Heberden Epidemic op 1775 Dr. Fothergill. Sir John Pringle Dr. Heberden . Sir George Baker Dr. Henry Revell Reynolds Dr. William Cuming . Dr. Thomas Glass Dr. Ash Dr. W. White Dr. Haygarth Dr. R. Pulteney Dr. W. Thompson G. Skene Dr. D. Campbell Dr. J. C. Fleury Dr. D. Rainey Epidemic op 1782 Dr. Edward Gray Dr. Carmichael Smith . London College of Physicians Dr. R. Hamilton Dr. Blagden Dr. Haygarth Epidemic of 1789-90 Dr. Warren Epidemic of 1803 Various Authors, and Editor's Annotation Dr. R. Pearson Dr. Carrick Dr. Falconer . Dr. Nelson Scott Epidemic of 1831 Dr. Burne Mr. G. Bennett Admiralty Reports Various Authors, and Editor's Annotations CONTENTS XV PAGE Epidemic of 1833 ...... 273 Mr. Hingeston 273 Mr. Youatt 278 Epidemic of 1836-37 . 279 Dr. Streeten . 279 Dr. Greenhow 322 Dr. Graves 323 Dr. Clendinning 335 Dr. Bryson, and Annotations . 340 Epidemic of 1847-48 . 349 Dr. Peacock . 349 Registrar-General 379 Epidemic of 1889-90 . 395 Dr. Hawkins .... 401 Sir Peter Bade . 404 Hon. Rollo Russell 415 Dr. Bezley Thorne 417 Mr. W. Burr . 419 Prof. W. T. Gairdner 420 Dr. J. Greig Soutar 428 Dr. J, W. Moore . 430 Dr. William Tibbies . 432 Dr. Gilbart-Smith 438 Mr. E. C. Barnes 440 Dr. H. C. Bristowe . 442 Dr. Thresh 455 Dr. Sheridan Delepine 460 Summary ..... 467 Chronological Survey of Recorded Epidkmics 473 Index of Places visited by the Epidemic 475 Index of Authorities quoted . 479 General Index . 483 ANNALS OF INFLUENZA GREAT BRITAIN The malady which forms the subject of this volume, is de- scribed, in an Irish manuscript of the fifteenth century, under the names of FuacM and Slaodan ; and it is mentioned in the ' Annals of the Four Masters ' as epidemic in Ireland in the fourteenth century. A disease, the symptoms of which answer to those of influenza, is also alluded to in our early Gaelic manuscripts under the term " creatan," probably from "creat," the chest; but the first visitation of the disease in the British islands, of which we possess an accurate description, is that of the year 1510.^ The sixteenth century, the great transition period from feudal tyranny to liberty and order, was ushered in with much commotion of the elements, and marked with destructive pestilence. A severe winter followed the wet summer of 1505. In 1506 a comet appeared, and an eruption of Vesuvius occurred. 2 In January the violent storm arose which drove PhUip of Austria, with his consort Johanna, from the Netherlands to Weymouth. ^ 1 Dublin Quarterly Journal of Medicine, Feb. 1848, p. 256. 2 Spangenberg (Cyriacus), ' Mansfeldische Chronica,' 1572; Webster (Noah), ' A Brief History of Epidemic Diseases.' 3 "The tempest that he suffered on the sea was huge and wonderful!, also upon the lande, insomuch that the violence of the wynde blew downe an eagle of brasse, being set to shewc on which part the wynde blew from pynacle or spire of Paule's Church ; and in the falling, the same eagle broke and battered another eagle that was set uppe for a signe at a taverne doore in Cheapeside. And here- upon many men that were given to gesse things that shoiilde happen, by marking s ^ 2 EPIDEMICS OF 1510-1581 The secret influences whicli affect animal life, gradually produced sensible manifestations. The unusual combination of circumstances requisite for the exuberant production of locusts, occurring in Europe, occasioned great swarms of that insect in Seville in the years 1507, 1508, and 1510. About the same period, a great murrain amongst cattle at Meissen led to the execution of some " bose Buben " (wicked knaves), suspected of poisoning the pastures. A very considerable blight of caterpillars in the north of Germany stripped the gardens and woods of their foliage ; and signacula, or blood- spots, supposed by Agricola, an ingenious writer of that century, to be lichens, so abounded on linen, the veils of women, the food in larders, and even in the atmosphere in the form of blood-rain,^ as to fill the popular mind with superstitious dread. ^ Sweating-sickness ravaged England in 1506; and for several subsequent years various fevers pre- vailed in Europe. In 1510, the first well -described and widely-prevalent epidemic of influenza appeared. The best account which can now be obtained of this epidemic is here presented in the words of Dr. Short, in whose accuracy the of sti'onge tokens, decined that the Emperour Maximilian, which gave the eagle, should suffer some greate mysfortune ; and hee did shortly after, by the losse of hys Sonne, the sayde King Philip." (Stow's 'Annals.') ^ These miraculous blood-spots have, at various periods, excited the alarm of the superstitious ; they awakened, for instance, the apprehensions of Alexander's soldiers at the siege of Tyre ; they constituted one of the prodigies which pre- ceded the successes of Hannibal in Italy (Plutarch, in ' Fabius ') ; and have been frequently recorded by authors of different countries and periods : but their nature does not appear to have been made an object of strict scientific scrutiny before the year 1819, when a farmer, of Padua, being alarmed by seeing spots of a vivid red colour, closely resembling drops of blood, upon his porridge, which was made of the maize which grew in the neighbourhood, a commission was appointed to investigate the phenomenon. M. Sette supposed them to be formed of microscopical fungi, to which he gave the name of zoogaladina imetrofa. Ehrenberg, however, considers these red spots to consist not of fungi, but of a species of animalcule, which, on account of its extreme smallness, he names monas prodigiosa. These little beings are transparent, when separately examined, but, when in a mass, appear the colour of blood. They are from a three-thousandth to an eight-thousandth part of a line in length, so that, as calculated by Ehrenberg, the space of a cubic inch may contain from 46,656,000,000,000 to 884,836,000,000,000 of these monads. (Ehrenberg, 'Passat Staub und Blut- regen,' Berlin, 1849 ; Bericht der Berliner Akademie, 1848, p. 353). This subject is more fully noticed at a later period of this volume. {See Epi- demics of 1803, 1830, 1833, 1837 ; and also concluding remarks.) 2 Mezeray (Comte de), ' Histoire de France ' (Paris), 1685, t. ii. p. 819. DR. SHORT'S HISTORY 3 Editor has reason to place confidence, although he has not been able, in his endeavours to verify the quotations, to obtain access to all the works to which Dr. Short refers. EPIDEMICS OF 1510-1581 SHORT 1 " The disease called Coccohiche, or Coccolucio (be- ■ cause the sick wore a cap or covering close all over their heads), came from the island Melite in Africa, into Sicily ; so into Spain and Italy, from that over the Alps into Portugal, Hungary, and a great part of Germany, even to the Baltic Sea ; every month shifting its situation with the wind from East to West, so into France, Britain, &c., Valeriola, Pechlin, &c. It attacked at once, and raged all over Europe, not missing a family, and scarce a person. A grievous pain of the head, heaviness, difficulty of breathing, hoarseness, loss of strength and appetite, restlessness, watchings, from a terrible taring cough. Presently, succeeded a chilness, and so a violent cough, that many were in danger of suff'ocation. The first days it was without spitting : but about the seventh or eighth day, much viscid phlegm was spit up. Others (though fewer) spit only water and froth. When they began to spit, cough and shortness of breath were easier. None died, except some children. In some, it went off" with a looseness ; in others, by sweating. Bleeding and purging did hurt. Bole armoniac was chiefly useful, with oily Hntus's, pectoral troches, and decoctions. Where blood was let, the disease proved malig- nant and pestilential, being attended with a violent, cruel, and unheard of malignity, and made bad work. It was preceded by a long, moist air. We shall find it again in '57, '80, and '97, &c. June 20th, at Chilick and Juliers, such extraordinary thunder and lightning, as struck all with a pannick. A thunderbolt fired the magazine, and did great damage." {Hist, of the Iron Age.) ^ A General Chronological History of the Air, Weather, Seasons, Meteors, &c. By Dr. Thomas Short. London, 1749, 4 EPIDEMICS OF 1510-1581 Stones, varying in weight from 60 to 120 pounds, fell from the heavens in Lombardy. (Surius, Cardanus de Berum Varietate.) During this year, there also occurred great earthquakes, and a volcanic eruption in Iceland. The air was humid. In the following year a comet appeared.^ During the prevalence of influenza in Britain, Spain was afflicted with sweating-sickness.^ "In the previous year, September 14th, was an earthquake at Constantinople, and the countries thereabouts ; it demolished a great part of the city walls and stately buildings, and slew 13,000 people. It lasted a month with very little inter- mission ; after it came a plague, which almost depopulated the city." (Ttirk's History.) ^ " This year a great mortality prevailed in England, '^' say our historians ; they call it (as indeed all dis- eases) the plague ; but to know what it was, we must consult foreigners. Says Cole, when dearth, scarcity of corn, famine, rainy seasons, and severe cold ones, had afflicted Italy for two years, and people were forced to eat uncommon and unwhole- some food, arose an epidemic contagious fever, with a dys- entery, and black spots over the whole body. And from this want of food, great weakness, and unhealthy juices, they had a pale cacco-chimic and depraved countenance, a swelling of their feet, and difficulty of breathing." The following account of the habits of our countrymen at this period, in a letter from Erasmus to the Physician of Cardinal Wolsey, may here be appropriately introduced.^ " I often grieve and wonder how it happens, that Britain has now, for so many years, been afflicted with a continual plague, and chiefly with the sweating-sickness, which is a malady that seems almost peculiar to the country. We have read of a state being delivered from a long- continued pesti- lence by changing the style of building, upon the advice of a I)hilosopher. If I am not deceived, England may be freed in a similar manner. In the first place, the English have no ^ Webster (op. cit.) '^ Villalba (Don Joaquin de), ' Epideniiologia Espanola,' 2 torn., Madrid, 1803. 2 Des Erasmi. Epist. (Lugdun. Batav. ), torn. iii. epist. 432 (as translated in 'Retrospective Review,' vol. v. p. 24, 1703). ERASMUS 5 regard to what quarter of the heavens their windows or doors are turned ; in the next, their sitting-rooms are generally so constructed as to be incapable of being ventilated, which is a thing that Galen particularly recommends. Furthermore, a great part of the wall is made transparent by glass plates (or squares), which admit the light, but exclude the wind : and yet, through the small crevices, they admit the air to be strained, which becomes somewhat more pestilent by staying there a long time. The streets, too, are generally covered with clay and rushes, which are so seldom renewed, that the covering sometimes remains twenty years, concealing beneath a mass of all descriptions of filth, not fit to mention. Hence, upon a change in the atmosphere, a certain vapour is exhaled, in my opinion, not at all wholesome for the human body. Added to this, England is not only surrounded by the sea on every side, but it is also, in many places, marshy, and inter- sected by salt streams, to say nothing at present of the salt food, of which the common people are amazingly fond. " It is my firm opinion that the island would become much more wholesome if the spreading of rushes on the ground were not used, and if the chambers were so built as to be exposed to the heavens on two or three sides, the windows of glass being so made as to open altogether, and close in the same way, and to shut so as not to admit noxious winds through the crevices. Since, as it is sometimes wholesome to admit the air, so it is sometimes as much so to keep it out. The common people laugh, if a person complain of the cloudy sky. If, even twenty years ago, I had entered into a chamber which had been uninhabited for some months, I was immediately seized with a fever. It would contribute to this object (to render the island more healthy) if more sparing diet could be more generally recommended, and a more moderate use of salt provisions ; and if certain public officers were commissioned to keep the roads more free from nuisances. Those parts, too, should be looked to more particularly, which are in the neigh- bourhood of a town. You will laugh at my having time to trouble myself about these matters. I love the country which has for so long a time given me an hospitable abode, and in it, should circumstances allow, I would willingly spend what remains of life. 6 EPIDEMICS OF 1510-1581 " I have no doubt from your character for -^isdom, that you know these matters better than myself ; I resolved, how- ever, to mention them to you, that you may, if my opinion coincides with yours, recommend these hints to the notice of the great. For, in former days, kings were wont to interest themselves- in such things," &c. &c. In 1566 there were showers of blood, and an eruption of Etna. The season was mostly wet ; but in some countries dry. In the subsequent year a comet appeared. -, f-PH " This year and last (proceeds Dr. Short) was a ' great scarcity of corn from the past great rains. It was a very unseasonable year in England, all the corn was choaked and blasted, the harvest excessive wet and rainy; before harvest this year, wheat was sold at 4 marks per quarter; malt, at 44s. per quarter; pease, at 46s. 8d. After harvest, wheat was sold at 5s. per quarter in London, 4s. in the country. Malt, at 6s. 8d., and in the country at 4s. 8d. Eye, at 3s. 4d. per quarter in London, and in some places at 4d. per bushel {Clark's Ex.) Quartan agues still reigned fatally. In some more remote countries, July, August, and September, were excessive hot and dry. In the end of September, came a very strong cold north wind; presently after were many catarrhs, quickly followed by a most severe cough, pain of the side, difl&culty of breathing, and a fever. The pain was neither violent nor pricking, but mild. The third day they expector- ated freely. The sixth, seventh, or, at the farthest, the eighth day, all who had that pain of the side died ; but such as were blooded the first or second day, recovered on the fourth or fifth ; but bleeding on the last two days, did no service. Slippery, thickening linctuses, were found of most service. Broths, or spoon-meats, or moist foods, were good. But where the season continued still rainy, the case was very different ; for at Mantua Carpentaria, three miles from Madrid, the epidemic began in August, and bleeding or purging was so dangerous, that in the small town 2000 were let blood of, and all died. There it began with a roughness of the jaws, small cough, then a strong fever, with a pain of the head, back, and legs ; some felt as though they were corded over the breast, and had a weight at the stomach ; all which continued to the third day at farthest ; then the fever went off with a sweat, or DR. SHORT'S HISTORY 7 bleeding at the nose. In some few, it turned to a pleurisy, or fatal peripneumony. — At Alcmaria, this year in October, raged such an epidemic, as seized whole families at once. In that smaU place, died in three weeks 200 persons of this mortal peripneumony. It attacked like a catarrh, with a very slow and malignant fever, bringing, as it were, a sudden suffocation along with it ; then seized the breast with so great a difficulty of breathing, that the sick seemed dying. Presently it laid hold of the precordia and stomach, and with a violent cough, which either caused abortion, or killed gravid women. Some, but very few, had continual fevers along with it ; others simple slight intermittents. All were worse by night than by day ; such as recovered were long valetudinary, had a weak stomach, and hypped. This disease seized most countries very suddenly when it entered, catching thousands the same moment. Thick, ill-smelling fogs preceded it some days. In some places, few recovered who had it accompanied with a violent fever. Semi- tertians were next dangerous. If intermittents accompanied the pain of the throat (which was neither a quinzy, nor scarce a slight iaflammation, but only from a meer defluxion, of which the sick seemed choaked), they were better off, even without bleeding. But if the fever supervened, and was not well managed, it was often fatal. Gentle bleeding the first day was useful. For the throat, gargles of plantin, scabious, and red rose waters, quinces, mulberries, and sealed earth, were used. For the cough and hoarseness, pectoral and oyly mixtures. Scarification with cupping succeeded better than bleeding. The year 1555 had been most excessively rainy, and 1556, as great a drought." This year, the season was mostly wet, but in some countries dry. The influenza set in about the time when a cold north wind succeeded intense heat. In the previous year was an eruption of Etna.^ "A sudden and terrible plague broke out between Delft and the Hague, in a small village, and spread over the whole country in June before the rising of the Dog star. In children it was attended with spots. This plague was presaged by stars and fire falling to the ground on the streets of DeKt. Children in their play digged graves and carried dead coffins 1 Webster (op. cit. ) 8 EPIDEMICS OF 1510-1581 on their shoulders ; sung funeral hymns like their priests, and pretended to bury living children, their play-fellows. So great was this mortality, that the poor fought for coffins for their dead relations. Abortions and death of child-bed women were common. This plague continued till May, 1558, and killed 5000 of the j)Oor of Delft only. {Dodoneus, Schinckius, Platerus Stow, &c.) A dearth afflicted England; wheat sold at 55s. per quarter ; but a good and plentiful crop this harvest brought it to 4s. or 5s. September the 7th, seven o'clock at night, in a black rainy cloud in the west, was seen a rainbow, the moon in the east shining bright, and at full the day before. In September excessive rains and a great death, chiefly of priests {Baker's 'Ghron.'). At JSTumigen, in July, raged an epidemic, which spared none, and so cruel, that it carried off many the fourth, seventh, or fourteenth day. It seized with a fever, roughness or burning inflammation of the throat, and the fever continual. The sick were afflicted with a grievous pain of the head, taring cough, and constant severe pain of the loins that they could not walk; and so large a discharge by the nose as would scarce suffer them to breathe. Such as escaped by bleeding, pectorals, and a stinking sweat supervening, had their entire strength in all parts continued. But such as sunk under the fever and want of eating becoming weak, all died. "Wherefore the cure turned on the use of speedy universals, recalling the appetite, keeping the vessels of the throat open. Lenitives only were used, strong purges being fatal. In harvest, a pestilential fever raged in France, and carried off many. Dysenteries, with a slight fever, prevailed at the same time; but by the early use of rhubarb, all had their gripes appeased and recovered. {Bever, Holer, &c) This year there was a great flood in the South of Languedoc, with so dreadful a tempest, that the people imagined it was the last day. {Vignier). The rapid descent of the waters about Nismes, removed divers heaps and mountains of ground, and rent and tore up many other places ; by which was discovered much gold and silver coins, plate, and other valuable vessels, sup- posed to be hid in the Gothish invasion." -if-nr. "In 1578, and on Ap. 364. ^ Mr. Rowe, of Portsea ; idem, p. 571. * Mr. Hunter, of Dumbarton ; Med. and Physical Journal, vol. x. pp. 234-236. VARIOUS AUTHORS 227 exasperated all his symptoms, and brought on so severe a vomit- ing, that everything he took was instantaneously rejected ; his belly was bound, skin dry, and his pulse 130, weak and intermitting. Before I saw him a number of injections had been given, some of them very stimulant, but without effect. I ordered an injection of Nicotiana 3ij, Infus. in Aq. Bullient §xij, to be given ; it produced an immediate evacuation of a considerable quantity of indurated faeces, caused severe vertigo, faintishness, and at last a copious perspiration, followed by sound and refreshing sleep : when he awoke his fever was greatly diminished, and the vomiting did not again come on ; and without any other application, except a plentiful use of wine, in which a smaU quantity of Ead. Gentian was infused ; he quickly recovered. "As this remedy had been so useful in this case I deter- mined to try it in others ; and, as in the beginning of the disease, costiveness was frequent, I began by giving the injection, of a strength in proportion to the state of the patient, but always wished that, besides emptying the bowels, nausea, or even vomiting, might be excited ; whenever this took place it was followed by a profuse sweat and sound sleep. " After having found the beneficial effects of the medicine in injections, its internal use by the mouth was tried ; the pre- paration made use of was the Vinum Nicotianse, given at first in smaU doses, frequently repeated, combined with some aro- matic water, or tincture ; it was always pushed so far as to produce giddiness of the head, or nausea, and when carried this length, it almost in every instance brought on a large discharge by the skin and kidneys, and sound sleep ; it also caused a considerable increase of expectoration, and relieved the cough ; indeed, in my opinion, its anodyne effects were equal to those of opium ; and, as it aided the discharge from the breast, which the other retarded, it was undoubtedly preferable. " Since I first became acquainted with the sudorific and narcotic powers of the nicotiana, it has been used in every case that came under my management, except those where gripes, and bloody, slimy stools took place, and always with evident advantage, nor did I see in any one instance the least dis- agreeable circumstance arise from its use. 228 EPIDEMIC OF 1803 " When after the first exhibition of tlie medicine any fever remained, and the cough was troublesome, a second dose was given in the course of two or three days after the first, and managed just in the same way; the operation was equally successful as before, and the symptoms proportionally dimin- ished ; a third application I never had occasion to make. I wish, however, to remark, that during the course of a month that the medicines, as mentioned in the beginning of this paper, were used, my practice was tolerably successful, but not equal to what it was afterwards, as my patients both recovered with less pain, and in a much shorter period, by the use of nicotiana than by all the other remedies formerly employed." 2. DR. EICHAED PEARSON i " The catarrhal fever, or influenza, which has lately spread itself over the whole metropolis, and has since made its way to almost every part of the kingdom, first shewed itself here about the middle of February, when a damp and mild state of the atmosphere had succeeded to severe cold. This again was fol- lowed by frost, and keen northerly and easterly winds during the first part of March, the latter part of which was very warm. In the beginning of April, the weather was mild and rainy ; in the middle dry and fine, the noon-days remarkably warm, but the mornings and evenings cold. Wind east. The latter part of the month was cloudy, windy, and very cold, with showers of rain and hail. Wind westerly and northerly. The last week of this month was unusually cold. This severe weather occa- sioned a great aggravation of the pulmonary symptoms. " Like all former catarrhal epidemics, the present influenza has exhibited various degrees of morbid affection ; having been in some instances so slight, as not to incapacitate persons from continuing their ordinary occupations and pursuits, and scarcely to require the aid of medicine ; while, in others, the attack has been of such a malignant nature, as to endanger and even destroy life.^ 1 Observations on the Epidemic Catarrhal Fever, or Influenza, of 1803. By Richard Pearson, M.D. London, 1803. ^ '• Between these epidemics, and the condition of the atmosphere, there seems to be a connection different from that which depends upon a mere alteration of DR. PEARSON'S ACCOUNT 229 " The following is its most frequent mode of attack : — After some alternations of chilliness and heat, the patient is seized with a heaviness or pain of the head, with sneezing, wateriness of the eyes,^ hoarseness, and cough. These symptoms come on in the order here stated. In the course of a few hours the headach increases, the skin becomes hot, with pains in the back and limbs, or transitory stitches across the chest. The tongue is white ; the pulse quick or frequent, and for the most part soft. There is more or less of sickness at the stomach, and sometimes vomiting. The bowels are generally costive ; and considerable uneasiness, or even a distressing pain, is felt in some part of the abdomen in many instances. By the second or third night, the cough and fever become greatly aggravated. The former, viz., the cough, is strong and incessant, sometimes dry, but often accompanied (even at its first coming on) with an expectoration of thin sharp mucus; the latter, viz., the fever, is attended with increased heat, and with extreme rest- lessness and anxiety. There is also some confusion of the head. At this time the pulse is often from 110 to 120. In the morning there is a considerable remission of the febrile symptoms ; but the cough (with more or less dyspnoea) still continues urgent, and the patient complains of excessive languor and dejection of spirits. " After the third or fifth day, where early perspirations have come on, or sufficient evacuations have been procured by the stomach and bowels, the fever declines ; and although the cough continues, the expectoration is more free, the sputum being of a thicker consistence and milder quality. The urine, wliich before was high-coloured and clear, now becomes turbid, or throws down a sediment. In other instances the cough temperature, or of dryness and moisture ; but what that peculiar connection is, we shall not attempt to explain. Yet it is proper to notice the changes of tem- perature, and other sensible qualities of the atmosphere, as giving rise to the predominance of a certain set of symptoms at one time more than another. Thus in frosty weather, and during northerly and easterly winds, the catarrhal and peripneumonic affection will be most conspicuous ; while in warm weather, and during westerly and southerly winds, the headach, sickness, disordered bowels, glandular swellings, etc., will constitute the most urgent symptoms. All these modifications have been observed during the changes of the weather in the present epidemic." ' " In some, an inflammatory appearance of the vessels of the tunica con- junctiva, and a puffy swelling of the eyelids." 230 EPIDEMIC OF 1803 continues very troublesome for many days, or even some weeks, after the abatement or cessation of the fever, and goes off very tediously without any remarkable degree of expectoration. " The lassitude and depression of spirits, with restless nights, harass the patient for many days after the decline of the fever ; which, indeed, in several instances, does not entirely go off after the fifth day, but becomes intermittent, the patient feeling him- self worse every other day. " Such is the most common form of this epidemic. Its modifications, however, as we have before observed, are ex- tremely numerous, so that in some there is a violent headach, with little catarrhal affection, in others a sore throat, in others a peripneumonic condition, and in others a disordered state of the stomach and bowels.^ In several instances, swellings of the parotid, maxillary, and cervical glands have been observed, especially during the month of April ; i.e., towards the decline of the epidemic. These and other varieties have been partic- ularly noticed in the histories of former epidemic catarrhal fevers, to which (in order to avoid repetition) the reader is referred. Eelapses were not uncommon. In such cases the mucous covering of the tongue was generally yellow or brown (not white, as in the first attack), and the whole condition of the patients resembled that of low fever. " From this sketch of the disorder, it is evident that this epidemic differs from a common catarrh, in the degree and kind of fever with which it is accompanied ; and that, as it is the fever which constitutes the essence of this disease, and not the catarrh, it should be denominated epidemic catarrhal fever, or synochus catarrhalis, and not simply epidemic catarrh. ^ Its infectious nature can scarcely be doubted ; but how long its contagion is capable of being applied before it takes effect, and what are the circumstances most favorable to its action, are points which have not yet been duly investigated. " As it is the fever which constitutes the essence of this disease, our first attention should be directed to it, and not to the cough (except when it is accompanied with pneumonic inflammation) ; otherwise, by prescribing only for one of its 1 ' ' The stools are more or less bilious in all instances. In some they are of a very dark colour and extremely offensive." - " In certain situations the fever degenerates into the typhus kind." DR. PEARSON'S ACCOUNT 231 symptoms, we shall make but little impression upon the general morbid affection. "We are not, therefore, to begin the cure with pectoral medicines, but with such remedies as are capable of acting upon the system at large through the medium of the stomach and intestinal canal. Such are emetics, and mercurial and anti- monial cathartics. " A bad taste in the mouth, oppression about the epigastric region, and nausea, indicate the use of an emetic, which even where some of these symptoms are wanting, should seldom be omitted. But, whether an emetic be administered or not, the bowels should be moved by a dose of calomel, joined with about half its weight of the Pulv. Antimonalis, Ph. Lond. " If, after some hours, this medicine shall not appear to be sufficiently active, its operation should be promoted by a solu- tion of the Kali Tartarisatum, Magnesia Vitriolata, or some other neutral salt, the patient all the while diluting freely with some tepid mucilaginous drink. " Before the purgative operation takes place, this combina- tion of calomel and antimonial powder produces a marked effect upon the skin, and a general diaphoresis breaks out. Nor does this appear to be checked in any considerable degree by the subsequent discharge from the bowels ; before the coming on of which, a pediluvium may sometimes be used with advantage. " As the calomel and antimonial powder produce their effect, the headach, anxiety, and heat of the skin abate. The cough, however, and dyspnoea, are little altered, and require the appli- cation of a blister. They are also further relieved by draughts composed of Aqua Ammoniae Acetatis, and ^ther, or Sp. ^th. Nitros., mixed with a proper quantity of common water, or mint water. ^ " After evacuations by stool have been procured, opiates afford relief ; but they should be prescribed in very small quantities, a full dose producing great mischief in this stage of the disorder. The Syrupus Papav. Alb. is a convenient preparation. Of tliis one drachm may be given to an adult, joined with five or six ' " The inhalation of cether- vapour is not so beneficial in this epidemic as it is in simple catarrh. Where, however, the cough is dry, and the dyspnoea urgent, without being accompanied with pneumonic inflammation, it may be resorted to with advantage." 232 EPIDEMIC OF 1803 drops of the Tinctura Opii. To young persons a double quan- tity of the syrup may be given, without the opiate tincture.^ "The day after the operation of the mercurial and anti- monial purge, the patient should drink freely of a solution of crystals of tartar in common water, unless (a circumstance which we have rarely observed in the present epidemic) a loose state of the bowels should come on.^ " The solution of this acidulous salt (the crystals of tartar) forms a pleasant and refreshing beverage ; and, along with its beneficial action upon the bowels, promotes a flow of urine, a mode of operation which contributes in no small degree to the removal of the fever. "Where the bowels are not readily acted upon by the medicines above mentioned, it will be necessary to have re- course to clysters, which indeed are most indispensable in the case of children. "In the course of this disorder, the calomel should be repeated two or three times, without the antimonial,^ and in smaller doses. "To promote expectoration, squill, in some form or other, will now be proper, provided the heat of the skin and frequency of the pulse shall have been greatly abated ; i.e., provided the fever shall, for the most part, have subsided. It may be joined with the Aq. Ammon. Acetat. and Sp. ^ther. Nitros. ; but oily medicines, and the common pectoral emulsions, are of very little use. Mucilages, however, such as gum arable or tragacanth, may, in some instances, be advantageously joined with the squiU. Also small doses of ipecacuanha. " In the beginning of the attack a moisture upon the skin is doubtless salutary ; but after the second or third day, it is not desirable to excite a perspiration by keeping the patient in bed, and giving him strong sudorific medicines and warm liquors, as in the case of a common catarrh. The heat which accompanies 1 " The dose of the opiate tincture may be increased towards the decline of the fever ; but even in the advanced stage of the complaint it will seldom be proper to exceed fifteen drops. I wish to call the attention of practitioners to the difference between small and large doses of opium in this epidemic." 2 " In that case the spontaneous evacuation is not to be checked. Plentiful dilution, with blisters and mild opiates, will form the whole of the cure. " 3 ' ' "Without the antimonial, if there be no peripneumonic affection ; if there be, either with it or with small doses of ipecacuanha." DR. PEARSON'S ACCOUNT 233 such a sweating process aggravates the fever, and the forced diaphoresis is constantly followed by increased languor and dejection of spirits. The recovery, under such circumstances, is extremely tedious. " Paying less attention, therefore, to the catarrhal symptoms than to the general febrile affection, we should avoid all accumu- lation of external heat ; and after the third day (except in those few cases where violent pneumonic inflammation occurs), direct the patient to sit out of bed, allowing him cool drinks, and taking care to have the room kept cool, and properly ventilated, especially when the temperature of the atmosphere exceeds 45° or 50° of Fahrenheit's thermometer.^ " Wliether the fever goes off entirely, or puts on an inter- mittent form, great languor and depression of spirits, with want of appetite, remain for many days. Contrary to what is ob- served in other cases of febrile debility, the Peruvian bark and mineral acids are here of no avail. They even do harm. But infusions of the simple bitters, or a solution of myrrh, may be prescribed with good effect, especially when joined with the acetated kali, or prepared natron. This last combination agrees best with young subjects. " At this period a less restrained use of opium is admissible, in order to counteract the disturbed nights. " During the convalescence, the bowels are liable to occa- sional irregularity ; which, if it incline to costiveness, will require a repetition of the calomel, in a smaller dose, with the addition of a grain or two of aloes ; or the Pil. Aloes cum Myrrha may in some cases be given without the calomel. " Throughout the whole progress of the disorder, the diet should consist of mucilaginous vegetable decoctions, and of animal jellies, flavoured with subacid vegetable juices. Broths should not be allowed during the feverish state, as they tend to ^ "As the weather grew warmer, the symptoms of the influenza in 1782 were more severe, and the recoveries more tedious ; and the inhabitants of low and close situations had the disease worse than the inhabitants of high ones. In some hospital patients it wore a malignant aspect. See the account drawn u]( by Dr. Gray. In like manner it is recorded by Sir G. Baker (on the authority of Dr. Petrie), that in the neighbourhood of Lincoln the epidemic of 1762 raged with unusual violence in low situations ; that is, in places where a due ventilation was wanting, (Baker, ' De Catarrho Epidemico.') And in the present epidemic, persons employed in heated and crowded workshops have had the disorder in its severest forms." 234 EPIDEMIC OF 1803 keep up an unsalutary perspiration, and never fail to increase the headach, nausea, and languor. " When the disease is complicated with pulmonary inflamma- tion, the same remedies are to be employed (the lancet, however, not quite so freely), as in the case of simple peripneumony ; but after the removal of the local inflammation, calomel should be given in small doses, together with the saline diuretics before mentioned, in order to counteract the morbid condition of the system at large. It is to be remarked, however, that free and brisk purging is not so well suited to the cases of this fever which are complicated with pneumonic inflammation, as to the other forms of the epidemic;^ but early and gentle evacuations by the bowels are serviceable, even in the first-mentioned cases. When venesection is judged necessary, it should be resorted to in the beginning of the attack ; for after three or four days have elapsed, the period for employing the lancet with advantage, or perhaps with safety, is past. A middle-aged patient who, in the month of March last, had the catarrhal fever complicated with pneumonia and diaphragmitis, was blooded on the fourth day of the disorder, and again on the following day. The blood exhibited a strong buffy coat ; but the case terminated fatally on the'^sixth day. Those who have seen much of this epidemic will easily bring to their recollection many similar instances of the unsuccessful employment of bloodletting in the advanced stage of the dis- order, though accompanied with symptoms of local inflammation. " Recapitulation of the Nocentia and Juvantia in this Epidemic. "things hurtful. "things useful. 1. Bleeding, except in those few 1. That degree of diaphoresis, which cases where there is evident either comes on spontaneously, pneumonic inflammation ; and or is consequent to the mer- even then, unless employed in curial and antimonial medi- the beginning. cine given at the beginning of the attack. 2. Forcing out sweats by accumu- 2. Copious evacuations by stool. lation of external heat and strong sudorifics. ^ "In like manner brisk and copious purging was not suited to very old people nor to consumptive subjects. In these a gentle and moderate catharsis answered best." DR. CARRICK'S OBSERVATIONS 235 "things HTJETFUIi. "THINGS USEFUL. 3. Emulsions, and other oily .3. Blisters and aether, or Sp. aeth. pectoral medicines. nitros. 4. Large doses of opium in the 4. Small doses of opium (after the beginning of the disorder. bowels have been acted upon), gradually increased as the fever declines. 5. A close and unventilated room. 5. Promoting a flow of urine by a solution of crystals of tartar. 6. Broths and warm animal de- 6. A cool and weU ventilated room. coctions, while the febrile state subsists. 7. The Peruvian bark, with very 7. Infusions of the simple bitters, few exceptions, even in the joined with the acetated kali advanced stage of the disorder. or prepared natron." 3. DR CARRICKi " 1. The first case of influenza that occurred to me with sjrmptoms distinctly marked, from the very frequent catarrhal affections of the season, was on the 5 th of March. In the course of a single week from that period, the disorder had become remarkably general, and continued with unabating frequency a fortnight longer. It then speedily declined both in frequency and severity, and very soon ceased to be epidemic, although a few insulated cases continued to occur for a length of time. " 2. The complaint was at first generally (I may say uni- formly) accompanied with inflammatory symptoms. The nearer the commencement of the epidemic, these were the more consider- able, and continued to decline during its progress, so that, in the latter instances, they were scarcely, if at all, perceptible. As this change of symptoms might be influenced by the temper- ature of the atmosphere, I shall subjoin a register of the weather at Clifton for the months of February, March, and April. " 3. The cases in which no sensible affection of the lungs took place, were, about the commencement of the disorder, not more than one in twenty. The cases attended with imminent pulmonic inflammation (pleurisy or peripneumony in a high ^ Observations on the Influenza, as it appeared at Bristol in the year 1803. By Dr. A. Carrick. Being Answers to certain Questions respecting that Disease, trans- mitted to him by Dr. Richard Pearson, Pliysician, London. (Annals of Medicine, vol. iii. p. 410.) 236 EPIDEMIC OF 1803 degree), so as to indicate the use of the lancet, were at no time more than one in thirty. In the progress of the complaint, these proportions varied exceedingly. " 4. The influenza was in general accompanied with a greater degree of languor than usually attends inflammatory disorders ; and the pains in the back, and headache, bore some resemblance to typhus. These symptoms were particularly striking, when the throat happened to be inflamed and ulcerated ; but latterly I have observed this languor and dejection to a very great degree in cases where no inflammation or ulceration of the throat took place. " 5. The actions of the stomach and bowels were not in general disturbed, at least not in any particular or unusual manner. Constipation was not unfrequent at the commence- ment of the attack. In some cases, bile was evacuated in large quantities by stool ; but, in the majority of cases, the stools were not unnatural ; neither was vomiting a frequent symptom. " 6. The expectoration was in general proportionable to the degree of pulmonic affection. " 7. It is not easy rigidly to prove or to disprove the con- tagious nature of this epidemic. The opposing facts and argu- ments are numerous. But I must decline giving any opinion of my own. It is not opinions you ask, but facts. In many cases, a whole family, of a dozen persons and upwards, have been seized with the disorder, one after another, in such a manner as to induce the belief that they caught it of each other, while in many other families, similarly circumstanced (as to situation, exposure, age, etc.), only one or two have been affected, while all the rest escaped. In the first-mentioned cases, the intervals of attack in the different individuals were from one to two or three days, in women, which although a shorter period than usually takes place in most infectious disorders, is by no means without example in the history of contagion. Even in cases where two or three individuals of a family were seized with the complaint at nearly the same moment, we have not an absolute disproof of infection ; for while the disease was so extremely prevalent, it was impossible to conjecture, with any degree of certainty, from whence or at what precise time the infection (supposing it to be infectious) took place. The slow progression of the disorder from one DR. carrick's observations 237 place to another seems to oppose the supposition of its arising from the constitution of the atmosphere, or from anything wafted in it. The influenza was certainly prevalent in London, at least two or three weeks before it made its appearance in this neighbourhood ; although the course and velocity of the wind, during that period, were such as to bring the whole atmosphere across the country in one day. By such accounts as I have been able to procure from Edinburgh, nearly a month must have elapsed from the first appearance of the disease in London before it reached that place, although the wind was for many days of that interval pretty violent from the south-west. Moreover, if the disease depended on the atmosphere, or on anything carried along with it from the eastern countries, it ought to have made its appearance equally soon on the east coast of Scotland as that of England ; whereas the history of its progress, the periods at which it commenced or became general in various parts of the kingdom, seem to favour the supposition of its having been originally imported into London, and the parts adjacent, by the Straits of Dover, and thence propagated to different parts of the island according to their respective distances and intercourse. " On the other hand, it must not be denied that many cir- cumstances were observable, which tend to invalidate this supposition, and to induce a belief that the disorder arose entirely from the condition and temperature of the atmosphere. The epidemic, whatsoever might be its nature, was evidently regulated in an imminent degree by the degree of exposure to cold, and to the sharp east winds which at that time prevailed. Those persons, who by choice or accident, remained in the house, either in general escaped the disease entirely, or had it much more slightly than those who exposed themselves, par- ticularly if the house was warm and comfortable, or in a low and sheltered situation, and screened by adjacent heights from the north-east wind. In that part of Clifton, called the Hot- Wells, which is sheltered in a very great degree from the north and east, the influenza was comparatively rare, as well as mild. In the low, confined, and ill-ventilated houses in the Hot-Well road, where typhus often abounds, the influenza was likewise very unfrequent; while in the exposed high -lying buildings on Clifton-hill, it was almost universal. One of the 238 EPIDEMIC OF 1803 most open and exposed of these is Eichmond Terrace, which forms three sides of a parallelogram, fronting respectively the east, south, and west. On the east side of this Terrace, not one family, and scarcely an individual, escaped the complaint ; while on the south side a great majority, both of persons and families, in all other respects similarly circumstanced, escaped entirely. That the catarrhal and pneumonic symptoms were chiefly owing to cold, appears, from their having been more or less frequent and severe, according to the degree of cold at the time. After the breaking up of the frost, very few instances of the complaint were accompanied with catarrhal or pneu- monic symptoms; and the most recent cases have been uni- formly exempted from them. In these the attack could hardly be distinguished from that of ordinary typhus ; but in their progress and general habits, they bore an exact resemblance (in aU other respects) to the late epidemic. " 8. No opportunity occurred to me, of observing the ap- pearances after death. Indeed very few died of the disorder in this neighbourhood : and of these, most, or perhaps all, seemed to fall victims to the accompanying pneumonia. " 9. The inflammatory symptoms yielded in general to the combined action of antimonials, diluents, purgatives, and blisters, even where they were considerable. But it is equally true, that in other cases the inflammation resisted these ; and when the lancet was altogether or too long withheld, death was the consequence. " Several instances occurred to me of pneumonia in its most violent degree, superinduced by the influenza, where the lancet was imperiously called for, and repeatedly employed ; twice, thrice, and, in one case, five times, with as liberal a hand as in ordinary pneumonia, and with as eminent and uniform ad- vantage. The loss of blood was borne every bit as well as in other diseases, where bleeding is indicated. No case so treated terminated fatally. But, on the other hand, I witnessed the unfortunate termination of several, where the patients, I am fuUy persuaded, fell victims to an unfounded terror of venae- section in all cases of the influenza ; derived, I suspect, from some foolish paragraphs in newspapers, which not only mate- rially influenced the opinion of the public at large, but likewise that of many medical practitioners. DR. CARRICK'S OBSERVATIONS 239 "10. In the milder cases of this epidemic, perspiration was in general very easily excited, and sometimes, likewise, easily and unintentionally protracted beyond the duration of any apparent febrile action. As under these circumstances it could not be expected to do any good, it was of course discouraged. And although it was certainly possible in such cases to carry perspiration, and detention in bed, to an hurtful extreme ; yet this could scarcely be supposed ever to happen where any practitioner of common sense was consulted. Upon the whole I have no hesitation in declaring, that decided advantage seemed to be derived from keeping up a moderate diaphoresis for one, two, or three days, by means of the more gentle, aqueous, saline, and antimonial diaphoretics, with a room and bed of moderate temperature. Powerful sudorifics, or great external heat, were seldom employed or necessary. "11. The liberal use of purgatives was always beneficial, particularly in relieving the distressing headache, which so fre- quently attended this disorder. The choice of the medicine seemed to be of but small importance. Calomel, being taste- less, and little liable to excite nausea, was perhaps in general the most eligible. But the common senna mixture, or neutral salts, or castor-oil, seemed to be of equal utility in those cases where they were employed. "12. There cannot be a doubt that full doses of opium in the commencement of the disorder, where the inflammatory action was considerable, with much heat, dyspnoea, headache, and constipated bowels, must have proved highly injurious. But on this point I cannot speak from experience ; common sense must have forbid it. I have, however, frequently ob- served very great relief from moderate anodynes, given to allay cough in every stage of the complaint, where their exhibition was not particularly counter-indicated, — such as syrup or extract of poppies, extract of hyoscyamus, or even opium. " Although I had little or no opportunity of observing per- nicious effects from the injudicious administration of opiates, it was not so with regard to wine and animal food. The pro- pensity of human nature, to search for and to frame some reason or excuse, for what it likes and relishes, together with the idle paragraphs in newspapers formerly mentioned, had induced a pretty general bias in favour of a generous regimen 240 EPIDEMIC OF 1803 in this disease, which in some cases it was not easy to remove. It was, however, in almost every instance, evidently pernicious, particularly in the early stages, and near the commencement of the epidemic ; and as the disorder was at that period so universally of an inflammatory nature it could not possibly be otherwise. " Some, to be sure, did survive such a regimen, but that is no proof of its propriety ; for it is very well known that patients in almost all diseases will sometimes struggle through in spite of any bad treatment." 4. DR. FALCONER 1 " The first appearance of the influenza, in such a form as to admit of no doubt respecting its nature, took place, as far as I can learn, about the middle of February 1803. "The access of this epidemic was not, I believe, dis- tinguished by any symptoms essentially different from those that usually mark the coming on of feverish complaints, especially those which incline to an inflammatory diathesis. Chilliness, shivering, a sensation resembling that of cold water running down the spine of the back, and often considerable pain in that part, together with a sensation of weariness and stiffness in the limbs, were, in general, the first symptoms. In some the approach of these was gradual ; but in many they came on with such suddenness, as to be almost instantaneous, and were in general more vehement than those of a similar kind which mark the approach of the usual catarrhal com- plaints of the season. " The above symptoms were soon followed by feverish heat, headache, cough, and difficulty of respiration ; together with an acrid distillation from the nose, great pain and throbbing of the temples, and great desire to spit, or throw off, by efforts of that kind, the mucus which collected in an inordinate quantity on the bronchial glands, and those of the fauces. The cough was in some subjects slight and inconsiderable, in others loud and oppressive ; and nevertheless often ineffectual to produce ^ An Account of the Epidemic Catarrhal Fever, commonly called the Influenza, as it appeared at Bath in the Winter and Spring of the year 1803. By William Falconer, M.D., F.R.S. Bath, 1803. DR. falconer's account 241 relief by the expectoration of mucus. The skin was at this period, in general, hot and dry, though in some persons sweats came on early in the complaint. In some bad cases, the peripneumonic symptoms increased to a great degree, the pulse rose to 100, 120, and 150, and were scarcely to be kept under by the most powerful remedies. Such cases, however, though not of extraordinary occurrence, were not, I believe, very frenuent. Out of more than 100 patients at the Bath Hospital, who were seized with the influenza, only six were attended with peripneumonic symptoms to any considerable degree. I must however own, that, in my private practice, the proportion of severe peripneumonic cases exceeded considerably what appeared in the Bath Hospital, probably because the advice of a physician was seldom asked in this disease, except iu cases that were attended with some anxiety respecting the event. " Vertigo, and that to a considerable degree, was, in some persons, one of the first signs of the disease, and, in several instances, very alarming and distressful. I saw a lady affected to such a degree as not to be able to raise her head from the pillow without losing all sense, and to whom all objects appeared thrice multiplied ; and these uncouth symptoms con- tinued four days in their full extent. I observed in several persons, that where the vertigo was most troublesome, and appeared early in the disease, the peripneumonic symptoms were but slight, and vice versa. Two of the worst cases of the peripneumonic kind that I saw, were not attended with any symptoms of vertigo. Those who were affected with vertigo, even to a less degree than in the case above described, were nevertheless unable to read a letter or a few lines in a book ; and in several a degree of delirium took place during the night, but not, as I saw, to any violent degree.^ " The expectoration, in ordinary cases, differed little from what is spit up in a common catarrh ; but in those instances where the peripneumonic symptoms were much aggravated, it was very large, of a yellow colour, and scarcely to be distin- guished from simple pus; it was, however, thrown up with ditficulty in several persons, and their inability to cough it up ^ "Dr. Haygarth has since informed me, that he saw one case attended with strong delirium." 242 EPIDEMIC OF 1803 completely, was one of the most alarming symptoms, and what I saw, in some instances, prove fatal. The breath was fre- quently much oppressed, and a great source of uneasiness : I counted it, in several instances, to be more than forty-five respirations in a minute. " Several persons, at the beginning of the disease, com- plained of soreness of the throat ; but no particular appearance in the fauces was observable, and in a few days it either went off altogether, or became so inconsiderable as to be nearly dis- regarded among so many other distressful symptoms. The catarrh or defluxion was, towards the beginning of the disease, thin and acrimonious ; but in a few days disappeared, especially in such cases as were combined with peripneumony, being probably carried off by the expectoration. " Pains of the limbs, especially about the joints, occurred to a considerable degree, in some instances in which the other symptoms were moderate, but generally went off in a few days. In one instance, however, they continued, in a very trouble- some degree, several weeks after the symptoms of the original disease had ceased. The body was, in those instances, I had an opportunity of observing, inclined to be costive during the course of the disease ; and I find that to have been the case with the patients at the Bath Hospital. I have, however, been informed, that a purging came on in some persons early in the complaint ; nothing, however, remarkable was observed in the appearance of this evacuation. " The urine was in quantity nearly as in health, but generally of a dark reddish colour, clear, and depositing no sediment. As the disease declined, it became tinged with a pink or whitish sediment, and paler in colour. In some cases the amendment was marked merely by the increase of quantity and change of colour in the urine to a pale amber hue, without any sediment being deposited. " The tongue was, at the beginning of the disease, hot and dry, and of a deep red hue. It soon, however, became moist, and of a whitish brown colour, and in some covered with a foul thick crust. In some instances, and those not the most favorable, the tongue was little affected, which I have often observed to be the case, even where the symptoms were very pressing, in cases accompanied with large expectoration. DR. falconer's account 243 " The skill was at first hot and dry, but this soon gave way to gentle perspiration, which took place pretty universally over the body as the disease abated. The appetite was, in the cases I saw, almost entirely destroyed, and the thirst pretty considerable. Acid juices of fruits were to some particularly agreeable ; but after a few days' use, seemed to create disgust. Iced creams, moderately taken, were highly acceptable, and served to cool the mouth and fauces ; the heat and dryness of which were among the most uneasy symptoms. " The pulse was variable, in some very quick, even to 1 5 in a minute; in others, not exceeding 80 or 90. Out of upwards of 100 persons afflicted with this complaint at the hospital, the pulse in no instance exceeded 100 beats in a minute. " In one of the worst cases I saw, the pulse never exceeded 72 beats in a minute, which was the usual number in health. Yet the patient at that time had every other symptom of peripneumonic fever, great heat, thirst and cough, with expec- toration so difficult that I apprehended suffocation would speedily take place ; and when, to relieve these urgent symp- toms, she was bled, as she was, twice in one day, to fourteen ounces, the blood drawn was so tenacious as to bear being lifted entire with a pin out of the cup of the crust, without affording more than a few drops of serum. " The debility that followed this complaint marked it very strongly. Few persons recovered their strength in less than three weeks, and several persons were so reduced as to be sensible of its weakening effects for a longer time after the fever had entirely ceased. In some a dimness of vision con- tinued sometime after the strength was pretty well recovered. " I have not had an opportunity of personally inspecting the body of any one who died of this disease, which was opened ; but the following account, authenticated by several medical persons of respectable character, was communicated to me by a gentleman who was an eye-witness, and whose accuracy and judgment may safely be trusted. I shall, there- fore, make no scruple of giving the detail of the case in his own words. 244 EPIDEMIC OF 1803 " Dr. Broderip's Account of a Case of Influenza, and what was observed on opening the Body. " ' I was desired to visit M. Ditcher, a young woman, in the 21st year of her age, who was indisposed with the prevailing epidemic disease ; it was on the ninth day of her indisposition ; and I found her in imminent danger. Upon inquiry into the origin of her complaint, and the symptoms which attended the incipient state of it, she informed me, that she was first seized with cold shivering over the whole body, drowsiness, and frequent chills, passing in the direction of the vertebrae; this was succeeded by feverish heat, a violent pain in her head, principally across her forehead, and immediately above the eyes ; throbbing at the temples, an acrid discharge from the nostrils, troublesome cough, and difficulty of breathing. The following day she was troubled with an internal pain, which she described as directly underneath the left mamma ; her respiration was more hurried, and she became more thirsty ; her urine was very high-coloured, and, after standing a short time, threw down a considerable lateritious sediment ; her tongue was much furred ; and the phlegm which she attempted to expectorate was so tenacious, that she could not loosen it from the fauces. With remissions in the day, but returning with more violence towards evening, the train of the chief symptoms continued to the day of my seeing her. " ' When I called, she was sitting in her bed, gasping for breath, and apprehensive of syncope. Her cough was in- cessant, and of a peculiar kind ; she expectorated a small quantity of mucus tinged with blood, her pulse was at 140, low, small and tremulous. Her tongue was foul, but not dry ; the coating different from what is usual in febrile affections, and more resembling the appearance which we generally find in cases of croup. She complained of unusual pain ; but particularly at the back part of the head, and across her chest ; in short, her situation presented one of those distressing cases which result from inflammation, protracted from the omission of timely bleeding, etc. Immediately on leaving the room I expressed my concern that she had not applied earlier to the medical gentleman who was then attending her ; and sub- mitted to him my opinion of the morbid state in which the DR. FALCONER'S ACCOUNT 245 thoracic viscera would probably be found, upon dissection, after death. " ' Soothing and such medicines as appeared to me the best calculated to relieve the pressure of the various symptoms, were administered till the 13th day, when she was suddenly seized with general spasm, and expired. The following day the body was opened by Mr. Cam, in the presence of Dr. Davis. When the contents of the thorax were exposed to view, the anterior part presented nothing remarkable ; but in attempting to take up the long lobe of the left lung, we found that adhesive inflammation had taken place over the whole posterior surface of that lobe. The adhesive exudation was considerable, and had attached that part of the lungs to the corresponding costal pleura, though the pleura itself was not inflamed ; but the connecting medium, being newly formed, readily gave way to the pressure of the hand, and enabled us to examine the posterior part of the lobe, which we found in a condition highly morbid. That part of the pleura, which is reflected over the lungs for its external membrane, peeled off in the same manner as the cuticle of a fcetus does, which has been some time dead in the uterus ; the substance of the lung was of a dark, livid colour, and appeared in a gangrenous state ; some vessels had given way in the diseased part, and about three ounces of extravasated serum, and some coagula, were found in the depending part of the thorax. Upon cutting into the lungs we found a good deal of extravasated coagulable lymph in its substance, and a very extraordinary quantity of blood was congealed in the vessels. The ramifications of the bronchia were loaded with puriform matter; and upon remov- ing and dividing a portion of the trachea, just above the beginning of the bronchia, we found its inner lining in a high state of inflammation ; the whole surface of the membrane putting on the appearance of what is usually termed ' great vascularity,' or, could we associate the idea of beauty with a destructive morbid action, I should say, that it looked like a beautiful preparation of a membrane, where the vessels designed to carry lymph had been filled with a vermilion injection. On viewing the inner membrane of the trachea with a magnifying glass, ulcers were clearly perceived at the edges of the small holes which supply 246 EPIDEMIC OF 1803 the trachea with mucus, to defend it from the acrimony of the air. " ' Upon dividing the pericardium the heart appeared natural ; but, on the posterior or lower side, the coronary veins were remarkably turgid with blood. The water in the pericardium was more than usual, but not exceeding what is sometimes met with in subjects unconnected with disease. " ' We were not permitted to extend our examination to the other viscera, — a circumstance which would have been a cause of much regret, had not the morbid state of the thoracic viscera so clearly evinced the nature and principal seat of the disease. " ' It may be proper to remark that the costal pleura, not being inflamed, accounts, in some measure, for the little relief afforded by blisters ; and it may not be undeserving of notice, that the patient's description of the seat of pain is deceptive ; for notwithstanding the disease was at the posterior part of the lungs, the sensation of pain was uniformly described as im- mediately beneath the anterior part of the chest.' " " ' We have perused the above accurate description, and find it perfectly conformable to the appearances presented by the dissection. " ' J. F. Davis, M.D. " ' Thomas C. Cam, Surgeon.' " " But notwithstanding this formidable detail of symptoms, the mortality that followed was not so great as might be apprehended, though greater than was commonly imagined. At the general hospital, in this city, where upwards of 100 persons had the disease, not one died, though several suffered severely. Four persons of those I attended died, and all of them peripneumonic ; but one of them had been subject to pul- monary complaints, and in a valetudinary state for the last six months ; another was in the decline of life and debilitated by repeated gouty attacks, and had his end hastened by a suppres- sion of urine, which, though relieved by the catheter, introduced without much trouble by an able surgeon, produced so much distress as to contribute in no small degree to his deatli. All whose cases terminated unfortunately were considerably past the meridian of life. " What proportion of people in society were attacked with this disease, I am unable to say. A large number were DR. falconer's account 247 certainly affected ; and it appeared to make no distinction in age, sex, habit of body, or state of health. The general hospital, which contained, at the time when the disease made its appearance, about 125 patients, had upwards of 100, or about 4 out of 5, seized with this complaint. " It will now be asked by what marks or symptoms is this epidemic distinguished, at or near its first appearance, from the usual complaints of the winter season, which it is acknowledged much to resemble ? I wish I could answer this question satis- factorily ; but I really know of no positive distinction, except in those cases wherein vertigo was among the first symptoms ; which, though often occurring, was by no means a constant attendant on this disease.^ The suddenness of the attack, indeed, afforded a pretty strong presumption ; but the epidemic spreading of the complaint afforded the strongest indication. All the symptoms, the vertigo excepted, which rarely occurs in catarrhs, and never I believe at their first coming on, are common to those complaints that accompany an inclement season of the year ; and it is more from the frequent appear- ance of the malady, and its aggravation of symptoms beyond a catarrh of the season, than from any specific diagnostic, that our judgment must be formed. " It is a matter of doubt with some, if this epidemic catarrh be a contagious disorder, or propagated from one person to another by infection, as the smallpox or measles ; or whether it be owing to a general cause, as a particular disposition, or, as it was formerly called, constitution of air ; affecting a large number of persons at the same time, which is the correct sense in which the word epidemical is used. " I have no doubt myself that it is contagious, in the strict- est sense of the word. It has scarcely ever appeared without spreading to a vast extent ; and has affected equally countries in the greatest variety, both in point of climate, and in the manners, diet, and habits of life of the inhabitants. But still there has always been a perceptible and, indeed, sufficiently- marked interval between its appearance in one country and another ; and it has never appeared in all parts at once, as it ^ "Dr. Haygarth observed to me, that tlie prostration of strength was much greater than in a common catarrh ; but I did not myself observe this to be the case at its fiist coming on." 248 EPIDEMIC OF 1803 would have done, had it been produced in each individual by some generally operating cause. " I proceed now to speak of the signs of amendment, or the contrary, that attend this disease. " The peripneumony has appeared to me by far the most threatening symptom of any. The abatement, therefore, of the cough, and some relief of the breath, are primary objects ; and except these can be attained, all other marks of amendment, even such as are drawn from the diminution of the numbers of the pulse, are fallacious, as I have experienced. A free and plentiful expectoration, if accompanied with the abatement of the difficulty of respiration, is a primary circumstance ; and next in importance to that, is an increased urinary discharge, which I have seen accompany the other, and prove, as it should seem, particularly serviceable. It is long before any appetite for solid food returns ; but some inclination for liquid nourish- ment is among the first marks of amendment. " On the other hand, when the difficulty and frequency of respiration both concur, in spite of the remedies used, the danger is increased, notwithstanding, as I have just before observed, the number of the beats of the pulse be diminished. " I have not noticed any bad consequences that seemed con- nected with the vertigo, wdiich, though threatening generally, went off in a few days. I shall now speak, as briefly as I can, of the practice which appeared to me most conducive to the cure. " And here I must freely own, that there appeared, in several instances, a strong necessity for active operations. The peripneumonic symptoms were so urgent as to supersede all general cautions respecting bleeding, and admitted of no alter- native. Nor have I observed, that the persons on whom this operation was practised, even to a considerable extent, suffered from any consequences that might be supposed to attend the excess of this evacuation. On the contrary, I found that those persons who were bled to such a degree as effectually to relieve, not merely to palliate, the more urgent symptoms, sooner recovered strength, than those on whom this operation had been most sparingly practised.^ In short, my decided opinion is, that, when it appears in a threatening peripneumonic form, it must be treated in the same manner as is found effectual in ^ " Clegliorn makes nearly the same remark. ' Diseases of Minorca,' p^). 261, 262." DR. falconer's account 249 that disease, without regard to any speculative opinions that may be entertained respecting its specific nature or character. " I freely own, that on the first appearance of this epidemic, I was somewhat deceived by the general opinion ; and, indeed, by some recollection of the same complaint in 1782, when bleeding appeared in some instances rather to aggravate than relieve the symptoms. The weakness, too, which this epidemic almost universally left behind, undoubtedly ought to suggest caution in the use of this evacuation. But, on the other hand, the urgency of the symptoms, the nature of the parts affected and their immediate importance to life, superseded these con- siderations ; and my observation of the relief which bleeding afforded, encouraged me to apply this remedy ; and I have the satisfaction to reflect, with the success I hoped for. " The application of leeches, in cases where the symptoms were pressing, I found inadequate to the purpose. They, indeed, when put on in considerable numbers (as to eight or ten) seemed to afford a present alleviation of the symptoms; but the relief was transitory only ; and bleeding by the arm was found to be the only means of imparting effectual assistance. It should, however, be considered that it is only in cases where the symptoms threaten life, that bleeding by the arm is necessary. In common cases,^ where the breath is little affected, other remedies supersede its use, or at least render the application of leeches sufficient. " Emetics have, in my observation, been found particularly serviceable. If administered at the beginning of the complaint, they ser^^ed to obviate the peripneumonic symptoms altogether, by throwing off with more ease the profusion of mucus, that in a good measure cliaracterises this disease. But in the advanced state I was soiTy to find the use of emetics less successful. When the breathing was greatly oppressed, it was difficult to make them operate upwards ; but they were subject to run off by stool, — an operation which did not afford the same relief with an emetic, and which, by diminishing the strength, without proportionably relieving the symptoms, seemed rather prejudicial than otherwise. " Diaphoretic, or ratlier sudorific, remedies seemed to succeed very well ; and, indeed, tliis seems to be the method pointed ^ " None were bled at the hospital, except with leeches, although more than 100 persons were attacked, and all recovered." 250 EPIDEMIC OF 1803 out by nature for the cure. The vol. sal. draught, with the jpulv. antiriion. or the vin. antimon. succeeded in most instances ; and in slight cases soon put an end to the complaint. With the same view I found moderate warmth, as that of a bed, highly- necessary ; together with the frequent administration of thin diluting liquors. I observed, however, that much heat, either of fires or of bedclothes, was prejudicial, and prevented rather than encouraged the salutary evacuation. The access of cold sharp air I found essentially necessary to be guarded against, as it immediately aggravated the cough and other morbid symptoms. " In one bad case, the excitement of the urinary discharge was particularly serviceable. A small quantity of the dulcified spirit of nitre was administered with a different view, and chanced to excite this evacuation very powerfully, and as it should seem with great advantage to the patient. " The medicines, usually called expectorants, as lac ammo- niacum and squills, could not in bad cases be employed ; and in the slighter attacks, there was no necessity for their use. The former was too heating and stimulant ; and the latter was apt to run off by stool. I must own, that nothing which I tried with this intent succeeded to my wishes, except the volatile alkaline, which, in the proportion of thirty or forty drops of spirits of hartshorn, taken pretty frequently in any warm vehicle, seemed to be of service. I had some expecta- tion that the steam of warm water drawn in by the breath, by means of some of the inhalers, might have answered this purpose, but was deceived. The breath was too short to admit of its being used effectually in bad cases, and in others it was superfluous. "Purgatives, taken by the mouth, were not so useful as might have been expected. When given in any effectual dose they seemed to weaken the patient more than to diminish the fever and relieve the most distressful symptoms. " Clysters, however, were of great service in preserving a due regularity of evacuation, and also in encouraging the secre- tion of urine, which I before observed was of considerable service. " Blisters were, I believe, pretty freely tried ; but, in the cases that fell under ray observation, I cannot say that they DR. FALCONER'S ACCOUNT 251 were as serviceable as I expected. In some bad cases they seemed to give a temporary relief to the difficulty of breathing ; but, in several instances, no good effect whatever was produced by them. I did not however find, except in one instance, that they were productive of any mischief. It should, however, be noticed, that I speak here of peripneumonic cases ; for in those where vertigo was the leading symptom, blisters were of great use; and, indeed, I think the principal cause of its abatement, even after leeches had been tried with little advantage. " Opiates I constantly found to be among the most neces- sary remedies. They were of the utmost service in abating the cough when convulsive and violent, and gave time for the expectoration to thicken into a consistence fit to be easily spit up. I never observed them to have any ill elTect in checkiug the expectoration. Some inconvenience, indeed, accrued from the costiveness which opiates occasioned ; but I saw no instance where this was not easily obviated by clysters. The black drop, called the Asiatic Balsam, seemed to me, in some instances, superior to the common Tindura Opii ; but its particular ad- vantages were not very considerable. " Having thus concluded my own observations, I wish to speak of the French account of the disease, as it appeared in the Moniteur of the 10th of February 1803, rather before (I think) its shewing itself at this place. This account is pub- lished under the inspection of the Soci6U de MMecine, at Paris, and signed by the President and Secretary- GeneraL " The general symptoms of the disease that they recite, are as follow ; and, probably, meant to be understood in the order in which they usually occurred. " General indisposition, want of appetite for some days, shiverings of longer or shorter continuance, and subject to be renewed by the slightest motion of the body, even when in bed, and alternating with a brisk heat ; heavy pain in the liead, in the forehead ; and above the eyebrows ; drowsiness, sense of weight, and weakness of the body ; inward heat ; partial sweats ; total loss of appetite ; tongue white, or inclining to yellow ; renewal of the fever at the coming on of the night ; and, some- times after midnight ; abatement of the symptoms in the morn- ing; quick, hard pulse, often very low, and becoming stronger, as the disease advanced to a favorable termination, and still 252 EPIDEMIC OF 1803 preserved its original nature and character. The fever con- tinued three, five, seven, twelve, fifteen days, and sometimes longer, but then changed its character. " It terminated either by urine, highly loaded, and deposit- ing a compact brick -coloured sediment; or by plentiful and universal sweats, or by expectoration of something resembling matter, which continued a shorter or longer time. Or, lastly, by mucous or bilious stools, and sometimes by a combination of several of the above-mentioned evacuations. " This disease is divided into seven varieties, each distin- guished by the parts principally affected. The first is the nasal catarrh or rhicme de cervemt, much the same as we mean by a cold in the head. This is marked in addition to the symptoms before mentioned by a stoppage of the nose ; vertigo ; tingling in the ears, and sharp pain in that part ; swelling of the parotid glands ; difficulty of breathing through the nostrils ; face swelled, red, painful, and of a bloated appearance, not unlike an erysip- elatous eruption ; the eyes watery and red ; discharge of a serous fluid more or less acrid from the eyes and nostrils, often swelling, inflaming, and even excoriating the nostrils and lips ; and sometimes a suffocating obstruction of every serous dis- charge whatever, "The next or second variety is, catarre guttural, or esqui- nancie catarrhcde, or what I believe we call the angina tonsillaris or common sore throat. The signs of this are a complaint of the throat, attended with shivering, swelling, and sliglit inflam- mation of the back part of the mouth, of the septuvi palati, of the uvula, and of the tonsils ; a painful sensation along the course of the trachea ; difficulty both of swallowing and of respiration ; hoarseness ; difficulty of speaking ; and the back part of the mouth covered with mucus, more or less thick. " The third variety is what is called catarre bronchial, rhume peripncumonic catarrhale. This is distinguished by a sharp dry cough, difficulty of respiration, sense of oppression ; a sharp pain in the side, felt principally near the false rib, and seemingly very superficial ; flying pains resembling rheumatism, moving up and down through the breast and the loins; saliva difficult to be collected, and frothy, often bloody ; bleeding from the nose, the lungs, or the hsemorrhoidal vessels, some- times symptomatic of the disease, and sometimes critical, but DR. FALCONER'S ACCOUNT 253 almost always relieving the pain of the head. This kind is often difficult to be distinguished from the simple peripneu- mony, which can only be done by considering the severity of the symptoms, and the particular seat of the pain. This variety terminated by expectoration, or by sweats ; the spitting became easier to be discharged, and thicker in consistence, and of a white colour resembling matter. Sometimes the disease seemed to be translated by a kind of imperfect crisis to the limbs, where it appeared in rheumatic affections. " The fourth variety is called catarre suffoquant, and was fortunately very rare. It principally attacked old people, and such as were of a bad habit of body, and was sometimes the consequence of improper regimen of living. It was apt to put an end to life at a time when danger was little apprehended. It was distinguished by a sensation of great weight about the chest, much oppression, and a wheezing sound from the bronchia ; the strength decreased rapidly, the powers of nature sunk, and a sudden congestion of mucus in the lungs soon finished the tragedy by suffocation. " The fifth variety is what they call catarre intestiTial, which happened when the disease took a course to the bowels, and appeared there in form of a mucous or dysenteric evacuation, which quickly exhausted the patient." The French physicians observe, that the above varieties are not all of them found distinct and separate, but are often much intermixed or combined with one another. " Another variety or distinction is said to be drawn from the nature of the disease, and is called catarre infiammatoire. The symptoms were a deep-seated pleuritic pain, occupying a fixed point about the middle of the third true rib ; considerable oppression of breathing ; frequent hard and compressed pulse ; great difficulty of respiration ; urine red ; the face swelled and inflamed. It attacked young, plethoric, and vigorous subjects, and was generally owing to the admission of cold air to the body when in a heated state. " Another distinction is taken from the complication of the epidemic catarrh with typhus ; or, as it is called, catarre gas- trique, catarre com2)liqu(^ de ficvre putridc ou adi/namique. This variety is described as common among those persons who gain their livelihood by their labour, and amongst artisans in the 254 EPIDEMIC OF 1803 civil and military hospitals. It particularly attacked poor people who lived on bad food, those who were subject to excessive labour, and in want of the common resources and comforts m sickness ; persons weak, exhausted, of bad habit of body, lying-in women, etc. Its distinguishing symptoms were prostration of strength ; tongue foul and bilious ; derangement and confusion of the intellectual functions ; low spirits ; loss of appetite ; flatulence ; heavy paleness of the countenance ; dislike of animal food ; nausea ; vomiting ; nervous symptoms ; pulse frequent and depressed ; signs of worms in the alimentary canal. " Prognostic or judgment respecting tlie termination of the disease. — The fever, when simple and properly treated, ceased about the fourth, or from thence to the seventh day, though it sometimes was protracted longer. The catarrh continued some- times after the fever was gone. Persons so affected were very liable to relapses, and their recovery was often difficult. These circumstances are recommended to be early attended to, as the catarrh may end in a consumption. Turbid and muddy urine, more or less of a brick colour, indicated the termination of the disease, at least of the fever, and the same often took place from sweating and expectoration. " This disease is declared not to be of itself dangerous, but liable to become so from the following circumstances : " 1. When those who were seized by it, persevered in refus- ing to change their manner of life, but continued to expose themselves to the action of the same causes which gave rise to it. In such cases the irritation was increased, the inflamma- tion of the chest shewed itself, and the catarrh became com- bined with a nervous or putrid fever. " 2. When those seized with it, mistaking the nature of the attack, attempted its cure by the exhibition of hot stimulating remedies, with a view to restore perspiration, which method of treatment was apt to convert a simple catarrh into a mortal peripneumony. "3. A third source of danger is said to originate from too large bleeding, when the quantity of blood drawn was regulated by the entire cessation of the local pleuritic pain, the relief of the breathing, and the disappearance of the inflammatory crust on the blood, wdiich last circumstance is condemned as extremely fallacious. DR. FALCONER'S ACCOUNT 255 " The immoderate use of syrups, and of oily lohocks or linctuses, is also condemned as prejudicial, and even dangerous, as is the early and inconsiderate administration of purgatives, especially when given at a time when nature was preparing for the crisis of the disease by another channel. The medical treatment of the disease consisted in a recommendation to avoid animal food, to keep in bed, and to preserve a moderate degree of warmth ; to use pectoral drinks, either sweetened with honey or otherwise, and taken pretty warm frequently, and in small quantities at a time ; to drink a decoction of bran, broths of veal, with onions and turnips, to inspire the steam of hot water through the mouth and nostrils ; in the evening, to take small quantities of the infusion of wdld poppy, sweetened with syrup of marsh-mallows, and with diacodion, provided the patient is in want of sleep ; to use the pediluvium, and emollient or gently laxative clysters. As the disease goes off, gentle purgatives are recommended, and afterwards mild tonic remedies. " Such is the general treatment, which they assure us, in general, is not less simple than efficacious towards the cure. In that variety of the disease that is accompanied with sore-throat, the use of leeches to the part affected is advised, together with emollient cataplasms round the jaw^s. If the pulse become weak, the stomach sick, and the glands loaded with mucus, an emetic of 1 5 or 2 grains of ipecacuanha is recommended ; and if that does not relieve the symptoms, a blister or sinapism applied round the throat, to be employed, however, as rube- facients, and removed as soon as symptoms of inflammation of the part come on. ' " In the third variety, called the catarrhal peripneumonyy they advise leeches to be put on the seat of the pleuritic pain, and these to be followed with the applications of emollient cata- plasms, or bladders half filled with warm milk ; and if these do not relieve, to have immediate recourse to a blister or a sina- pism. If, besides the pain in the side, the tongue be foul, if the patient complains of a bad taste in the mouth, an emetic of ipecacuanha often affords relief Opiates are also recom- mended, as fulfilling all the indications. If the expectoration stops, and the breathing becomes oppressed, blisters between the shoulders, and to the legs and arms, are advised. " In the fourth variety, or catarre suffoquant, they recommend 256 EPIDEMIC OF 1803 not to lose a moment of time. Warm iuciding draughts are advised, with large doses of oxymel scilliticum ; ipecacuanha and antimonial vomits to be repeated till a discharge be ob- tained. Blisters are also advised as before. " In the fifth variety, or the catao^e mtestinal, ipecacuanha is advised to be given as an emetic at the beginning of the disease, with pectoral draughts, mucilaginous clysters, gentle purgatives, bolusses with opium, ipecacuanha, or the Peruvian bark, according to circumstances. " In the catarre inflammatoire they recommend bleeding at the beginning, and to be repeated as the symptoms seem manifestly to indicate. We are cautioned, however, to attend carefully to the state of the pulse, both before and after this operation, and to keep in mind the observation that a great prostration of strength attends the frequent repetition of bleed- ing in the generality of epidemical complaints. " When the catarrh is complicated with typhus, we are advised, at the beginning of the complaint, to use ipecacuanha and tartarised antimony. To keep the body open by mild evacuants ; to use pectoral drinks, rendered gently emetic ; vermifuge remedies ; mild antimonial preparations ; oxymel of squills ; camphorated juleps ; sinapisms and blisters to different parts ; gentle purgatives, and slight tonic preparations, which last are directed to be continued for a considerable time during the recovery of the patient." " Such is the abstract which I have given from the account of this disease, published by the Faculty of Medicine in Paris. The symptoms are much the same with those observed in this country ; but I suspect, if these were as urgent as here de- scribed, that the mortality must have been greater than they seem willing to allow. The vertigo seems to have been more general and more distressful in the cases that fell under my observation, than it is represented to have been in the French accounts. " The method of cure seems to be, as far as respects the general indications, judicious and proper, but encumbered with a farrago of decoctions and pectoral drinks, wdiich were in use in the old French practice ; and which the modern practitioners, notwithstanding their pretences to lay aside old prejudices, have not yet reformed. DR. FALCONER'S ACCOUNT 257 " Probably the greatest improvement that could be suggested, would be the more free use of emetics at the beginning of the complaint. The recommendation of this remedy, together with bleeding and blisters early in the disease, is however a proof that they attended to its leading symptoms, and to the indications which they suggested. " The editor of the last edition of M. Sauvage's Nosologia Methodical has described this disease as it appeared at Paris, A.D. 1743, under the name of rlieuma cpideinicum, anno l743, — la grvpije, — which is the name by which it is at present distinguished in France. " It came on about the beginning of Lent, which appears that year to have taken place on the 5 th of March, not very different from the season when the late epidemic came on in this country. Its symptoms were a dry cough, pain of the limbs, fever during the day-time, and headache ; but, in young subjects, these symptoms did not continue longer than the fourth day, and were relieved by increase of spitting and ex- pectoration. In old people, these symptoms came on with greater violence ; and when accompanied with a hissing noise attending the cough, carried the patients off", about the ninth or the eleventh day. On dissection, the lungs were found either gangrenous, or much charged and distended with blood. In many persons a haemorrhage from the nose had come on before death, and sometimes afterwards, notwithstanding the patient had been bled two or three times. Forty persons died daily of this disease, for some time, in the Hospital of the Invalids at Paris. " The most successful method of treating this disease was as follows : on the first day, two bleedings ; on the second, an emetic or purgative ; on the third, bleeding again ; and in the evening, an opiate julep ; from the fourth day to the ninth, a medicine was given, composed of three grains of Kermes mineral, with half a drachm of vitriolated tartar, and the like quantity of diaphoretic antimony. This quantity was divided into six doses, of which one was taken every three hours : about the tenth day the recovery was perfected by the accom- panying expectoration. " This practice seems in the main judicious, though some of 1 Vol. iii. J). 225, edit. 179.5 ; Lipsise. 258 EPIDEMIC OF 1803 the remedies advised are now rather out of date. By the recommendation of repeated bleeding, I am apt to suspect it resembled the late epidemic, which last certainly partook more of an inflammatory disposition than those in 1775 and 1782. That in 1788 more resembled the late influenza in this respect ; but the inflammation of the throat was in that more common and more vehement, and the peripneumonic symptoms less urgent. Bleeding, however, which, in those of 1775 and 1782, had been less necessary, was in that indispensable, as it was in the one with which we have been lately visited. " The state of the lungs appeared, on dissection, according to the account in the ' Nosologia Methodica,' to resemble that above described by Dr. Broderip ; and these circumstances argue strongly for decisive measures towards the cure being- adopted early in the complaint, should it appear again in a similar form to that of the years 1782 and 1803." 5. DE. JOHN NELSON SCOTT i " Observing, in your interesting volume of Annals for this year, that you intend in your next to present some account of the influenza, permit me, residing in this detached spot of the British empire, to trouble you with my observations on the late epidemic, premising, that the climate of the Isle of Man very much agrees with tlie description of that of Ireland, as fur- nished by the ingenious Rutty. Our weather is very vicissi- tudinous, and our atmosphere exceedingly moist. The latter quality is very peculiarly possessed this last winter. Patients under typhus were in a greater proportion. The pertussis had been among us, and we met with some sporadic instances of scarlatina simplex. " In detailing my experience of the influenza, I shall sup- pose that you have proposed the questions which Dr. Richard Pearson did in his circular letter ; not that I had the honour of receiving one from him ; but, I presume, you approve of the plan of queries, by your adding two very apposite ones to the doctor's. ^ Observations on the Influenza as it appeared in the Isle of Man, in Spring, 1803. By Dr. John Nelson Scott, in a Letter to Dr. Duncan, Senior. ' Annals of Medicine,' vol. iii. p. 424. i DR. NELSON SCOTT'S OBSERVATIONS 259 " 1. The influenza appeared among us towards the end of March. The first patient I saw was on the 24th, who had received the infection from a gentleman, who, two days before, had arrived from Park-gate, and who had been seized with the complaint in London, and was still labouring under it. In a few days after, one of our Liverpool packets arrived, having many passengers on board under the epidemic. From my inquiries, I have every reason to think that thus it was im- ported among us. "2. It was not generally attended with symptoms which shewed an inflammatory tendency ; and even much less so, in tliis respect, than in the epidemic of 1782. By referring to my late father's notes, I am clear on this point. " 3. The proportion of pneumonia cases was very small. They amounted to a few, indeed, when compared to the number of other patients. Stout young men, who were exposed to wet, etc., had strong pneumonic symptoms. Pregnant women were also much affected with pain in the side (particularly the left) ; had great cough, and difficulty of breathing, and, on the whole, suffered much from the complaint. But, except in these two sets of patients, genuine marks of inflammation in the lungs and pleura were seldom to be met with. " 4. In the generality of my patients, the attack of the disease, and its progress for a day or two, were much alike to what we observe in typhus. In so much so was this the case, that at the first breaking out of the disorder, we were difficulted in the diagnosis ; for the typhus here often comes on attended with some of the phlegmasia, particularly simple catarrh and cynanche tonsillaris ; and I am confident that much liarm ensues in practice, in paying too much respect to the presence of such phlegmasiae, as in a day or two they very generally disappear, at least are not so material in themselves, as is the withholding the proper remedies for typhus, especially the cold affusion. None complained of acute pains on the attack, except the few in whom the pulmonic symptoms were high ; then the side, or middle and upper part of the chest, were the parts specified. I had some patients under acute rheumatism, who had lost much blood, and who were attacked with the influenza in their bed. In all of these, but more remarkably in one (a gentleman of plethoric habit, and who had had a 260 EPIDEMIC OF 1803 violent rheumatic fever three years before), the violent pains of rheumatism subsided for a few days on the first seizure of the epidemic ; instead of which he complained of the usual un- hinged sensations in the head, back, and limbs, attendant on influenza : on tlie declining of which, that is, in three or four days, the rheumatism returned, and, owing to the violent pains in the joints, required further evacuations of blood. There could not possibly be a finer elucidation of the state of the system, induced by the influenza supervening on a rheumatic diathesis, than this gentleman's case afforded. " r>. The stomach was very commonly much out of order from the first, with nausea, inclination to vomit, and, as I suppose, arising from this state of the stomach, there was a disagreeable heat, and unpleasant taste in the mouth. This last was a very much complained-of symptom, and continued, with a furred tongue, in some far advanced in convalescence. Except where the disease was very light indeed, patients were not inclined to take anything but drinks ; and those of the acidu- lated kind were most grateful. Many, by this way, found a temporary relief to the heat in mouth, and nausea, from half a pint of Henry's soda-water, and from equal parts of porter and water, which were never interdicted. The bowels commonly were much inclined to be constipated ; but in some, the super- vention of a diarrhoea, on the fifth or sixth day, seemed critical. In such cases the faeces were surcharged with bile, otherwise there seemed a deficiency of that secretion by the clayey appearance. Few complained of pain in the bowels. " 6. In a number of cases, the complaint terminated with very trifling expectoration. Where the pneumonic symptoms were high, and the patient doing well, we had the sputum album et bonum. I remarked that the sputum, where the pain in the side was violent, was generally streaked with blood. In some patients, where the disease had not been severe in any respect, a copious viscid expectoration, with a trifling hawking cough, supervened, and continued for a week or two, after the person might be said to be well. Such were relieved by bark and equitation. "7. I feel quite satisfied as to the infectious nature of the influenza. I had many opportunities of observing the most incontestable proofs of it, from the persons who first imported DR. NELSON SCOTT'S OBSERVATIONS 261 the complaint, to the infection of the distant mountaineer. I have reason to suppose, that the contagion often exerts its influence much sooner than is commonly imagined. I have witnessed its specific action in the course of a few hours. It is curious to remark the insusceptibility shown by some constitu- tions to take on the disease : one or two very striking instances [ had an opportunity of observing, in the members of large families. " 8. From the superstitious notions annexed to the opening of dead bodies in this country, my curiosity in this respect is never gratified. I should much sooner be pardoned for murdering a man, than opening him afterwards. " 9. With the class of strong and athletic males, especially those resident in high and mountainous situations, the lancet could be used pretty freely. In general, bloodletting from ten to fifteen ounces was required at first ; and it often was neces- sary to repeat it a second time, but not to such an extent. With pregnant -women, I found the French practice of bleeding frequently repeated ; but very small bleedings, the most advis- able. But however violent the cough, pain in the breast, and other pneumonic symptoms were, neither males nor females could bear with impunity such a loss of blood, as may be sus- tained in genuine pneumonia with advantage. I know it for a fact, that several fell victims to the immoderate use of the lancet, as prescribed and practised by old wives and rustic phlebotomists. Antimonials and blisters I found of great and special use, conjoined and separate, in many cases, and were great auxiliaries to the lancet, particularly the latter. But where the pneumonic symptoms were high, they were not sufficient of themselves. I cannot speak much of the calomel alone (except as a purgative). When combined with opium, as recommended by the late Dr. Hamilton, I am in tlie liabit of using it in cases of catarrhus senilis, and with decided benefit. But I cannot say so much for its effects in influenza. " 10. Profuse sweating was exceedingly hurtful at any period, particularly if excited by strong diaphoretics ; but I invariably kept the patients to bed for some days, if the com- plaint was not very trifling indeed, and this practice I hold to be of the first importance. In the first days, I looked on the bed as half the cure ; and when we consider the less irritation 262 EPIDEMIC OF 1803 there is tlius offered to the system, and the freedom with which the vessels of the skin act, we are not to be surprised. I do not of course mean that the patients were closely covered in bed, and under much perspiration. I attended assiduously to the temperature of the chamber, and I continually observed, that where it was cool, and ventilation practised, that it contri- buted much to the comfort of the sick, and tended to accelerate their recovery. In the habitations of the poor, where ventila- tion, etc., were not well attended to, their sufferings were in proportion greater ; and where, as I often had occasion to observe it, a man, his wife, and three or four grown-up children were crowded in a small dirty apartment, 1 thought it a charity to order the window to be taken out, and to remain so night and day. This practice seldom failed to relieve the stuffing of the head, dejection of spirits, etc. When the pneumonic symptoms were high, this was had recourse to with more caution. "11. I found it necessary to keep the bowels soluble. But I did not find that the symptoms were relieved by a hyper- catharsis ; neither was I sensible that more benefit accrued in effecting the purpose of a purgative, by using the decoct. Tamarind, cum Sen. and such like, or by having recourse to the more drastic means of Calomel, which alone, and with Jalap, I tried freely. As a purgative and stomachic, I used with advantage a large dose of Calcined Magnesia and Pulv. Ehei, with a drop of 01. Cin., to be taken over night in a large draught of any simple water. "12. I seldom administered Opium by itself at first; but when the complaint was farther advanced, and it became necessary from a teasing cough, etc., I exhibited Tinct. Opii in large doses, finding that small ones manifestly did harm, by adding to the irritability of the system. Many, on being attacked, took Tinct. Opii camphorat. of their own accord, with various effects. In general, they were prepossessed in its favour, and continued its use. " I shall now proceed to answer the queries proposed by yourselves ; first, observing that we have in this town about 6000 inhabitants, and in the island about 35,000. " 1. I have seen a very large number of persons under influenza, amounting certainly to some thousands. Not that I DR. NELSON SCOTT'S OBSERVATIONS 263 mean to be understood that I was called in to the greater number, but that with a view of observing the symptoms of the disorder on different constitutions, and in different parts of the island, I put myself to much extra trouble. Of patients immediately under my own care, I lost five of pure influenza; they all died with symptoms of pneumonia typhodes. No petechise appeared that I could discover on any. In two there was an eruj)tion, but it seemed of the miliary kind, and arose, I believe, from their being kept too warm in bed, very much contrary to my orders. " Two (in whom was the miliary appearance) were bled, but with evident bad effect ; but, indeed, I was in a manner com- pelled to it, by the violent pain in the side, and tremendous cough. Strong soups, wine and stimuli, including blisters, were the means used. "The subjects were all above 20, and under 55. " The mortality, in an indirect way, was truly very consider- able ; in which class I include persons who had been long tottering over the grave from age. Old people, I observed, had not the complaint unusually violent, but it was so, relatively considered with their frail constitution. " Though a little out of place, I must remark, that I had no infant patients, nor many very young people, and those labouring under various chronic ills, as asthma, catarrhus senilis, hydropic affections, etc. ; and one (a much regretted friend, a captain in dragoons), a martyr for some years to angina pectoris, and who, by the way, had been greatly bene- fited in this dreadful malady by the use of issues. " The influenza, also, most manifestly hurried off many who were in different stages of phthisis. This effect, I observe, is doubted by some, and denied by others, in the full history of the influenza of 1782, given in the first volume of ' Medical Communications,' But my own experience leads me to a perfectly contrary conclusion ; and surely it seems as probable, that tubercles in the lungs will be irritated as much by a cough induced by a specific cause, as by one arising from cold. "2. In scrofulous habits, the influenza often is followed by phthisical symptoms ; and when consumption is a sequel, it runs on to its fatal termination with greater celerity than I have observed as arising from other excitatives. Some, I am 264 EPIDEMIC OF 1803 sorry to say, have become victims to phthisis this autumn, iu whom no symptom of the disease had appeared previous to the attack of influenza last spring ; a very short course for a com- plaint, as often lingering as it is certainly mortal. " The epidemic left, in many males above 50, a great liability to be affected with cold, in the way of cough, which may eventually become catarrhus senilis, or may give an aptitude to an attack of peripneumonia notha. " A frequent immediate consequence of influenza in pregnant women was to induce miscarriage, which in the latter months was attended with the most dreadful floodings. On reasoning on this consequence of the influenza, it seems to me, that perhaps the epidemic exerts an analogous, though not so violent an influence on the pregnant female, as variola, however favourable, is known to do ; and that thus, and not from the mechanical effect of the cough, etc., are we to account for so serious an occurrence. " Some few patients had epiphora and inflamed eyes, as we observe in measles, for a considerable time after the influenza had gone off. Some were afflicted with repeated attacks of epistaxis ; and one patient had hamoptoe to a serious degree after the epidemic had left him, who had never before been subject to such an ailment. The patient with haemoptoe had no hereditary claim to phthisis. Perhaps all these cases arose from the debility occasioned by the previous increased action in the vessels of the head and lungs." In reference to the meteorological phenomena of the year, it may be interesting to mention that, on the nights of the 5th and 7 th of March, red snow was observed on the mountain Tolmezzo in Frioul. Eed rain and snow fell at the same time in Vienna, and passed over Italy and Sicily, falling from a dark red cloud, coming from the south-east, and attended with lightning, thunder, and hail. The cinnamon-coloured dust with which this was associated contained eighteen species of poly- gastric animalcule, one of which, namely the Synedra entomon, is known only in South America.^ 1 Ehrenberg, Passat-Staub uud Blutregen, jip. 107, 129. DR. BURXES REPORTS 265 EPIDEMIC OF 1831 DR. BURNEi " The present influenza — a disorder according exactly with the Tussis epidemica of Sydenham, and the influenza of later authors, — has prevailed epidemically for the last two weeks in this metropolis, affecting all ages, and supervening without any assignable cause. Of seventy patients who presented them- selves at the public Dispensary, on Thursday, the 23d inst. (June), more than one-half were suffering from the influenza. The influenza may be said to centre in the chest, although the whole body is affected by it, the head particularly. When at its height it consists in a severe, hard, harsh, dry cough, recur- ring more or less in paroxysms, with great soreness behind the sternum or a fixed pain on one side of it. The whole mucous lining of the throat, nares, and eyes, participating in the affection, the eyes being vascular, the nose stuffed, and the throat slightly sore. The head, too, is heavy and painful, and it jarred distressingly by the paroxysms of coughing, which gives the sensation as if the head was splitting. Withal, there is an unusual languor and debility disproportionate to the local affection. The skin is generally very hot, and at the same time chilliness is felt on exposure to a current of air. Tiie tongue is foul, the taste impaired, and the appetite gone. The urine is scanty and high coloured, and there is a great and general malaise. The pulse is accelerated, and increased in volume and force, yet it is by no means full or strong. The attack commences with a sense of rawness, with irritation, and at the same time constriction in the trachea, extending down- wards to the chest, which provokes a cough of the character above described. In addition to which is a heaviness of the head and dullness of the sensorial powers, and great bodily languor. The eye soon feels stiff and weak, the nares dry and stuffed, and the throat rather full and sore. There is also this circumstance peculiar in the attack, namely, that the patient is not sensible of having taken cold, nor of any cause that can ^ Dispensary Reports by John Burne, M.D., Physician to the Public Dispen- sary, Chancery Lane. London, Medical Gazette, 1831, vol. viii. p. 430. 266 EPIDEMIC OF 1831 have produced his illness. The invasion does not depend on the usual exciting cause — cold, but must be considered spon- taneous. Some persons, it is true, date the attack from a particular chill or exposure, but this is rare compared with the number affected. The influenza generally goes off with an abundant nocturnal perspiration, about the third or fourth day, and with a considerable discharge from the nostrils, but not by an abundant expectoration ; the cough continuing nearly dry to the last, and there being only a little thick, tenacious expectoration, which is detached with difficulty. Cases of this description in which the pneumonic signs are severe, require the antiphlogistic treatment of bloodletting and antimony ; but I have not been induced to bleed largely on account of the great depression of the strength and dullness of the sensorial powers, nor have I in any instance had occasion to draw blood a second time. I have found the abstraction of eight, ten or twelve ounces of blood sufficient, in the worst cases, to mitigate the severe symptoms immediately, and with the assistance of the Tartarized Antimony and the Tinctura Camphoratse Comp., and a blister, or warm plaister, to remove them altogether in a few days, leaving the patient, however, weak and languid. In the milder cases of the influenza the pneumonic symptoms are less urgent, while the pain and heaviness of the head, with the depression of strength and dullness of the sensorial powers, is greater than in the description above given. Indeed many of these patients present the aspect of persons attacked with the adynamic fever, so much are the vital powers depressed. The pneumonic symptoms in these milder cases, consisting of a tickling sensation in the trachea, with a dry, troublesome cough, are relieved by saline medicines and the Compound Tincture of Camphor, and warm plaisters to the chest ; but so prominent is the prostration of the powers of the muscular and nervous systems, that I have, in many instances, been obliged to commence at once with the Carbonate of Ammonia, which lias been followed by the best effects. With this various treat- ment, adapted to the peculiarities of the case, the patients have all done well. " Case I. — A young man, about 2 2 years of age, presented himself at the Dispensary, on Monday the 19 th inst. He complained of a sense of rawness and irritation in the trachea. DR. BURNE'S reports 267 with a dry and rather harsh cough recurring by fits. His eyes were very vascular, but dull and heavy. His nares felt stuffed, his skin was dry and hot ; the tongue foul, the appetite gone, and the urine scanty and high coloured ; his head also was heavy and painful. The most prominent feature, how- ever, was a very great muscular debility and dullness of the sensorial powers, which deprived his face of expression, and himself almost of the power of supporting his body. The character of the febrile movement was markedly adynamic. I directed a warm plaister to be applied to the chest, and one drachm of the Liquor Ammoniee Subcarb., to be taken every four hours, with 20 drops of the Spir. Lavand. Comp. in peppermint water. By this treatment he improved speedily, the cough abated gradually, the headache and heaviness diminished, and his strength began to return. He is now convalescent. " Case II. — On the 2 3d inst., early in the morning, I was called in haste to visit a medical friend, who although rather subject to colds, felt himself now unusually ill. He was lying in bed, distressed by a hard, harsh, dry cough, which jarred his head excessively, as well as aggravated a fixed pain on the right of the sternum. The cough recurred in paroxysms, during which he suffered more from its effect upon the head than upon the chest. He had, in addition, considerable pain in the head, with depression of strength and spirits, believing himseK to be very ill, and having feelings of apprehension which he had not experienced on other occasions. The pulse was accelerated, and somewhat increased in force and volume, but it was neither full nor strong ; the tongue was foul, the skin hot. He was restless, and had been indisposed for two or three days, with pain of the head, and wandering pains about the chest. He was bled immediately to twelve ounces, and began to take one sixth of a grain of the Antimon. Tartariz. every two hours, with 20 drops of the Tinct. Camph. Comp. By the evening he was much relieved ; the severity of the pneumonic signs was checked by the loss of blood, and effect- ually relieved as soon as the antimony produced nausea, which happened in a few hours, his stomach being easily acted upon by that remedy. Still, however, he felt ill at ease ; his head was light from the loss of blood ; he was weak, and anxious 268 EPIDEMIC OF 1831 about himself. The antimony was discontinued, and after having passed a tranquil and refreshing night, he was next day in a more comfortable state, and free from apprehension. From this time he has recovered rapidly." About the same time that influenza visited London it also prevailed at Plymouth, where delirium was not an uncommon symptom ; and at a later period some of the cases terminated in diarrhoea. The complaints of this spring, as well as of the previous year, were considered peculiar in character, as though from some unusual atmospheric influence.^ " The disease first appeared, as related by Mr. Lawson,^ on board the Hon. Comp. ship ' Inglis,' while at China, on the 25th of January 1830, on which day eight or nine men were suddenly seized ; on the following day twenty -four were at- tacked; on the 27th eight or ten; and on the 28th and 29th six more cases are recorded, after which there were no new cases. The attack was sudden, and the disease, within two hours, as severe as during any time of its continuance. The symptoms were pain in the head, more especially over the frontal sinus. Cough, discharge from the nose, sense of raw- ness in the throat and chest, rather than severe pain ; great prostration of strength ; in some of the cases there was pain in the epigastrium, as well as across the loins, with severe aching pains in the limbs ; pulse frequent, but generally soft. The febrile symptoms in most cases had entirely subsided on the third or fourth day, and the cough, in the majority of instances, in about the space of a week from the commencement. There were, however, some exceptions, where a troublesome cough remained for two or three weeks. The remedy employed at the commencement was an emetic of Bj Pulv. Ipecac, with subsequently febrifuges and purgatives. One man who had for a length of time been confined to his hammock with swelled testicle, was also attacked among the rest ; but it left him about the usual time, his other complaint having been in no way affected by it. " The disease prevailed again in China during the month of September, and at the same time visited Manilla, where it had 1 On the Epidemic Catarrh Avhich prevailed at Manilla, etc. By George Bennett, M.R.C.S. London, Med. Gazette, 1831, vol. viii. p. 522. - Idem, 1831, vol. viii. p. 525. ADMIRALTY REPORTS 269 also raged in the year 1810, and exhibited similar symptoms to those which were presented in China. " Previous to the appearance of the epidemic catarrh at Manilla, the weather had been nnnsually hot and dry for the season of the year, which combined with a very variable atmosphere, during the day and night, was considered by the inhabitants to forebode a severe hurricane or an earthquake. . . . The crew of the ship ' Charles Forbes,' which arrived at Manilla from China, on the 18th of September, was attacked with the epidemic during the voyage. "During the month of May the weather was unusually variable; the barometer rising and falling suddenly, and the thermometer standing one day at 80° Fahrenheit, and a few days afterwards at .32°. The wind was prevailing steadily from the north-east. The month commenced with heavy clouds, murky storms, copious precipitations of rain, and remote thunder ; the thermometer ranged from 55 to 60 degrees, and the wind blew for a few days from the west, and then shifted round to the north. This condition of atmosphere was succeeded by an overcast sky, with intervals of sunshine ; a keen, cutting wind from the north-east, frost, ice, and snow; the thermometer rapidly sinking to 32 degrees. Greatcoats which had been thrown off were resumed, and the fire-hearth became accept- able. By the middle of the month the weather cleared, and became warmer ; the sky brightening, a high blustering wind prevailed from the north-east, drifting before it clouds of the dust from the roads ; the thermometer ranging with celerity between 62 and 32 degrees. During the severest intervals of this weather ice was formed upon the ponds at night ; the early fruits were partially blighted ; the petals of the new-blown rose dropped from the shrub, and the hedge-row box seemed as it were singed ; ' the frosty air burnt froze.' The north- east wind was heightened into a gale, by which several vessels were drifted from their moorings in the port of the Thames, and a heavy atmosphere, a calm, and a soaking rain followed. From this time, the 20th, to the end of the month, either a grey mist, with a hot sun, 80°, occasionally gave way before a gelid wind, 40° from the north-east, the usual forerunner of storms and thunder, or the soil became dry and dusty under a light sunshine, with fleeting cloudlets, or a sultry sun gleamed 270 EPIDEMIC OF 1831 through a hazy atmosphere. The thermometer stood at 32° and, in the day, varied between 50° and 80°. A pelting rain, north 50°, and a fine, clear, breezy day, west 60°, closed the month. Then followed the month of June, remarkable only for a high temperature, a singular humidity of air, a soft wind from the south-west, and a bright, hot, summer sun. During the first days of the month the sunshine was interrupted by a light rain, once by clouds, rain, and a gale from the north 40°, and occasionally by transient hail-storms, and remote thunder. The thermometer ranged between 40° and 80° ; but it generally varied between 75° and 60°; and this was the month in which the influenza made its appearance." ^ " Additional evidence of the unhealthy character of this year is afforded in the following extract from the 'Statistical Eeports on the Health of the Navy' for the years 1830-6.^ ' In certain positions within the tropics, or on their confines, little surprise is excited when an unhealthy succeeds a healthy year, or when a series of years in which there is much mortality follows a number in which there had been comparatively little ; because we are prepared by experience for the eruption of sweeping epidemics there, which leave no room to question the cause of difference, whatever doubt there may be as to the origin of the epidemic on which the difference evidently depends ; but in the force under review, embracing the ports and shores of Great Britain and Ireland, and the adjacent seas, and in the absence of any uncommon, generally-diffused, or epidemic disease, it is surprising that the mortality of one year should more than double that of the year which immediately preceded it. In 1830 the rate of dying, from all causes and in both sections of force, the home and various, was 7'5, while in 1831 it was nearly 16 per 1000 of the number employed. The former is lower than that of any foreign station in any one year, excepting two years in South America, and is under the annual average of seven years there: the latter is within 4 per 1000 of the annual rate of dying, on seven years' average, in the "West Indies and North American command, and nearly double the ^ J. A. Hingeston, in London Medical Gazette, 1831, vol. viii. p. 587. ^ Part II. Africa. Home and varions forces, p. 157. The preceding tables in these reports present results which differ strikingly from those of the year 1830, and for which there are no means of accounting satisfactorily. VARIOUS AUTHORS 271 annual average of the South American. . . . The augmented mortality depended chiefly on increase of force in the causes of febrile disease, and that not only of idiopathic fevers, but also of other diseases in which there are febrile manifestations.' There was no adequate meteoric or other cause discovered. " The pervading influenza which occasioned increased mor- tality among the citizens and the shore-residents appears to have been extended to the harbours and coasts of these islands, giving to common forms of disease, as on shore, more than ordinary degree of fatal force. During the following year the cause of malignant cholera became operative in many parts of the United Kingdom, with great concentration of power, and proved fatal in a very higli proportion of the number attacked. Whether the same, or an altered agency, with less concentra- tion and more diffusion, co-operated with the common causes of disease during the year in question, and endowed them with greater destructive agency, cannot be determined ; but looking at all the circumstances, and bearing in mind the peculiar power of endemic, epidemic agency in some other cases, it is reasonable to conclude that it did." A large proportion of the cases of catarrhal fever noticed in these reports were from the receiving-ship off the Tower of London. During the prevalence of influenza many other diseases exhibit more than the ordinary degree of fatality. On the continent, during the year 1830, intermittent fevers prevailed, succeeded by remittent and gastric fever. At the beginning of 1831 the prevailing type was again intermittent. In May influenza appeared, to be followed in summer by cholera.^ There were great variations in the duration and severity of this visitation in different places. Thus for example it did not increase the mortality in Paris, but at Berlin was as fatal as cholera. At Berlin it lasted only a few weeks, at Moscow and St. Petersburgh two months, but at Paris it hung about for a year." Dr. Lombard observed that the symptoms in Geneva were similar to those in England. That physician found emetics so useful that patients often felt cured the day after their employ- ' Medicinische Zeitung, pp. 242, 247. ^ Gazette Medicale, 1833. 272 EPIDEMIC OF 1831 ment. The pulse sinking from 100 to 80 or 70, and the head- ache, whatever its intensity, disappearing as if by enchantment,^ Adynamic fever, influenza, dysenteric diarrhoea and cholera succeeded each other, and indeed, to a certain extent, prevailed together in the year 1831, so as to present a resemblance to the epidemic constitution described by Sydenham as prevailing from the year 1675 to 1679. The disease prevailed very extensively amongst horses, affecting the whole system, and often making its attack whilst they were under a medical regimen adapted for its removal. In the months of August, September, and October many horses in the neighbourhood of Chester were affected with dysentery, and the same disease was very widely diffused amongst dogs.^ A similar transition was observed in epidemic influence exerted on the human subject, especially at Paris. In tliat city, during the month of July, which was even hotter than usual, diarrhoea and dysentery took the place of influenza ; and in August the intestinal catarrh was called cholerine. Some degree of intestinal irritation, indeed, attended some of the cases of influenza.^ In the year 1832 epidemic diseases extensively affected the lower animals. Chickens, in various parts of France, had an affection analogous to cholera. They were thirsty, suffered from spasm, sought the sun, and crowded together for warmth, and their blood was darker than natural. Great mortality was also observed amongst fish, especially carp, and their spinal cord was found in a state of great congestion.* On the 15th of May 1830, during the prevalence of the Sirocco, red-dust fell on the ship " Eevenge " at Malta. This dust was accompanied by rain, and the atmosphere was at the time thick, and of a yellow colour. The wind was east- south-east. On the 27th of October similar dust fell on board the Prussian merchant-ship, " Princess Louisa," to the west of Africa, and at the Cape de Verd Islands.^ 1 Gazette Medicale, 1883, p. 729. ^ Veterinarian, 1831, pp. 185, 217, 223. 3 Chomel ; Gazette Medicale, 1831, p. 314. ^ Groguier Recueil de Med. Veterinaire, vol. ix. Olivier, Gazette Medicale, No. 27, 8th May 1832. ^ Ehrenberg, op. cit., p. 116. MR. HINGESTON'S REMARKS 273 EPIDEMIC OF 1833 MR. HINGESTONi " The passing features of disease are quickly lost and for- gotten if we do not pause and depict their aspect while yet they are present. He who has not made the exj^eriment, or who is not accustomed to require rigorous accuracy from him- self, will scarcely believe how much a few hours take from certainty of knowledge and distinctness of imagery, — how the succession of objects will be broken, — how separate parts will be confused, — and how many particular features and discrimina- tions will be compressed and conglomerated into one gross and general idea. (Dr. Johnson, Western Isles, etc., Inch Kenneth.) The following sketch of the influenza, so lately prevalent in London, has been drawn with a rapid pencil from a distinct survey of many cases, and a characteristic outline of the disease is presented as it appeared to one within the circuit of his own recognition. " In the middle of the month of March, several persons were attacked with the affections of the bronchia and larynx common in the spring of the year, but it was not till the 6 th of April that the influenza developed its pathognomonic character, and within the city started up widely on a sudden, manifesting itself in three different forms ; each of these forms arose in succession, the active preceding the passive, and thus it happened : " 1. Bronchitis with acute fever and keen arterial action, which presented itself in single cases towards the end of the month of March, and in the beginning of April. It yielded to the ordinary antiplilogistic treatment, and ended in a copious pituitous expectoration. " 2. A catarrh of aU the air passages, announced by sneezing, heaviness of the forehead, suffusion of the eyes, running at the nose, and a teazing cough. There were fugitive pains along all the great muscles of the limbs, pain of the hypochondria, and loins, and nape of the neck; perspiration and soreness pervaded the skin, but the perspiration was not critical. The bowels were naturally relieved, the tongue was clean, but the ' London Medical Gazette, vol. xii. p. 199. T 274 EPIDEMIC OF 1833 urine was scanty. In healthy persons this attack lasted from three to six days, and yielded to salines, nephritics, rest, abstinence, and sudorifics. " 3, Adynamic catarrh, announced like the former by sneezing and the usual symptoms of a common cold, but distinguished by deep nervous depression and a subacute fever, running on, in some instances, to twenty-one days. The tong-ue was foul and loaded, and there was nausea, a complete loss of taste and appetite and smell, a pale languid countenance, torpor of the bowels, prsecordial distension, and a deficiency of bile. In some cases there was a sudden and very marked prostration of all the vital powers. The sleep was broken and interrupted, with frightful and fantastic dreams ; the cellular tissue was lax, and the skin humid and universally sore ; the urine was scanty, high coloured, and turbid. In tliis form of the disease the thorax was internally sore, with an incessant cough, and a teazing glutinous expectoration ; and occasionally by fits and starts, there would be a fixed pain in the head or abdomen, simulating inflammation ; the pulse being at the same time quick, and often accelerated. The patient was cast back on his bed, and appeared alarmed at his own situation. " This form of the influenza obeyed no simple febrifuge, but seemed to run a certain course, and then expire of itself, leaving a very characteristic lassitude, so as to depress the patient greatly. It was aggravated by bleeding and active antiphlo- gistic treatment; it was alleviated by mild purgations of mercury, rhubarb, and colocynth ; but the chief means of relief, was by acting on the kidneys, and causing a copious flow of urine. The soreness at the chest might be removed by a blister, and as soon as the febrile condition had passed away, the quinine was serviceable. It was always proper to impose abstinence and absolute rest under the bed-clothes, but all patients were not submissive. The muscular languor continued for some time after the outward restoration to health and vigour of aspect had apparently returned, and the patient was still reminded of his weakness by a lurking pain which tarried in the loins. The expectoration became chronic, plentiful, and inconvenient, the appetite might fade, the stomach and bowels falter, and a relapse occasionally ensue. The animal spirits drooped, and some invalids felt and confessed an unaccountable MR. HINGESTON'S REMARKS 275 sense of woe ; and so much for the three forms of this malady. Under the influence of this epidemic, asthmatic old people gradually became ill, and the medical man's attention was attracted at first to the stomach. There was vomiting of all the ingesta, pains in the hypochondria and shoulder, bladder and loins, a rapid pulse, often irregular costive bowels, and restlessness. Gradually the respiration became high and laborious, the breath wheezing audibly, a stifling cough being incessant, and the air tubes becoming choked up with froth and tough mucus. The patient fixed his hands and shoulders, and assumed various erect or reclining attitudes, always indi- cative of the greatest uneasiness. The urine was diminished or entirely suppressed, the lips darkened, the countenance expressed alarm and anguish ; the pulse in some was quick, large, and bounding, in others rapid, little, and irregular ; the skin was hot and dry, the tongue clammy, the thirst great, and the appetite gone, and so the patient might die suffocated. "The disease seemed to have its seat in the air-tubes, the smaller ramifications of which were filled with a tough yellow phlegm, causing an incessant short cough, so as to clear them for the permeation of air, and the indispensable oxygenation of the blood. Here lay the disease : 1st, in tough phlegm which could be thrown off only by coughing ; 2d, in an imperfect and impeded oxygenation of the blood. The liver was always deranged, either as a sequence or a cause. The object of treatment was : — (1) to give the lungs less work to do, therefore to bleed once ; (2) to relieve the lungs by external irritants, by blisters ; (3) to loosen the phlegm by warm expectorants ; and (4) to act on the bowels, kidneys, and skin. "As far as my experience has gone, any treatment was fallacious. One bleeding from the arm was beneficial, but it could not be repeated, for though the blood might be both cupped and buffed, yet the crassamentum was weak, and the serum abundant. Diffusive stimulants and generous food, when it could be taken, were more useful than depressants, and the difficulty seemed to lie in making the kidneys act efficiently. Vomiting was unfavorable, but a spontaneous purging seemed to be beneficial and decisive. The restlessness and vigilance could be opposed by opium, only towards convalescence. " These patients might linger for the space of two or three 276 EPIDEMIC OF 1833 weeks aud then get up well, or they might die in the same number of days. Children of ten months old were also afflicted with pulmonary disease about this same period. Now their symptoms were those of pneumonia notha, and they looked like little old persons labouring under asthma. Leeches, Ipecacuanha, and Mercury specifically, killed them; but relief seemed to be procured by mild doses of Rhubarb, with half-grain doses of Calomel as a purge, and a combination of Oxymel of Squills with the Acetate of Ammonia. A bland milk food was the best. Many died. "And so much for the influenza manifested in its three forms, and in its particular modes of attack upon the old and the young. " The disease was ushered into London during the prevalence of a bleak wind and a cold vernal atmosphere succeeding to a long, warm, moist winter. Storms of hail, snow, sleet, thunder, and rain, from dark fragments of clouds, were alternated only by currents of gelid air and harsh squalls from the north and north-east. Under these coarse rude flaws of heaven, the pul- monary organs of man, so susceptible of atmospheric changes, were excited and parched or moistened and depressed, and the whole surface ot the skin must have suffered universally in its functions. Those persons were the least liable to the influenza who were the most exposed to the outward changes of the weather, and those had it the worst who were irregularly exposed, as servants and kitchen-maids. The valetudinarian, the epicurean, and the profligate, seemed to fall readily under the distemper ; and it was both curious and interesting to remark in the mingled population of this immense city, when all were equally exposed to the same evil, the patience of the poor and the impatience of the rich. Disease may be modified or aggravated by any native or acquired irritability of tempera- ment, and the sudden and unexpected accumulation of wealth often inflicts upon its surprised possessor a restlessness of spirit which, in animated nature, is the attribute only of birds and children. The patience of the poor is founded upon hope; they anticipate death as a refuge, a port, a harbour of safety ; they foresee in the end of their days the only certainty in life. But the offensive intrusion of illness sullies the furniture of a handsome apartment ; and death is bitter to a man in the MR. HINGESTON'S REMARKS 277 midst of his possessions. ' Une malade degoiite,' says Voltaire, speaking of happiness in prosperity, ' ne mange rien d'lin grand festin prepare pour lui ' (Articles cle Littirature tHs inUressans). — He who is engaged in the active pursuits of merchandise and money, or who exhausts his intellect in schemes of worldly parade and ostentation, brooks not the imperative restraints of sickness and pain, and seems astonished that his will no longer commands the servile functions of his limbs. Pride, proper to man and fostered in polite society, may be checked by adver- sity, but can be extinguished only by disease and the visible approach or vicinity of death. The physician beholds the commonalty of human nature, and hears the same words and the same phrases expressive of the same sensations, as if the rich and the poor, the foolish and the wise, had previously met by concert and agreed to speak the same language in their separate habitations. But as soon as health is again confirmed, the distinctions of wealth, rank, and intellect, become again paramount, and all equally defer the end of life, the certainty of which is equally unacceptable to all. — At length the canopy of clouds was withdrawn, and the summer sun shone brightly as the disease faded." The previous visitation of 1831, occurring in summer, and attacking subjects exhausted by heat, was attended with more debility: this of 1833, occurring in spring, was attended with greater nervous disturbance, and the convalescence was more tardy: nearly four -fifths of the inhabitants of Paris were affected. In this city it appeared under three varieties : — 1st, the form complicated with angina, pleurisy, or pneumonia; 2dly, with fever and local disturbance ; 3dly, with malaise and hoarseness. Tic douloureux, neuralgia, and rheumatism, prevailed shortly before the onset of the epidemic, especially at Geneva ; indeed, an eminently nervous constitution of atmo- sphere seemed to prevail in the year 1833 as well as in 1831.^ It was observed by many continental practitioners, that if purgatives were not administered, the appetite was slow to return. The most approved treatment was to administer emetics at the onset, and afterwards purgatives.^ In London, concurrently with the prevalence of the disease in man, horses were affected with influenza ; but for some time, ' Gazette Medicale, pp. 345, 729. - Idem. 278 EPIDEMIC OF 1833 whilst those in the low parts suffered, those in the upper and north-west districts escaped. Not many weeks afterwards, there was not a mews in Marylebone which did not contain some patients, while Westminster was exempt from disease, and in Marylebone, observes Mr. Youatt, " I have known it to be confined to a district not a furlong square. In one extra- ordinary case, a fifth part of the horses in a certain mews died, while there was no vestige of disease elsewhere. I recollect, that in one of our barracks, the majority of the horses on one side of the yard were attacked by epidemic catarrh, while there was not a sick horse on the other side. These prevalences and these exceptions are altogether unaccountable. The stables and the system of stable management have been most carefully inquired into in the infected and healthy districts, and no satisfactory difference could be ascertained. One very import- ant fact, however, has been established, namely, that the prob- ability of the disease seemed to be in a tenfold ratio with the number of horses inhabiting a stable. Two or three shut up in a comparatively close stable would escape. Out of 30 dis- tributed through 10 or 15 little stables, not one would be affected; but in a stable containing 10 or 12, although proportionably larger and more ventilated, the disease would assuredly appear; and, if it does enter one of the largest stables, almost every horse will be affected." ^ At Alfort, many horses convalescent from internal diseases, or affected with surgical maladies, were in the hospital suffering from Anorexia, weight and heat of head, weakness, red con- junctivse, and dry cough ; and many previously in good health became affected, when brought into the neighbourhood of the sick.^ In the spring of 1834, a minute species of ant so swarmed in London and Brighton, that many of the inhabitants were obliged to quit their houses.^ In 1835, the turnip suffered from the ravages of the wire- worm {elater segetes), the favourite food of the water-wagtail ; * but the general failure of the crop, which occurred in the southern and midland counties, was attributed to the incursions 1 Mr. Youatt, Veterinarian, p. 117, 1833. - Rec. de Med. Veter. vol. x. p. 530. ^ Entomol. Magazine, vol. ii. p. 310. * Farmer's Magazine, vol. iv. p. 28. DR. STREETEN'S REPORT 279 of the 'Altica Nemorum,' the glossy, tiny, skipping, hopping, merry- Andrew kind of beetle, called the turnip-fly.^ During the space of about three weeks, namely, from the 16th of January to the 8th of February, the wind being north- easterly and the atmosphere hazy, that the visible horizon was only one mile distant, a peculiar dust fell at St, Jago in the Cape de Verd Islands. Much of this dust, which was of a reddish-brown colour, yielded a blackish or grayish bead to the blow-pipe, and did not effervesce with acids, was collected on the deck of the ship ' Beagle.' The dust was excessively fine grained, and so constantly falling as to roughen, and in some degree injure, the astronomical instruments.^ EPIDEMIC CATAEEH OF 1836-37 DE. STEEETEN3 •' At the close of the epidemic catarrh which prevailed so extensively in the months of January, February, and March, of the year 1837, the Council of the Provincial Medical Association issued a circular to the members, requesting information respecting the origin, progress, and duration of the epidemic, its symptoms and treatment, the atmospheric pheno- mena attending and preceding it, together with such other particulars as might be necessary for the elucidation of many questions of interest immediately connected with it. The following were the questions to which the Council more espe- cially directed the attention of the Society, and upon which they were desirous of obtaining explicit information : " 1. When did the influenza appear in your neighbour- hood ? and how long did it prevail there ? ^ Entomol. Magazine, vol. i. p. 363 ; vol. iv. p. 338 ; vol. v. p. 342. 2 An account of the dust which fell in the Atlantic, by C. Darwin, F.R.S. ; ' Geological Transactions,' 1845, p. 27. ^ Report upon the' Influenza or Epidemic Catarrh of the Winter of 1836-37. By Robert J. N. Streeten, M.D. With Observations upon the Meteorological Phenomena, by Wm. Addison, Esq., F.L.S. ' Transactions of Provincial Medical Association,' vol vi., London, 1838, p. 67. 280 EPIDEMIC OF 1836-37 " 2. Did it attack a great many individuals at the same time ? " 3. Did it appear partial to any age, sex, or temperament ? or did it appear to attack all indiscriminately ? "4. Was it milder when it attacked children ? " 5. What age appeared to suffer most from it ? " 6. Was the spread of the distemper very extensive in your neighbourhood ? " 7. What was the proportion of deaths to the number attacked ? " 8. What circumstances predisposed the patients to a fatal termination of the disease ? " 9. What was the ordinary duration of the disease ? " 10. Were relapses common ? "11. Were persons whose occupations exposed them to the vicissitudes .of the weather in the open air, more liable to the distemper than those who were confined chiefly to the house ? " 12. Are you in possession of any proof of its having been communicated from one person to another ? " 13. In persons attacked by the epidemic, who at the time laboured under pulmonary disease, was the former malady found to be aggravated on the subsidence of the influenza ? " 14. Were there any circumstances that appeared to exempt individuals from an attack of the disease ? and, in particular, did the having been attacked during the last similar epidemic of the year 1834, appear to aflbrd any protection ? "15. What were the usual symptoms of the complaint? "16. What unusual symptoms occurred in your practice? " 1 7. What was your mode of treating the disease ? "18. Did any peculiar atmospheric phenomena precede or accompany this epidemic ? " At the anniversary meeting held at Cheltenham, in the month of July last, a committee was appointed to take this subject into consideration, and to draw up a report from the answers sent in reply to the foregoing questions. These answers, though not so numerous as could have been wished, are yet sufficiently so to afford valuable information ; at the DR. STREETEN S REPORT 281 same time, having been received from nearly all parts of the kingdom, they furnish data from which the influence of locality, and other causes depending thereon, in modifying the general features of the disease, may be inferred. " In collating and comparing the various particulars con- tained in these replies, the authors of this report are of opinion, that they cannot proceed better in this inquiry than by follow- ing the plan already laid down, taking the questions in the order in which they were proposed by the Council. " 1. WJien did the influenza appear in your neiglibourhood, and how long did it prevail there ? — The answers to this question present considerable discrepancies, some of them dating the first appearance of the epidemic as early as the third week of November; others giving the second, tliird, and fourth weeks of January, and one assigning for its commence- ment a period as late as the 2d of February, The dates of cessation are also as indefinite, varying from the first week in February to the month of May. All accounts, however, coin- cide in referring its greatest prevalence to a period extending from the middle of January to the end of the first week in February. " The following table exhibits the range of the dates assigned for the commencement and termination of the epidemic in various parts of the kingdom, which we have denominated, respectively, the Northern, Midland, Western, Southern, and Eastern Districts : District. Commencement. Termination. Northern November ; middle of January. February 8 ; April. Midland November ; January 16. Middle of February ; May 1. Western End of December ; February 2. Feb. ; beginning of April. Southern Middle of Dec. ; middle of Jan. Middle of February ; May. Eastern End of Dec. ; beginning of Jan. Beginning of Feb. ; middle of March. " From the preceding table it is obvious, that no conclusion can be drawn as to there having been any regular progression of the disease from one part of the kingdom to another ; and, indeed, the individual details from which it is drawn up are 282 EPIDEMIC OF 1836-37 too imperfect and too discrepant to warrant such a conclusion, even had the general summary of them appeared to favour it. Thus, in the northern district, in which the range of appearance in the various localities comprised within the district is, accord- ing to the answers, from November to the middle of January, nearly the same diversity exists in the statements of different individuals residing in the same town, — Dr. Macrorie assigning November as the date of commencement, and April as that of termination at Liverpool ; while Dr. Baird and Dr. Eamsay assign the month of January as being the period of commence- ment, and from the 8 th to the middle of February as that of termination. To prevent any imputation from resting upon the general correctness and fidelity of the answers, it may be desirable to make some extracts from such of the replies as throw light upon the causes of this diversity of opinion. One of these causes would seem to be the latitude in which the term Influenza is made use of by different medical men. Dr. Baird says : ' The first decided case of influenza which I met with occurred on the 3d day of January, and the last on the 8 th of February : catarrhal complaints continued to be pre- valent amongst the resident inhabitants for the three succeeding months, but their systems had either become proof against the distemper, or it had lost its intensity, for in no case could it be fairly said to be an attack of influenza. That the atmo- sphere of Liverpool, however, was still contaminated by the epidemic influence up to the middle and latter end of April was apparent, from the fact that many of the officers and men of the American ships, and generally the most robust, were violently attacked shortly after their arrival in port.' The •same also is stated to have occurred among the black sailors of ships coming from South America and the coast of Africa. It is not an unwarrantable assumption, that the catarrhal affections here spoken of by Dr. Baird, may have been con- sidered by other observers as connected with the prevailing epidemic. Many of the replies from other parts afford illustrations of the preceding remarks. Dr. Hastings, of Worcester, states that he had observed several more than ordinarily severe attacks of bronchitis, frequently complicated with pleuritis, during the month of December 1836, these attacks being more fatal than in former winters, but that he did DR. STREETEN'S REPORT 283 not notice any decided case of influenza until the ISth day of January 1837. Other practitioners, residing in the counties of Worcester and Warwick, seem to have considered that these bronchial attacks partook more or less of the character of influenza, as may be inferred from the nature of their replies to tliis question ; and it would appear that, notwithstanding that the chief prevalence of influenza was during the months of January and February, cases of catarrhal disease, amounting even to a partial epidemic, may have occurred in some localities previous to the general outbreak throughout the kingdom. " The greater number of the replies from all parts agree in assigning the early part of January (from the 3d to the 13th) as the period of this outbreak ; but setting aside those answers in which the information upon this point is less explicit, and confined merely to the announcement of a certain date or period as that upon which the epidemic made its appearance, there is evidence to show, or at least to lead to the inference as above stated, that a partial, and, as it were, preliminary epidemic, may, in certain localities, have been the forerunner of the more general one. Mr. Eice, of Stratford-npon-Avon, distinctly states this as the result of his observation : ' The influenza,' he says, ' appeared in this neighbourhood at two distinct periods, the first commencing the third week in November, when it continued about five weeks ; the second about the 10th of January, when it continued epidemic in this town and the neighbouring villages up to the first week in March. A few cases occurred in the interval ; and some cases have occurred since, and still continue (June 30 th) to present themselves occasionally.' " Another of the causes tending to give rise to a degree of uncertainty upon this point in the replies, is the different manner in which different individuals would regard the (question. Some in their answers have simply stated the date of the first case to which they themselves were called, while others appear to have given a more extended signification to the terms of the question, and have thus stated the results of general observation, rather than of their own immediate experience. In the Chichester report, which contains the results of the united experience of the medical profession of 284 EPIDEMIC OF 1836-37 that place, this source of ambiguity is avoided ; and it may, therefore, be taken as affording the most correct information as to the outbreak of the epidemic in the southern and south- eastern part of the kingdom. According to this report, ' The influenza began about the middle of December 1836, was at its height during the latter half of January and beginning of February 1837, and ended about the first week in March. There were, however, a few cases bearing all the characters of the epidemic as early as the middle of November, but they were detached, both in regard to time and place, and, therefore, not mentioned in the account.' Mr. Maul, of Southampton, bears similar testimony to the occurrence of sporadic cases pre\'ious to the general outbreak of the epidemic, to which, however, he assigns a date somewhat later than that given in the Chichester report. ' A few scattered cases,' he observes, ' of anomalous catarrh and bronchitis occurred in my practice at the end of December 1836. These cases increased in number at the beginning of January 1837; by the end of the first week the disease prevailed more generally, and assumed the character of an epidemic. During the second, third, and fourth weeks in January, and the first and second weeks in February, the cases became most numerous, and far exceeded anything that I had ever before met with. In the last two weeks in February, they declined in number, but many in- dividuals were more severely assailed. In March, the disease again manifested itself, but rather in a modified form, and prevailed with diminished consequences through the month of April.' This last statement of the reappearance of the epidemic in the months of March and April, is consonant with the observations of several other practitioners, and may per- haps afford an explanation of the extended range given to the whole epidemic, in the replies from some of those gentlemen who have not entered into particulars upon this point. " 2. Did it attack a great many individuals at the same time ? — The replies to this question are uniformly in the affirmative, and by far the greater portion of them speak decidedly as to the simultaneous outbreak of the disorder throughout the localities to which they severally refer. Dr. Davis, of Presteign, observes, that within his district, compris- ing a circle, the diameter of which is about fourteen miles, it DR. STREETEN'S REPORT 285 was impossible to mark any progression — cases in every part of it occurring simultaneously. Mr. May, of Eeading, and . several other gentlemen make the same remark. Dr. Shapter, of Exeter, however, states, that for the first ten days occasional cases only occurred, but that on the 18 th, 19 th, 20 th, and 21st of January, it was a most prevailing epidemic. Mr. Bree, of Stowmarket, Mr. Maul, and some others, also refer to sporadic cases preceding the general attack. The terms in which the very great prevalence of the e^^idemic in all parts of the kingdom are spoken of, are most decided. " 3. Did it a'ppear partial to any age, sex, or temperament ? or did it appear to attack all ituliscriminately ? — A consider- able portion, amounting to more than half of the returns, answer the latter part of this question affirmatively, stating that the epidemic in its attacks was irrespective of age, sex, or temperament. Others, however, point out a certain degree of exemption, or an increased liability, as attaching to one or other of the conditions mentioned in the former part of the question : — And first, as respects age, there seems to be a very general impression that infants and young children were less the subjects of this epidemic than adults or those advanced in life. Dr. Davis states, as the result of his experience, that persons of all ages were attacked by the epidemic, except young children, those under six years of age almost entirely escaping. Dr. Baird, Mr, May, Mr. Maul, Mr. Davis of Tenbury, Mr. Gwynne Bird of Swansea, Mr. Fletcher of Croydon, Dr. Grove and Mr. Sampson of Salisbury, Dr. Barlow and Mr, Godfrey of Bath, and other practitioners, express, in terms more or less decided, the entire or comparative immunity of children from attack during the late epidemic. Mr. Appleton, of Evesham, says, that of ninety-nine cases occurring during the month of January, there were only five under five years of age. Mr. Pritchard, of Leamington, gives the following statement of the ages in 1 7 cases occurring in his practice : Under 14 years 26 cases, about one-sixth. Between 14 and 65 .... 1191 ,., u >. c ■ t-u Above 65 25/1'^^' ^^°^*^^^-'^^*^^- " The Chichester report, however, makes the subjoined statement in reply to this question, ' In regard to age, it seems almost equally to have attacked young and old. Of cases 286 « EPIDEMIC OF 1836-37 recorded, the greater number appears to be at the periods under ten, and from thirty to forty, but the difference in the intermediate decades was trifling, and the uniformly decreasing numbers beyond forty would probably about tally with the small population of those ages.' " It does not fall within the province of the authors of this report to decide which of these views, — that children were equally liable to, or comparatively exempt from, the attacks of the late epidemic, — is the correct one ; but they may observe, that notwithstanding the high value to be placed upon the Chichester report, as embracing the united experience of the medical practitioners of that city and neighbourhood, and the support which this obtains from the experience of Dr. Brown, of Sunderland, Dr. Hastings, and other eminent individuals, who state unreservedly, that persons of all ages were attacked indiscriminately, their own experience would lead them to say that young children had manifested less liability to the attacks of the recent epidemic catarrh, than individuals more advanced in life. With one or two exceptions, it does not appear from the replies that the aged were the subjects of the inflluenza more than adults of an earlier period of Kfe. " Secondly, as respects sex and temperament, there seems to have been, for the most part, no appreciable difference in respect of liability to the disease. Mr. Myles, of Warrington, indeed, in his reply to this question, says, that ' those in the meridian of life, whose temperament was melancholic, princi- pally males,' were more liable than others ; and Dr. Macrorie considers the feeble and those of the lymphatic temperament to have been most subject to attack. The Chichester report gives the following statement : — ' In regard to sex it seems to have had no great partiality. Of the entire number of recorded cases, the males to the females are as fourteen to nineteen ; but the reports of parish practice give a very nearly equal share of each. It should perhaps be mentioned, that of one hundred and fifty -five cases in the parishes of Chichester and its suburbs (population between nine and ten thousand), eighty- two were males and seventy-three females. In the Manhood (?) district (population four thousand), of twenty-two cases, nine- teen were males and three females. In this district not one patient was under thirty. In the Donnington district (popula- DR. STREETEN'S REPORT 287 tion three thousand), of sixty cases, twenty-two were males and thirty-eight females : twenty-six were under thirty, and nineteen under ten years.' This statement is in itself quite sufficient to show, in accordance with an ascertained principle in statistical inquiries, that the apparent exceptions derived from the limited experience of one individual, or one locality, must not be taken into account in deriving the general con- clusion. It is only the accumulation of facts by numerous observers from a great extent of country, or a considerable period of time, which can enable us to correct the errors of a partial or limited experience, and to arrive at conclusions founded on truth. " It should perhaps be mentioned, in connection with this question, that some of the replies state the liabiKty to the dis- ease to have been greater in those subject to chronic bronchitis, and in those of debilitated constitutions generally. " 4. Was it milder when it attacked children ? — At least tliree-fourths of the returns answer this question in the affirma- tive. There are, however, some exceptions of importance. Dr. Fife, of Newcastle-upon-Tyne, states, that some of the most severe cases which he witnessed occurred during the period of dentition, from the age of six months to the third year ; and Dr. Shapter says, that it was certainly not milder among children, but was, on the contrary, very fatal to them. Mr. Ceeley, of Aylesbury, reports that, except in vevi/ yoimg children, it appeared to liim to be rather milder in the young than in those more advanced in life. Mr. Nott, of Bew liegis, makes a similar exception ; and Dr. Clendinning, of London, states, in reply to this question, that ' except in the cases of very young or of unhealthy children, it was mild,' It would seem, therefore, upon the whole, that the epidemic generally assumed a mild character when it attacked the young, but that cases of considerable severity were not uncommon among very young children and infants. This is readily accounted for by the predisposition which exists at an early age to bronchitis and to convulsive attacks. Thus, at Eeading, according to the report of Mr. May, the disease appears to have assumed amongst children the characters of severe broncliitis or pneu- monia; while Dr. Brown reports that he beheld the death of tliree infants, and heard of other fatal cases at this period 288 EPIDEMIC OF 1836-37 of life, all of whom died with symptoms of cerebral con- gestion. " 5. What age appeared to suffer most from it ? — The answers to this question are almost unanimous in the statement, that the aged suffered most from the attacks of the epidemic ; and next to the aged, it is remarked in several of the replies, that infants or very young children were most severely affected. Some practitioners, however, make a distinction between the severity of the symptoms and the fatality of the disease ; and, according to these gentlemen, the actual suffering would appear to have been greater among the robust and adults of middle age, although, at the same time, they state the disease to have been most fatal to the aged. It is proper to observe, that this severity of suffering in the robust and those of middle age, was by no means general, as the subjoined extract from the replies sent in by Dr. Hastings sufficiently testifies. In answer to this query he says, ' From sixty upwards. I answer this question most unhesitatingly. Under the age of sixty, persons, male as weU as female, required many of them but slight attention to get safely, and in a few days, through the malady ; but all of those, indiscriminately, male and female, who were so far advanced as sixty, suffered most severely, and had a long and dangerous illness, being confined to bed with cough and copious expectoration for some time. Of twelve persons above the age of sixty attacked, all were in bed for a week, all suffered most severely from profuse muco-purulent expectora- tion, all became considerably emaciated ; eight were in bed for a fortnight, and had a dry tongue, with small feeble pulse ; lour were in bed for a month, all the time so critically ill that I scarcely expected them to live from day to day ; and two died within nine days of the attack. The four old persons who were in bed a month have not yet ^ quite recovered, and neither of them left the house till the month of June. Among the persons attacked below sixty, although in number thirteen times more than those above that age, I had comparatively few. that were in bed a week, and those were persons who had been previously ill, either with pulmonary or other complaints. ^ «' The communication bears no date, but we believe it to have been fonvarded to the Committee in July or August last." DR. STREETEN S REPORT 289 " 6. Was the spread of the distemper very extensive in your neighhourhood ? — The answers to this question are uniformly in the affirmative ; the terms in which the prevalence of the epidemic in all parts of the kingdom is spoken of, being most decided. ' I never knew an epidemic prevail so extensively.' ' Whole families in bed together.' ' It was, indeed, a general disease.' ' Very few persons, indeed, that escaped.' * Almost general.' ' It would be difficult to point out an individual who had not the disease,' etc., are expressions taken indis- criminately from the replies, and furnish most conclusive evidence as to the widespread and almost universal influence of the causes which gave rise to this epidemic. " 7. Wliat was the proportion of deaths to the numbers attacked ? — The replies to this question, as might be expected from the circumstances of accurate numerical records not having been in every instance preserved, are extremely in- definite. It will still appear, however, that an approximation to the correct ratio is capable of being deduced. Several of the returns afford numerical details, giving the number of cases attended, and the number of deaths which ensued. Others afford a mere statement of the proportion which the deaths bore to the cases ; — a statement which although less satisfactory than the more explicit details, may be presumed, for the most part, to have been made with due consideration. In those returns in which the actual numbers are given, the total of the cases is 2347 ; of the deaths, 54. These were distributed in the usual districts as follows : — District. Deaths. Cases. Proportion. Northern Midland . Western . Southern Total 3 22 4 25 171 932 73 1171 1 in 57, or 1 7 per cent. 1 in 42, or 2-3 1 in 18, or 55 1 in 47, or 2-1 54 2347 1 in 43, or 23 ,, " The returns from the eastern district do not give any precise numerical statements. " Omitting the western district, in which the number of u 290 EPIDEMIC OF 1836-37 cases actually reported is so small, there is no great difference in the general result, and thus, as far as these data go, the conclusion may be drawn, that the proportional mortality of the epidemic was about one in fifty of those attacked. This agrees remarkably with the estimate formed by the greater number of those who have not given a precise numerical statement. Thus in two of the returns from the eastern part of the country, Kenninghall and Burnham, the deaths are stated to be about one in fifty, and about two and a half per cent of the cases ; and the Chichester report estimates them as being from about one in forty to about one in fifty. Others of the returns give the proportion of about one in a hundred, or even a smaller ratio, while Mr. Bree did not see a single fatal case, although he thinks he could not have attended less than five hundred persons affected with the disease. The general result, however, as we have stated, affords a ratio of mortality of from two to two and a half per cent of those attacked, whether the numerical statements are taken as a guide, or the estimate deduced from the aggregate experience of those who have furnished the replies. " In two or three of the returns an attempt is made to throw some light upon the actual mortality resulting from influenza, by comparison of the parish registers for the period during which it was prevalent, with the corresponding period of one or more preceding years. Dr. Brown states ' that the funerals in the different parish churches of Sunderland were doubled in January, during the height of the epidemic ; but that in February, when it was declining, though still existing, they exceeded but little the ordinary average.' From a valuable statistical table sent by Dr. Black, of Bolton, it appears that there were four hundred and twenty burials at the parish church of Bolton during the months of January, February, and March, of the year 1837, being an excess of one hundred and thirty-two over the average for the same months of the five preceding years. In Bolton, however, this increase in the number of burials seems to have occurred for the most part during the month of February, as is shewn by the following table : — DR. STREETEN'S REPORT 291 January February . March Total . ■j^gg- 1 Average of Five ' ■ preceding Yrs. Excess. 115 111-2 205 79 100 97-8 3-8 126-0 2-2 420 288-0 132-0 " The only other return which furnishes any information of a similar character is that of Dr. Shapter, who says that in the two large burial-grounds belonging to the city of Exeter, the registered number of burials during the months of January and February 1837, were two hundred and twenty-seven, whilst in the corresponding months of the year 1836, they were only one hundred and twenty-five, giving an increase of one hundred and two as probably owing to the prevalence of influenza during that period. " 8. JVJiat circumstances predisposed the patient to a fatal termination of the disease ? — The circumstances enumerated in the replies to this question may be resolved into those which are connected with the age of the patient, the previous general health, and the presence of or predisposition to actual disease. Nearly all the returns state old age to be the chief circumstance predisposing towards a fatal termination, and several of them add infancy as next in importance to old age. Many of the returns specify debility of constitution, without evident disease, from whatever cause arising, as materially conducing to a fatal result. But next to old age, previously existing disease of the pulmonary organs would seem, from the returns, to afford gTounds for an unfavourable prognosis. Chronic pulmonary disease, chronic thoracic disease, affections of the lungs and heart generally, are mentioned as circum- stances rendering the attacks of the epidemic more likely to prove fatal ; and among those diseases which are more specifically characterised, bronchitis and asthma hold the first place. Some difference, however, in this respect would seem to have existed at different periods of life. Dr. Shapter observes that ' the circumstances which particularly predis- posed to a fatal termination were, amongst children, hooping- cough, and the recently having had some of the infantile 292 EPIDEMIC OF 1836-37 eruptive diseases, which prevailed very much during the pre- ceding ISTovember and December ; amongst the more advanced in life, pectoral weaknesses generally, but more especially asthma.' Dr. Brown, again, remarks : ' Besides the time of life, old age, and infancy, already mentioned, chronic thoracic disease, or peculiar proneness to such disease, predisposed the patients to a fatal termination. Of the aged persons who died, in almost all there was some previously-existing disease, generally chronic bronchitis, affection of the heart, or both conjointly. Of the young and middle-aged who ultimately fell victims, the majority died of phthisis, leading me to suppose that a tubercular diathesis pre-existed, and in such cases there were either previous indications of pulmonary disease, or a family tendency to it.' Dr. Brown adds that ' of all circumstances which predisposed to a fatal event, neglect, or mismanagement of the disease, in its early stage, was the most influential,' a statement confirmed by Dr. M'Cabe, of Cheltenham, who forcibly points out the mischiefs which arose from the empirical use of stimulants and other remedies recommended at the time in the public press. " 9. What was the ordinary duration of the disease ? — From a careful consideration of the answers to this query, it appears that the disease may be divided into two stages, — one which may be termed the acute stage, lasting generally from two to four or five days, the disease frequently terminating altogether at the end of this period ; and a second or more chronic stage, in which the symptoms continued in a slighter form for a period varying from five to ten days, or even a fortnight more. In addition to this, however, a state of debility seems to have hung over many of those who suffered, for an indefinite period. These circumstances, taken in connection with relapses and sequelse, will sufficiently account for the extreme variation in the replies to this question, the greater number of which, how- ever, give in general terms from five days or a week to a fort- night as the ordinary duration of the symptoms. Dr. Hastings, Mr. Rice, and several other gentlemen observed, that the dura- tion of the disease was very various in different individuals, and Dr. Baird states that it was much longer in the aged, than in persons of the middle period of life. "10. Were Relapses common? — This is one of the queries. DR. STREETEN'S report 293 in the replies to which much difference exists. The diversity is probably owing, in many instances, to the vague and indefinite nature of all information of the kind which is not founded upon numerical data. The language of the Chichester report, which bears every evidence of having been drawn up from such data, although in the present instance it does not give the details, is strongly corroborative of this remark. ' Eelapses,' it is stated, ' were very frequent, but probably in relation to the entire number of attacks, not very numerous ; when they occurred they were generally severe.' One only of the returns gives a proportionate statement, that of Dr. Hastings, who assigns one in twenty -one as the proportion borne by the relapses to the primary attacks in his practice. The following are among the chief localities in which relapses are stated to have been of frequent occurrence : — Sunderland, Newcastle- upon-Tyne, Leicester, Stratford-upon-Avon, Stroud, Holywell, Presteign, Hereford, Kenninghall, Framlingham, Burnham, Chichester, Southampton, and Bath. Dr. Fife and Dr. Davis state, that in some of their cases relapses occurred as many as three and even four times. At Liverpool, also, according to Dr. Eamsay, secondary attacks were very frequent; but Dr. Baird is of a different opinion, and Dr. Macrorie, whose opportunities of observation are very extensive, states, that in his practice relapses were not common. In the Midland counties generally, secondary attacks of the epidemic appear to have been of less frequent occurrence ; the greater portion of the replies to this question, from the Midland district, being decidedly in the negative. " The symptoms are stated in several of the returns to have been more severe in the relapses than in the primary attacks ; and Dr. Shapter thinks that they were modified also in their nature. " Were persons, whose occupations exposed them to the vicissi- tudes of the weather in the open air, more liable to the dis- temper than those who were confined chiefiy to the house ? — The answers from all parts of the country are, with scarcely an exception, in the negative, and from the expressions made use of in several of the returns, it would even seem that those exposed to the vicissitudes of the weather had been somewhat less liable to the attack than those whose occupation did not 294 EPIDEMIC OF 1836-37 subject them to such exposure. ' I do not think (says Dr. Brown) that seclusion from vicissitudes of the weather in the open air, diminished at all the liability to attacks ; indeed the few instances of exemption from this epidemic which fell under my observation, appeared generally to be in the instance of persons very constantly exposed to such vicis- situdes, excepting during the hours of repose.' Dr. Baird states that some of the most severe cases which he met with, were in aged females previously confined to the house. Dr. Hastings saw one lady, eighty years of age, who had not been down -stairs for forty years, who had the disease very severely, though she ultimately recovered. Mr. Davis, of Tenbury, observes, ' that exposure to atmospheric changes did not ajDpear to exert any influence in rendering the person liable to the disorder, some of the worst cases occurring in those who led sedentary lives.' Mr. Smith, of Stroud, says, ' I think those most exposed to the vicissitudes of the weather, that is, those continually in the open air, were less susceptible of it.' Dr. Davis, of Presteign, writes, that as far as his observations went, exposure made little difference, and, indeed, that a majority of the cases requiring medical treatment, were delicate persons shut up in houses on account of the cold. " The exceptions to this very general statement are few, but at the same time sufficiently important to require notice. Thus, Mr. Ceeley reports that ' persons exposed to the vicissi- tudes of the weather in the open air, were certainly more liable to attacks ; yet a slight exposure to cold, in numerous instances, appeared sufficient to give rise to an attack.' He adds, 'a few cases occurred in patients confined to bed with other disorders.' Mr. Bird, of Hereford, says, ' From the disease attacking a greater number of males than females, I should say those persons whose occupations exposed them to the vicissitudes of the weather in the open air were more liable to the distemper than those who were confined chiefly to the house.' Dr. Clendinning also enumerates exposure to the vicissitudes of the weather among the causes which rendered persons predisposed or liable to the attacks of the epidemic; and Mr. Myles thinks that the exposed suffered more severely. But, however we may feel disposed to place reliance upon the observations and opinions of these gentlemen, the very general DR. STREETEX'S REPORT 295 testimony of others, no less competent, must lead us to the conclusion that some circumstances, accidental or otherwise, have interfered in rendering the results at which they have arrived less to be relied upon in tliis particular than would otherwise have been the case. " 1 2. Are yoii in jMSsession of any proof of its having been commvAiicatcd from one 2>^'>"S07i to another ? — The answers to this question are also of an almost uniform tenour, the opinion of nearly all those who had the most extensive opportunities of investigating the disease, and the best means of arriving at a definite conclusion, being, tliat there is no proof of the existence of any contagious principle by which it was pro- pagated from one individual to another. ' A gentleman (says Dr. Brown) subject to very severe bronchial affection, and in whom I apprehended that influenza would prove very severe, if he were attacked, escaped it altogether, and attributed his escape to avoiding all close intercourse with the members of his family when it prevailed among them ; but as there were exceptions when no such precautions were adopted, I did not think myself justified in coming to the same conclusion.' In the Chichester report it is stated, ' We have no proof of the disease having been communicated from one person to another, though the patients often suspected it themselves. Our ob- servations, however, incline us to the opposite belief. It w^as no uncommon circumstance for the persons who had nursed a number of influenza patients to escape it themselves entirely.' " With these statements the greater number of the returns agree ; those which express any difference of opinion are the following : — Mr. Williams, of Holywell, writes, that he had no decided proof of the disease being communicated from one person to another, but very strong suspicions that such might be the case. Mr. Smith, of Stroud, observes, ' In some families I thought it contagious, as it affected one after another, until it had gone through the whole of a large family. I have known from seven to nine affected in this way ; in other large families, only one, two, or three had the disease, the other parts of the family not being in the least affected by it.' The following statement, made by Mr. Fox, of Cerne, affords an instance of this progression in the time of attack, although tliat gentleman does not seem disposed to give much weight to 296 EPIDEMIC OF 1836-37 evidence of this description : — ' In a family of ten persons residing in a small and generally healthy parish, one was first attacked, on the third day two more, another on the fourth, two more on the sixth, on the ninth two ; these were all children. The mother, who had been in constant attendance, and had not left the house during the whole time, was seized on the tenth day, and on the twelfth the father was seized, and had a very slight attack. He had during the preceding eleven days heen constantly exposed on horseback. Many such instances could be produced, but they scarcely deserve to be called proofs.' Dr. Shapter seems to lean to the idea of a contagious influence. He says, ' Though in many instances it appeared not improbable that the disease was communicated by one person to another, yet from the very general prevalence of the epidemic, any such conclusion cannot be positive.' It is obvious, however, that nothing approaching to tangible evidence is afforded by any of these statements ; and the only really important observation in any way favouring the idea of contagion or infection, is made by Mr. Maul, who remarked, that ' if an individual came from a distance with the disease, the inhabitants of the house into which he arrived were usually attacked.' Mr. Maul, however, draws no conclusion from this fact, contenting himself with simply stating it ; and standing alone, as it does, the observation in itself carries little weight. "13. In persons attacked by the epidemic, who at the time laboured under pulmonary disease, was the former malady aggra- vated on the subsidence of the influenza ? — This seems to have been decidedly the case, and generally speaking with but few exceptions. According to some of the returns, however, persons affected with certain forms of pulmonary disease, would appear to have especially suffered, particularly those lal^ouring under phthisis pulmonalis and bronchial affections. Dr. Baird, in his reply, states, that it was only the purely phthisical cases which were aggravated on the subsidence of the attack. The testi- mony of Mr. Appleton, of Evesham, and Mr. Smith, of Stroud, is to the same effect ; and Mr. Pace says, that in the only instance of this kind (previous pulmonary disease) which he attended, a case of haemoptysis, the attack proved speedily fatal. Mr. Bree, Dr. Shapter, and Dr. Clendinning, observed DR. STREETEN'S report 297 that the attack of the epidemic seemed to hasten the develop- ment of phthisis or other pulmonary disease, when it had been previously latent, or when a predisposition had existed. Dr. Hastings, at the same time that he bears testimony to the facts above stated, says, ' I may also remark that this is not confined to pectoral complaints. I find muco-gastritis and muco-enteritis of long standing, referred in its commencement by patients to the influenza. Wherever, in short (he continues), any latent disorder existed in the system, the effect of the disturbance of the functions of the body by the epidemic seems frequently to have been, to call into activity disease which had been pre- viously for a length of time dormant,' " In two only of the replies is this question answered alto- gether in the negative, and in one of these, from Mr. Welch- man, of Kineton, it is even stated that certain cases of pulmonary disease were decidedly benefited after recovering from the epidemic. ' I do not think (he observes), any of my patients who were attacked by the epidemic, who at the time laboured under pulmonary disease, had their former malady aggravated by the more recent affection ; two or three who had previously had chronic bronchitis, were decidedly free from it after recovery from influenza.' Dr. Hastings refers to a case in which he observed the same circumstance. ' In a lady, who has for years been very liable to bronchial attacks, and has for many winters been under the necessity of taking great precau- tions as to exposure to weather, the influenza came on with great severity, and much aggravation of the usual pectoral symptoms. They did not, however, continue longer than a week, and this lady has ever since that time been more free from pectoral complaints than for three years previously.' These, however, are obviously but exceptions to the general rule. " 14. Were there any circumstances that appeared to eocempt individucds from an attach of the disease ? and, in particular, did the having been attacked during tlie last similar epidemic of the year 1834, appear to afford any protection? — Several of the returns are expressed in very doubtful language in the reply to these questions, and in some of the returns they are passed over altogether. The greater number, however, agree in stating tliat the having undergone an attack of the previous epidemic, 298 EPIDEMIC OF 1836-37 afforded no protection, and that there were no circumstances wliich appeared to exempt from an attack of the disease. With respect to the influence of the former epidemic, some practi- tioners would seem to thinlc that those who had suffered from it, shewed themselves even more liable to the late epidemic than those who had escaped its attacks. Dr. Fife says, 'Many of those who suffered most severely from the former epidemic, were violently affected during the late visitation. In fact (he continues), I was almost led to believe them even more prone to attack ; ' and Mr. Smart, of Cranbourne, expressly states it as his opinion, 'that the influenza of 1834 had rather left a susceptibility to, than protected the constitution from, the attack of the late epidemic' In many of the returns, instances are adduced of individuals having suffered severely from both epidemics ; still, however, there are some few in which the opposite opinion is stated. Mr. Appleton remarks, that persons who had had the disease before, either escaped it altogether, or were but slightly affected. He adds, however, ' I notice this, not as the result of my own observations in many cases.' Dr. Grove, of Salisbury, states, that he knew several persons formerly attacked, who were not attacked by the late epidemic; and Mr. Ceeley observes, that he met with several instances of apparent exemption from an attack of the disease of 1836-37, or of a much milder attack, in those who had suffered from the influenza of 1834, or in the intervening period between the two epidemics. Mr. Ashwin, of Abergavenny, also thinks that the attack was milder in those who had the disease during the previous epidemic. Mr. May and Mr. Maul notice that it was the popular belief that such as had been attacked previously, were protected in consequence from the recent visitation ; but it does not appear that this belief received any confirmation from the personal experience of either of these gentlemen. " Among the very few circumstances mentioned in addition to an attack of the previous epidemic, as affording exemption in some cases, and modifying the severity of the symptoms in others, are, — the actual existence of other severe disease, noticed by Dr. Fife of Newcastle, and Mr. Bloxam of Newport ; general strength of constitution and. regular habits of life, by Dr. Davis and Dr. Clendinning ; and the age of infancy, by Mr. Gwynne Bird. DR. STREETEN'S REPORT 299 " 15. Wliat ivere the usual symptoms of the co)n2Jlainf ? — Of the answers to this question, some are expressed in general terms, while others go into considerable detail. From a careful consideration of the valuable information thus given, and a com- parison of the several accounts, we have not been able to arrive at the conclusion that any very appreciable variation exists in the oreneral features of the disease as it occurred in the different localities to which the returns refer. The symptoms enumerated as constituting the usual course of the complaint, may be divided into those indicating the existence of a general febrile condition of greater or less intensity, and those more immedi- ately characteristic of the epidemic, whether purely catarrhal and resulting from an affection of the mucous lining of the pulmonary organs and air-passages, or connected with one or more of the other organs or systems of the body. " The symptoms referable to a general febrile state were very much the same as those observed, either as precursors, or as arising in the progress of mild febrile diseases in general. Such of the returns as enter into any lengthened account of the symptoms almost uniformly describe the disease as commencing in mild cases, with indistinct chills : in the more severe ones, with shivering, or even actual rio;or. In some instances the rigors appear not to have occurred until the second or third day of the disease ; in others, to have arisen suddenly, affording the first indication of attack, and to have continued to recur at intervals during two or three days, or even for a longer period. The chills and rigors are described as alternating with heat of skin and flushing, until the febrile state became com- pletely developed, at which time the more peculiar features of the disorder seem in general to have shewed themselves. The fever from this period appears to have been usually of a mild open character, attended with some heat of the skin, and, occasionally, a dry iraperspirable state ; but more frequently there was a tendency to perspiration, which, when free, gave considerable relief. In more severe cases, the morbid tempera- ture was more urgent, the skin hot and dry, the face flushed, with mild delirium at night, and there was considerable fever- ish restlessness and anxiety ; at the same time there was great debility and languor, with an overpowering sense of sinking and depression of spirits. In some few cases the fever seems 300 EPIDEMIC OF 1836-37 to have assumed a typhoid character, but no very definite account of this modification is given. Nearly all the returns mention general pains, or pain and soreness of the back and limbs, and of other parts of the body, as among the most well- marked symptoms. These pains may, in part at least, be considered as appertaining to the general febrile state ; but the pain of the back and loins in particular was so very gener- ally felt, was in many cases of such extreme severity, and so prolonged in its duration, and, in almost all, gave rise to so much inconvenience and distress, being complained of more than any other symptom, that it is certainly to be classed rather as one of the symptoms especially characteristic of the epidemic, than as connected merely with an ordinary febrile condition. " The catarrhal symptoms, to which we have next to direct attention, were, according to the returns, a suffused state of the eyes with discharge of tears ; sneezing ; tingling of and acrid discharge from the nostrils ; sense of weight and pain of fore- head ; soreness of the fauces ; hoarseness ; cough ; expectora- tion ; dyspnoea ; and pain and sense of constriction about the throat and chest. Several of these symptoms are lightly passed over, and appear to have been either not of very general occurrence, or so trivial as to be thought not of sufficient con- sequence to be recorded. The suffused state of the eyes does not appear to have been commonly observed ; sneezing and watery discharge from the nostrils are more frequently men- tioned ; but the sense of weight and frontal headache were very prominently marked, being recorded in almost all the re- turns. In many cases the pain was exceedingly severe and distressing to the patient, and by no means confined to the frontal region, extending to the vertex and occiput, and over the head generally. It is in connection with this severe form that giddiness, delirium at night, and, in one instance, deafness, were noticed. The headache is variously described as violent, severe, intense, oppressive, etc. Mr. Ceeley says : ' It was fre- quently complained of as unlike in nature and degree to any- thing ever before experienced.' Mr. Bree remarks : ' The pain in the head was generally supra-orbital, and for a short time very severe ; in three cases there was delirium, and in one decided meningitis.' DR. STREETEN'S REPORT 301 " The soreness or rawness of the fauces is only occasionally alluded to, and, in some cases at least, seems to have heen observed more particularly in connection with the more marked symptoms of coryza. The Chichester report, in which ' de- fluxion at the nose and eyes, sneezing, and frequent epistaxis,' are mentioned as prominent symptoms of the disease as it ap- peared in that city and neighbourhood, describes the fauces as being ' generally red and tender,' which state in some cases ended in quinsey. Dr. Fife also noticed inflamed pharynx and tonsils as being among the symptoms of the disease observed at Newcastle ; and Dr. Shapter alludes, among other symptoms, to a sensation of painful rawness of the fauces and trachea as quickly following frontal pain, sneezing, and ' a very copious flow of a thin acrid discharge, chiefly from the mem- brane of the nose.' " The sense of tightness or constriction about the throat and chest, with more or less soreness beneath the sternum, is very generally noticed in the replies ; but the symptom to which the greatest prominence is given is the cough, which is variously described as being short and harassing, troublesome and fre- quent, harassing and incessant, preventing sleep, very distress- ing from its aggravating the pain of the head, sometimes as severe, violent, or coming on in frequent paroxysms of long duration. Mr. Smith, of Stroud, mentions, that in two cases occurring in his practice, it produced haemoptysis to an alarm- ing extent, and that premature confinement followed in two others. The expectoration is by no means so generally noticed ; but when it is mentioned, is stated to have been scanty, difficult, and consisting of clear viscid mucus at the commencement, afterwards becoming more copious and free, opaque and muco-purulent in its character, and occasionally tinged with blood. In some cases it is described as excessive and profuse. The respiration seems to have been very gener- ally more or less affected ; in some cases short and hurried, or uneasy and oppressed, in others difficult. Pains in the chest are mentioned in some of the returns in addition to the sore- ness under the sternum, and in one these pains are described as having been acute and lancinating. Examination by the stethoscope, according to Dr. Shapter, revealed the existence of sonorous and sibilous rdles, and for the most part also a well- 302 EPIDEMIC OF 1836-37 marked crepitation in some part of the thorax, generally in the lower portion. " The symptoms of disturbance in other organs of the body may be briefly noticed under the following heads, — those con- nected with the organs of circulation, those indicative of a disordered state of the digestive and urinary systems, and those which may be referred to the nervous system. The circulation seems in almost every instance to have been in a state of depression rather than of excitement ; accordingly the pulse, although usually characterised in the replies as accelerated, frequent, quick, is at the same time stated to have been variable, small, and feeble ; in two only of the returns is it stated to have been occasionally full but soft. Mr. Ceeley remarks, that in the decline of the disease in simple cases it was slow and occasionally intermitting ; and Dr. Brown also observes, that during the convalescence it was frequently slo^ and feeble. " The symptoms which may be referred to a deranged state of the digestive and urinary systems, are pain and tension,' with tenderness at the epigastrium and upper part of theJ abdomen ; loss of appetite ; thirst ; nausea and vomiting ; a^ furred state of the tongue, and a morbid state of the alvine and urinary secretions. The oppression and tenderness of the ■ upper part of the abdomen is noticed in several of the returns, % and seems to have been often accompanied with nausea and vomiting. Dr. Barlow remarks, that when the chest affections were of trifling importance, the special irritation of the epidemic appeared to be seated in the stomach and bowels, and men- tions a case in which a fit of spontaneous vomiting carried off the attack, all the constitutional disturbance being well-marked but mild, without any cough or bronchial disorder. Thirst does not appear to have been a very urgent symptom. The tongue is described either as furred, white, and moist ; or as loaded with a thick coating of moist yellowish fur. Occasion- ally it became, in the progress of the disease, brown and dry, or as stated by Mr. Dent, of Kenninghall, ' morbidly red and shining,' in which case ' there was a good deal of tenderness about the right iliac region.' The bowels are very generally reported to have been constipated, though occasionally a re- laxed state was observed. In the Chichester report is the follow- DR. STREETEN'S REPORT 303 ing observation relative to this point : — ' Bowels not much affected. It is, however, right to say, that previous to the accession of the epidemic in the latter part of the last year, diarrhoea was rather prevalent, but ceased with the increased violence of the distemper.' The urine was observed, according to such of the returns as afford information as to the characters of this secretion, to be, for the most part, scanty and high- coloured, — rarely abundant and limpid, — sometimes becoming, during the progress of the disease, thick and reddish, or of a whey-like appearance, and depositing a cojdIous sediment. "Among the symptoms which appear to have depended upon or been connected with a disordered state of the brain, spinal marrow, and nerves, may be enumerated, in addition to the delirium, etc., before alluded to, prostration of strength, pain of the back and loins, and various neuralgic and rheumatic affections. The extreme prostration of strength, which, in many of the reports, is stated to have arisen suddenly at the very commencement of the attack, is, in almost all of them, characterised as presenting a striking feature in the disease. It seems even in some situations to have approached the coUapse of the late visitation of cholera ; and to have been accompanied also, notwithstanding the generally observed torpor of the intestinal canal, with a relaxed state of the bowels. Dr. Davis, of Presteign, observes, that the prostration of strength was instant and universal, and attended with extreme depression of spirits, and, in a vast majority of cases, spontaneous diarrhoea. Another" peculiarity in the character of this symptom, is the length of time which the patients continue to labour under it, even after the cessation of the other symptoms of the disease. The pain of the back and loins is also very generally described as of peculiar severity, and seems to have been scarcely of the same nature as the pain and sense of weariness usually attend- ant upon febrile disease ; or if of the same nature, certainly of much greater intensity than what is commonly observed in diseases of this character. In addition to this pain, and the general pains of the limbs and soreuess of the trunk before mentioned, some of the returns enumerate among the usual symptoms of the epidemic, either as attending its progress, or making their appearance upon the decline of the more acute symptoms, certain painful affections, which are variously termed 304 EPIDEMIC OF 1836-37 rheumatic, neuralgic, or local rheumatic neuralgia. These, however, do not seem to have been of very general occurrence, and may possibly be connected with some local peculiarity : Salisbury and Aylesbury are the places in which they appear to have been most frequently observed among the ordinary symptoms. " Such is a condensed account of the usual characters of the epidemic, as far as we have been able to ascertain from the several returns : and in these characters there is little differ- ence, upon the whole, in the statements received from different places. The most important variation is one to which no allusion has been made in the preceding statement, mentioned by Dr. Fife, who remarked that, in several cases, ' the parotid gland was enlarged to such an extent, as to lead to the belief that the patient was actually suffering from cynanche parotidea.' This, however, does not seem to have been observed elsewhere, and must, therefore, we think, be placed among the ' unusual symptoms ' to which the next question refers. " We cannot better conclude this summary of the general features of the epidemic, than by extracting the following account of its progress as it presented itself at two widely separated localities, Exeter and Sunderland, with the view of exemplifying the course of the disease. ' The usual symptoms of this epidemic (says Dr. Shapter) were : — First, oppressive pains of the head, especially over the region of the frontal sinuses ; diffused muscular pains of the shoulders, loins, and legs ; constant sneezing, early followed by a very copious flow of thin acrid discharge, chiefly from the membrane of the nose (the membranes of the eyes were not so greatly affected as in the influenza of 1831 and 1834). Secondly, these symptoms' were quickly followed by an overwhelming feeling of lassitude and prostration of strength, with, in many cases, a loss of all muscular power, together with great anxiety of the praecordia, and agonising fears of death ; a sensation of painful rawness of the fauces and trachea, a voice hoarse and hollow, frequent short cough, for the most part dry, stricture and acute lancin- ating pains of the chest. By the stethoscope, there were heard rales, sonorous and sibilous, and almost always in some part of the thorax, generally the lower portion, a well-marked crepitation. Tongue covered with a copious white mucus. DK. STREETEN'S REPORT 305 with inflamed elevated papillae showing themselves at the tip and edges. Bowels not confined, and easily acted upon : in fact, there was rather a tendency to diarrhoea than otherwise ; appetite gone ; occasional thirst ; pulse small, quick, but soft. Paroxysm generally severe during the night. In this stage of the disease I was sensible of a peculiar and very characteristic odour proceeding from those affected ; though not able pro- perly to describe it, I may state its general character to have been that of a flat musty smell. Thirdly, about the fifth or sixth day a mucous discharge from the nose came on, together with a muco-purulent expectoration in coughing. The various symptoms now gradually declined, leaving the patients in a state of great general weakness, together with a peculiar aching feel, and loss of power in the muscles of the legs.' " Dr. Brown's statement is as follows : — ' The tongue was wliite, and considerably swollen ; the fauces were inflamed ; the eyes were often injected ; the nostrils felt hot and ii-ritated, with abundant thin secretion ; and there was pain across the forehead in the situation of the frontal sinuses. A sense of heat and irritation extended down the trachea to the thorax, where besides, there was a feeling of constriction ; there was cough, very distressing from its aggravating the pain of the head ; it was dry at first, but soon became attended by a copious mucous secretion, often opaque and straw-coloured, sometimes with slight streaks of blood ; and, in some cases, there was a considerable degree of dyspnoea. Sickness and vomiting were very common symptoms, especially at the com- mencement of the disease ; and there was sometimes (especially in relapsed attacks) acute pain in the lower part of the ab- domen, aggravated by pressure. There was much thirst, total want of appetite, and the sense of taste was impaired and vitiated. The urine was scanty and high-coloured, and, on standing, speedily deposited a very abundant lateritious sedi- ment. The pulse was in general soft, but not deficient in strength; it was frequent, but not considerably so, from 80 to 100 being its average range. When convalescence was ap- proaching or had taken place, it often became unusually slow, even below 50, and was feeble. There were the ordinary febrile feelings of bodily and mental oppression, and pain and weariness in the back and limbs. The skin, in the early stage X 306 EPIDEMIC OF 1836-37 of the disease, was warm and • generally moist ; towards the close, cool, if not cold, and moist. In bad cases, where the dyspnoea was considerable, the advanced stage of the disease, with the cold and wet skin, and bluish hue of the countenance, often recalled to my mind the collapsed stage of cholera. " ' This description will be understood to apply, where exceptions are not stated, to cases of the ordinary severity. Like all epidemics, influenza has a wide range of intensity, being, in many cases, a very dangerous disease, in others, little more severe than an ordinary catarrh.' "16. What unusual symiotoms occurred in your practice? — As might be anticipated, certain symptoms enumerated as of occasional occurrence in some of the replies to the former question, are mentioned in others under the present question as unusual symptoms of the complaint. This is especially the case with the more severe cerebral affections, and also with acute bronchial and pneumonic inflammations, with certain abdominal affections, and with rheumatic and neuralgic pains. On this account it might perhaps have been advisable to thro the answers to this and the preceding question into one : still, however, it seemed desirable to preserve the mode of inquir pointed out by the council unbroken, and a comparison of the statements severally drawn up from the answers to these questions, will sufficiently fulfil the object of pointing out those symptoms which, upon a general view of the whole phenomena, may be considered as unusual. At the same time the occur- rence of such symptoms among the usual characteristics of the disease, indicates that under certain circumstances, and in certain situations, they assumed such a degree of prevalence as in some measure to modify its general type. " Among the most prominent and important of these un- usual symptoms of the complaint, or rather of the variations from the usual type presented by the epidemic, must be classed those indicative of severe affection of the cerebral organs. Dr. Brown mentions the occurrence of three fatal cases of meningitis in adults, to which he had been summoned in the advanced stage, and which appeared to him to have originated in a neglected inflammatory affection of the lining of the nostrils and frontal sinuses. Dr. Hastings knew of one instance of meningitis, in which, however, the disease was IS. DR. STREETEN'S REPORT 307 subdued by the use of bleeding and purgatives, and other appropriate remedies. In this case the individual had been in a state of considerable anxiety of mind previous to the attack. Another instance is also referred to, where insanity succeeded to the attack of the epidemic, and lasted several weeks. Mr. Godfrey, of Bath, mentions acute pain in the head, in a few cases so severe as to last above a week, and then only relieved by a copious discharge of pus from the ear ; and Mr. Fox, of Cerne Abbas, notices abscesses of the ear among the unusual symptoms. Symptoms of pressure on the brain are also enumerated as of occasional occurrence. The Chichester report, in answer to the question, is as follows : ' There was delirium occasionally. In some cases the speech was affected, so that the patient was unable to articulate ; in a few cases there was coma at the outset which soon went off.' ' In one case ' (writes Dr. Fife), ' the disease at its commencement appeared to be apoplexy ; in another, partial paralysis existed. In this case,' he adds, 'perhaps the term paralysis may not be justified, as it rather consisted in the inordinate or spasmodic action of the extremes of the fingers and thumbs of the hands, than in loss of power in the flexors.' Dr. Hastings also saw one instance in which apoplectic symptoms occurred, but without subsequent paralysis. Mr. Ceeley observed, * that in a few old and feeble persons, the primary effect on the sensorium resembled a sudden apo- plectic seizure, from which, by sinapisms and diffusible stimu- lants, they slowly recovered, with fever and the usual affection of the mucous membrane of the air-passages ; one of these cases, however, proved fatal in four days from its commence- ment.' And Mr. Fox states, that in a few cases there was sudden insensibility, continuing from one to two hours. The same gentleman also observes that there were some instances of boys dropping down in the fields while ploughing, — a circum- stance, however, to be attributed rather to sudden exhaustion, or to the shock upon the nervous system generally, than to any influence acting more immediately upon the brain alone. Convulsive attacks w^ere noticed in some instances by Dr. Eamsay ; and Mr, Appleton mentions inflammation of the spinal marrow as having occurred in some cases which had not received early attention. ' Inflammatory affections of the lungs are included in certain 308 EPIDEMIC OF 1836-3? of the returns, under the unusual symptoms of the disease. These affections, however, appear for the most part to have arisen, either in neglected cases, in those previously disposed to pulmonary disease, or in aged persons, and are perhaps rather to be regarded as the effects of the disease acting upon unfavorable constitutions. It may be observed, in connection with this subject, that Mr. Godfrey saw three cases of pneu- monia, in which he used the lancet freely, and upon the subsidence of the inflammatory symptoms, the usual symptoms of the influenza continued. " Among the symptoms indicating unusual affection of the circulatory system as connected with this epidemic, are syncope and intermittent pulse. Dr. Eamsay states, that syncope was not an unusual occurrence in his practice, and Mr. Godfrey noticed the same symptom. Intermittent pulse is mentioned by Dr. Baird only. " Unusual symptoms connected with the abdominal organs are more frequently alluded to. Dr. Brown mentions excessive pain in the abdomen, generally situated mid-way between the umbilicus and symphisis pubis, as of frequent occurrence in relapsed cases. It was sometimes associated with obstinate constipation, at others with mucous and sanguinolent stools, resembling in their appearance and the manner of their expul- sion, those of dysentery. " Mr. Appleton observed, amongst the ill-fed and ill-clothed, considerable disturbance of the biliary functions, with loose- ness, in the early onset of the disorder. In others of the returns, however, this relaxed state in the commencement of the disease was noticed as of usual occurrence, although the greater number agree in stating that the bowels were generally constipated. Mr. Ceeley remarks, that in his practice a few cases occurred in which there was more affection of the mucous membrane of the intestines than of that of the bronchi. Diarrhoea is also enumerated among the unusual symptoms attendant upon the epidemic by Mr. Bloxam and Mr. Sampson, and Dr. Shapter notices three cases of gastro-enteric affection as the only peculiarity occurring in his experience of the epidemic. Mr. Bird, of Hereford, observed pain of the pubic region and retention of urine ; these last symptoms, however, are probably to be considered only as an accidental complication. DR. streeten's report 309 " Eheumatic and neuralgic pains were mentioned under the preceding question, as constituting, in certain situations, a usual feature in the disease. In other localities, symptoms of this description were also observed to occur in some instances, and are noticed in the returns in reply to the question now under consideration. Dr. Brown mentions as an irregularity next in point of frequency to the abdominal affections, ' pain of the head, often wearing the aspect of neuralgia of the branches of the fifth pair. It remitted,' he observes, ' but never totally intermitted. It was often associated with in- flammation of the lining of the nostrils and frontal sinuses ; indeed, it was not always easy to discover whether the pain did not purely depend on this inflammation. In some cases it yielded to arsenical solution or other remedies of neuralgia.' Intermittent pain in the head and temples, and sudden attacks of pain in different parts of the body in a most acute degree, are mentioned by Mr. Eice, and were probably of a similar character. Mr. Bree writes, 'A frequent symptom, in females only, I found to be a neuralgic affection on one side of the face, similar to that produced by decayed teeth, and which also afiected the hearing of the same side. I had in several cases also a similar pain though more acute, affecting the parietes of the chest, which produced disorder of the respiration, and if not carefully observed might have been mistaken for pleuritis.' Mr. Davis, of Tenbury, states, 'that in three or four cases, he observed acute rheumatism as an accompaniment of the disease ; and Mr. Gwynne Bird, that it was often followed by rheumatism. Rheumatic or neuralgic pains were also observed by Mr. Smart of Cranbourne, who considers that the disease assumed three different types. 'In one there was merely a spasmodic cough, with symptoms of a common cold ; in a second, all these symptoms were increased so as to resemble bronchitis or fever ; in a third, there were rheumatic or neuralgic pains of the head or neck.' " The only other peculiarity requiring notice here, is soreness of the lips, mouth, and fauces, of unusual severity, which both Mr. Godfrey and Mr. Rice mention as having occurred in their practice. The latter of these gentlemen also observed spon- taneous ptyalism in connection with the tenderness of the gums and mucous membrane of the mouth and fauces. i 310 EPIDEMIC OF 1836-37 "It should be observed, that a considerable number of the replies state, in answer to this question, that no unusual symp- toms occurred in the experience of the writer. " 1 7. What was your mode of treating the disease ? — In the general plan of management adopted during the epidemic, there appears to have been little difference, certain principles of treatment being laid down in nearly all the returns. The main features of this plan are, a very cautious employment of evacuant remedies in general ; the use of diaphoretics and mild aperients in the earlier stage, with a diluent diet, regulated temperature, and cessation from all active pursuits ; in the more severe cases, occasional local bleeding and counter-irritants to the throat and chest, and confinement to bed. In the second stage, expectorant and anodyne medicines, with sulphate of quinine or mild tonics, where there was much debility remaining, are most commonly recommended ; in the relapses, a more active treatment, with a freer use of evacuant remedies ; and in complications with acute bronchitis, pneumonia, muco- enteritis, or cerebral disease, — venesection, leeches, blisters, mercurials, cathartics, or other remedies called for by the nature of the symptoms complicating the disease, though perhaps, as far as depletion is concerned, with less freedom than would have been required had no epidemic influence existed. " The abstraction of blood by venesection was very rarely had recourse to, and is almost always spoken of as a measure of doubtful propriety ; in some instances as having proved positively injurious. " Dr. Fife says, ' General hloodletting, in the abstract, I am a decidedly of opinion is seldom required, and very frequently most injurious in its effect.' Mr. Eice writes, 'I very seldom used the lancet, in not more than six cases, and in only two of tliem am I satisfied that it did not do mischief.' Dr. Davis observes, ' Venesection was always mischievous, and even local bleeding, by leeches and cupping, was not w^ell borne.' Mr. Ashwin says, ' Bleeding was always regretted when used.' ' In no case,' says Dr. Shapter, ' did depleting or severe purging hold out encouragement for a continuance of such means ; ' and Dr. Barlow remarks that 'for the ordinary disease bloodletting was neither required nor borne. Some practitioners,' he con- tinues, ' bled in the beginning, but were soon obliged to desist. DR. STREETEK'S report 311 faintness being induced by small loss of blood, and great weakness ensuing. Cases did occur, however, which required bleeding, and when the disease passed into pneumonia, as occasionally happened, as active treatment was necessary as if no epidemic existed.' Dr. Baird, Mr. Davis of Tenbury, Mr. Prichard, Mr. Bree, and other practitioners, never employed general bloodletting, and the almost unanimous testimony is, that this measure was seldom had recourse to, except in active inflammation of the pulmonary organs. The following is the statement of the Chichester report upon this question : ' Except in severe attacks bloodletting was not required, and when it was tried, it frequently seemed to weaken without benefit. Detraction of blood was, however, practised with benefit in some cases where the pulse indicated an active and acute state of inflammation. The number of severe cases, however, calling for active treatment, was very small. It is right to state that a very small quantity of blood drawn from the Schneiderian membrane, relieved the distressing headache in a marked manner ; even a few drops accidentally flowing, in two cases, gave almost instantaneous relief.' " The local detraction of blood by leeches or cupping, is more frequently recommended ; though even in this manner, depletion to any extent is discouraged, and seems to have been rarely practised. The plan of drawing blood from the mucous lining of the nostrils, mentioned in the Chichester report, is also spoken of in terms of commendation by Mr. Prichard. Counter-irritation, by means of blisters, sinapisms, stimulating plasters and liniments, warm cataplasms, etc., is very generally mentioned in the returns as proving of service, more especially in the early stage of the complaint, and in aged persons. These remedies were applied to the throat, chest, pit of the stomach, or interscapular region, according to the varying circumstances which called for their use. " Of internal remedies, emetics are spoken of, in a few of the returns, as productive of considerable benefit at the onset of the disease ; but the measures most generally recommended, are the exhibition of mild aperients and saline diaphoretics. In some of the returns more active cathartics are stated to have been given with advantage ; in others, a combination of anti- monials, ipecacuanha, or squill, with the saline diaphoretics. 312 EPIDEMIC OF 1836-37 Anodynes are also recommended in some of the returns as of use in allaying the cough. Of these, hyoscyamus, acetate and muriate of morphia, and opiates generally, were most frequently employed ; but conium and colchicum are also mentioned. Some difference of opinion would seem to exist as to the benefit derived from remedies of this description. Mr. Ashwin gives it as his opinion, that opiates were, at least, useless ; and from the silence of a considerable portion of the returns respecting them, it may be inferred that they were by no means generally employed. Dr. Barlow, however, has the following observation upon the subject : — ' Some practitioners withheld opium, and had protracted disease, as I had occasion to witness. There being no counter -indications I combined it throughout, and with decided advantage.' The exhibition of tonics and stimu- lants is also a point of practice upon which some diversity of opinion has existed. In consequence of an extensive empirical use of such remedies in the early stage of the disease, arising from the mischievous reliance too often placed upon the public press, serious and even fatal effects were in many instances observed. Dr. M'Cabe brings forward examples of this mis- chief, and other practitioners agree with him in pointing out the injurious tendency of the indiscriminate employment of these remedies. From the silence of the returns, it may be inferred that many practitioners, for the most part, withheld tonics and stimulants altogether. Others, however, state that considerable benefit was derived from the use of sulphate of quinine, in the debility remaining during the decline of the disease, and in the convalescence ; and some even recommend ammonia, wine, and other more active stimulants, in cases where the debility was extreme and in aged persons. Mr. Myles says that in old people, when the cough was a prominent symptom, he found a blister to the chest, with the sulphate of quinine internally, to act as a specific in all the cases which he attended. Dr. Baird was in the habit of administering, in the more severe cases occurring amoug the aged, asthmatics, or those affected with chronic pulmonary complaints, a grain of the sulphate of quinine at intervals, alternately with calomel and tartarised antimony, continuing the quinine, or some other light tonic, without the mercurial when the mouth became affected ; and states, that after the adoption of this plan of DR. STREETEN'S REPORT 313 treatment, he had no fatal case, nor had occasion to resort, in a single instance, to bleeding, leeching, or cupping. In the intermittent pains again, in which it might have been pre- sumed that quinine would have proved most beneficial, Mr. Eice states that lie found it positively injurious, the pains being aggravated rather than alleviated by its employment. " There are two powerful remedial agents, mercury and antimony, which, in addition to their respective employment as cathartics and diaphoretics, were occasionally used with other views, either separately, or in combination with each other, or with other remedies. Dr. Baird's practice of giving these medicines in combination has been already alluded to ; the mode, of administration was in the form of powder, three grains of calomel, with one grain of tartarised antimony, twice, thrice, or even four times in the twenty -four hours, the sulphate of quinine being given during the interval, as before mentioned. ' The effect of the powder,' he says, ' was to produce extreme nausea for the space of an hour, and frequent vomiting ; to cause a vast discharge of purulent -looking matter from the lungs, excite a copious diaphoresis, and procure several dark pitchy evacuations from the bowels. So soon as the mouth became slightly affected by the calomel, and in many instances before this was apparent, the cough and expectoration had been greatly diminished, the restlessness had ceased, the coun- tenance and eyes had assumed a more natural expression, the tongue had begun to clean at the edges, and the pulse returned to its natural state.' Mr. Ceeley was in the habit of giving a combination of calomel, opium, and squill, in similarly severe cases, when the pulmonary organs were much congested ; and several of the returns mention calomel, either alone or vari- ously combined with James's powder, ipecacuanha, Dover's powder, opium and henbane, as being resorted to in the more severe cases. Antimony was also exhibited alone, either in the form of James's powder or of tartar emetic, to produce its nauseating and sedative effect, as appears from some of the replies. In others, however, a caution is given against its employment in this mode. " In conjunction with these measures, a light, diluent, or farinaceous diet is very generally recommended, though from some of the returns, one ratlier more nutritious seems to have 314 EPIDEMIC OF 1836-37 been occasionally found necessary ; regulated temperature, rest, and in the more severe cases, confinement to bed, are also enjoined. "18. Did any 'peculiar atmospheric phenomena pi'>^^^^^^ or accompany this epidemic ? — It is to be regretted that, with the _ exception of a valuable meteorological register forwarded by I Dr. Black, of Bolton, and some important tables from Dr. Shapter, the information given in the answers to this question _ is expressed in general terms. In the subjoined analysis, the m division into districts, formerly mentioned, has for obvious reasons been adhered to. « " To commence with the northern district, it appears that ^ in Sunderland and its neighbourhood, the autumn had been cold and wet, with frequent thunder and lightning ; and that at Liverpool, according to the statement of Dr. Macrorie, the weather preceding the outbreak was unusually cold and humid. The epidemic commenced at Sunderland during an intense frost, and cold frost and snow prevailed throughout its continuance. A similar state of weather was observed at Warrington, the atmosphere being cold and humid, with winds generally from the east and north-east. Dr. Fife, however, observed no peculiar atmospheric phenomena, the disease pre- vailing at Newcastle during the severest frost, and in the opposite state, without any perceptible mitigation. " In the midland counties there is less mention made of the coldness of the weather, but the returns from this district remark very generally upon the extreme humidity of the atmosphere immediately preceding or during the epidemic. At Aylesbury, according to Mr. Ceeley, ' the weather was very bleak, cold, and piercing, just before the epidemic, and the breaking up or thawing of the immense fall of snow, seemed to attend the increase of the epidemic ; but,' he adds, ' I look upon these phenomena as merely aggravating causes, since in- fluenza exists in summer, and I have observed it at all periods of the year, sporadically more or less, especially on atmospheric changes, or during the prevalence of south-east and north-east winds.' At Tenbury, Mr. Davis noticed that the atmosphere was remarkably humid during the prevalence of the epidemic; and an unusual quantity of rain fell in the months of January and February in that neighbourhood, producing the highest DR. STREETENS REPORT 315 floods which are remembered to have occurred during a period of forty years. The returns from Worcester and Evesham also mention the extreme humidity of the atmosphere, both before and during the prevalence of the disease. Mr. Eice, of Stratford-upon-Avon, remarks, that early in January there were two or three days of very mild weather, followed by a cold north-east wind, of which, however, he made no memo- randum at the time ; and Mr. Smith says, that at Stroud the epidemic was ushered in with a damp warm atmosphere, which was suddenly changed to cold rain, snow, or hail, scarcely a day passing without several changes of this kind, the disease abating as soon as the weather became more settled and warm. " The returns from the western district, which includes Wales and the counties of Hereford and Monmouth, mention a similar humid state of the atmosphere. Mr. Ashwin states, that at Abergavenny severe storms of wind from the north, north-west, and north-east, with heavy rains, preceded the out- break of the disease ; and that unusual falls of snow with high winds accompanied it. Mr. Bird, of Hereford, observes, that the weather was wet and damp, with cold winds, and thinks that the disease prevailed most in exposed and elevated situa- tions ; he adds, that the cases were certainly more severe in the country than in the city. At Holywell, there were in- cessant and dense fogs, which prevailed also at Presteign. ' The atmosphere,' says Dr. Davis, ' was throughout dark and gloomy, with frequent fogs, and the wind, for the most part, from the east or north-east.' There are also two circumstances deserving of notice, alluded to in the returns from this part of the kingdom, of which no mention is made as having been observed elsewhere. One is the occurrence of the aurora- borealis, noticed by Mr. Bird, of Swansea. The other is con- tained in the following extract from Dr. Davis's letter : — ' A gentleman in this neighbourhood, who is a naturalist, observed a large quantity of dead flies in hollow lanes and on the surface of the ponds, where they had evidently been drifted by the wind during the prevalence of the epidemic. The same thing was observed, I hear, in different places.' As we have just stated, no mention is made of such a phenomenon having been noticed elsewhere, in any of the returns sent in to the Council ; but the circumstance itself deserves to be recorded, 316 EPIDEMIC OF 1836-37 especially since a similar occurrence is said to have taken place during other epidemics. "In the replies sent in from the eastern counties, it is stated, that previous to the epidemic, the weather was cold and wet (according to Mr. Priest, of Burnham, cold and dry, with much snow), and the atmosphere hazy, the wind varying from north to north-east and east ; and the disease appears to have made its appearance immediately after the commencement of a thaw, when the atmosphere was saturated with moisture. Mr. Hargraves of Wotton says, that there was a sudden change from cold to warmth, there having been severe storms of snow for some time previous ; and Mr. Priest remarks, that the snow was succeeded by a mild and damp atmosphere, before which change the disease had not appeared. " In the south-eastern counties a similar atmospheric state is noticed as having occurred. ' The epidemic came on,' says the Chichester report, 'immediately after the melting of the snow, and certainly at a time of year not generally the most sickly, it having disappeared by the end of February, just, when, in ordinary circumstances, there is most sickness.' In the Isle of Wight, however, according to the statement of Mr. Bloxam, the snow appears to have been constantly on the ground, and the temperature of the atmosphere varying a few degrees above or below freezing point ; but this, he observes, continued for some time after the subsidence of the epidemic. Several of the returns from the southern counties mention a long continuance of cold winds as preceding or accompanying the disease. At Croydon, Mr. Fletcher observed a moist state of the atmosphere, with a long continuance of cold winds. At Salisbury, Dr. Grove states, that easterly winds, frost and snow, preceded the epidemic ; and Mr, Sampson, that those winds continued throughout. Mr. Smart, of Cranbourne, observes, that the outbreak of the epidemic was preceded by a sudden thaw, and its progress attended by easterly winds. At Bew Eegis the disease was observed to follow after the occur- rence of easterly winds, and the breaking up of the frost ; and Dr. Clendinning says, that he observed no peculiar atmo- spherical phenomena in the neighbourhood of the metropolis, with the exception of an unusual prevalence of winds from the north, east, and north-east. One gentleman, Mr. Fox, of DR. STREETEN'S REPORT 317 Cerne, states, that the principal atmospheric phenomenon observed to precede the late epidemic in this neighbourhood, was a difference of twenty-six degrees in the temperature in a very few hours, but does not mention whether this difference proceeded from a change from a low to a higher temperature, or the reverse. " The tabular reports of Dr. Shapter, referring to this part of the kingdom, and those of Dr. Black from the northern districts, will be found at length in the Appendix,^ and together with the observations of Mr. Addison made at Malvern, in the midland district, afford valuable materials for comparison. " Observations on the Meteorological Phenomena. " The identity of the influenza so universally prevalent throughout all parts of Europe in the early months of 1837, with those epidemic catarrhs which, at various periods, have visited this and other parts of the globe, cannot be disputed, and it is highly important to determine, if we can, what are the exciting causes of this widely-extended malady. In en- deavouring to bring this important question to as unexception- able a test as an inquiry so doubtful will admit of, it is requisite that doubtful or uncertain points should be discarded, and those facts only which are established by general testimony and experience be made use of for the purpose. " From all the documents we have seen relating to this subject, it is evident that catarrh, bronchitis, and other inflam- matory disorders of the chest, were more than usually prevalent in many parts of England in the period just preceding the outbreak of influenza, and that this epidemic raged not only throughout the whole of England, but in most other parts of Europe, between the first week of January and the third week of February, forcing itself upon the attention of medical prac- titioners, in some places a little earlier, in others rather later ; whilst again, influenced perhaps in some degree by local circumstances, it lingered among the population, in certain situations, for a more extended period than usual. "It is quite uncertain what time elapses between the application of the exciting cause and the appearance of the disease ; but supposing in the first place, that it had its origin 1 See First Edition, pp. 334-339. 318 EPIDEMIC OF 183G-37 solely in the changes of temperature, of pressure, or of weight of the aqueous vapour of the atmosphere, such an origin ought to be detected by examining these phenomena for two con- secutive months, the one being the month previous to, and the other the month including, the most active period of the disease, and comparing them with the same phenomena in the same months in preceding years. " With regard to the actual weight or pressure of the air, this could only have been increased by the introduction of some foreign gaseous, or other extremely attenuated form of matter into the mass of our atmosphere. The quantity and weight of vapour is so closely connected, particularly during the winter season, to which our observations are restricted, ■ with the temperature of the air, that a separate examination of ^ this subject is uncalled for. " It remains, then, to investigate the changes of temperature which took place in December 1836, and in January 1837, comparing them with the changes observed in December and | January of the two preceding years, in order to discover whether any peculiarities characterise this period. " In the annexed diagram^ the dark line shews the variation of maximum temperature in December 1836, and January 1837; it may be called the influenza line : the ligliter shaded line shews the temperature for December 1835, and January 1836, and the dotted line for December 1834, and January 1835:— DECEMBER. JANUARY. 5 10 15 20 2 5 3/ 5 )0 )5 20_ 25 30 DR. STREETEX'S REPORT 319 Upon attentively examining the dark line, there is nothing calling for remark until we arrive at a great depression of temperature between the 2 2d and 25th of December — a fall of 25° F. in three days. This depression was caused or accompanied by a change of wind from west or north-north- west to north-north-east. On the 25 th the wind blew a gale from the latter point, and during the three subsequent days a very unusual quantity of snow fell, unequalled in this country for duration, severity, and extent. A rapid thaw commenced on the 2d day of January, the influenza appeared in London at the same time, and it was general throughout the country on the 7th, or at farthest on the 10th. " The accounts from all parts of the country, of the disastrous gales, the drifting of the snow, the floods caused by the thaw, and the outbreak of influenza, rapidly succeeded each other. " If we now examine the shaded line, which shews the variation of maximum temperature for December 1835, and January 1836, we shall find a great depression of temperature between the 18th and the 24th December, after which the thermometer rose quickly 20° F., and then fell again the last day of the month and during the first three days of January. The temperature then again rose 18° F. in two days, reaching 50° on the 5th. Snow fell on the evenings of the 19th and 20th of December, lying nearly two inches deep on the morn- ing of the 21st. The weather was frosty on the 21st and 2 2d, with a north-east wind, then frosty and foggy until the 27th, when a thaw took place, which continued, with occasional rain and snow, to the 4th of January ; and on the 8th I read the following remark, penned at the time in my journal : — ' A particularly sickly time, catarrhs, and other inflammatory affections of the chest and larynx, accompanied, in many instances, with neuralgic pains.' " We will now shortly refer to the dotted line. Here we see a great change of temperature, amounting to 27° F., occurring between the last day of December 1834, and the 7th of January 1835. On the former day the thermometer stood at 55°, with rain and a south-west wind ; frost began on the 2d of January, and it continued with fine weather and light north-east wind until the 8th, when the temperature rose 320 EPIDEMIC OF 1836-37 rapidly, and rain again fell. There was no snow during these changes. There is another considerable fall of the thermometer shewn between the 15th and 20th of January, and on this occasion it both rained and snowed. Scarlet fever prevailed at this time ; but catarrhal diseases were not particularly remarked. " From this examination — indeed, from the most casual survey of the foregoing lines — we may conclude, that very great variations of temperature may and do occur in a short time without producing any influenza, perhaps no unusual in- crease in the ordinary affections of the chest, to which all persons are more or less liable during spring and autumn, except when these sudden alterations are accompanied by melting snow, which does under certain circumstances appear sensibly to increase the prevalence of inflammatory affections of the air passages. " This condition, — melting snow, — was operating at the breaking out of influenza in January 1837; but did it produce the disease, or did it only co-operate in giving greater effect to other causes ? That it did not produce the disease is evident, because this occurred in situations on the Continent nearly about the same time, where there was no melting snow, and because the same disease has occurred before, in this and other countries, in summer months. In 1833 it was very general in this country in April and May, and again in June 1831, partially. Dr. Bardsley, speaking of the influenza of 1802, says, The present epidemic cannot have originated from any remarkable severity of the weather or sudden changes in the temperature of the atmosphere ; no season has been apparently less unfriendly to the human constitution than the whole of the late winter and early part of spring. The epidemic catarrhs of 1762 and 1782 prevailed during uncommonly warm and steady weather, in the months of May and June. The remark- able epidemic catarrh of 1580, which, according to Senuertus, — ' Totam fere Europam, uno fere omnes mundi regiones per- vagata est,'-'- — raged chiefly during the sultry weather of autumn. In the month of September 1830, influenza prevailed at Manilla, with the thermometer varying from 78° to 92°.^ ^ Medical and Physical Journal, vol. ix. p. 527. - Medical Gazette, vol. viii. p. 525. DR. STREETEX'S REPORT 321 » " Without uselessly multiplying instances or authorities, it must be evident that the exciting cause of influenza cannot be found in sudden vicissitudes of temperature, great heat or cold, damp weather or melting snow, however much all or any of these circumstances may predispose to or originate the more ordinary catarrhs, eruptive fevers, and other disorders of spring, autumn, and winter." A Meteorological Eegister for January, February, and March 1837, with a Nosometrical View of the Epidemic Influenza during the same months, as observed at Bolton-le- Moors, is inserted at p. 334 of the first edition. In proceeding to communicate further particulars regarding this visitation, it may be mentioned that the disease made its appearance at Sydney on the second week of October 1836; and at Cape Town, Cape of Good Hope, on the 1st of Novem- ber : much about the same time it was observed on the shores of the Baltic, and soon afterwards in the north of Scotland. Its simultaneous appearance in countries so distant from one another, and so different in climate, is well worthy of notice, and inconsistent with the opinions of practitioners, who would refer the epidemic to any variety of weather. In this country, indeed, it appeared in some places, as in Sunderland, during the frost ; in others, as in Bury, not before the occurrence of thaw and sudden alternations of temperature, and in Dublin it raged during weather remarkable for its mildness and serenity.^ The following table, given by Dr. Heberden - from the weekly bills of mortality, exhibits very clearly the progress of the epidemic in London. 1837. Christenings. Burials. Christenings to Burials. Influ- enza. A^e from 30 to 40. 50 to 60. 20 70 to 80. 22 January .3 .36.3 228 4 to 2-5 14 10 487 284 4 to 2-5 23 42 30 „ 17 384 477 4 to 5 13 49 70 53 24 520 871 4 to 6-6 106 69 95 122 31 307 860 4 to 11 99 71 54 113 February 7 532 589 4 to 4-4 63 41 69 77 14 474 558 4 to 4-7 35 54 70 59 21 316 350 4 to 4-4 20 36 36 31 28 809 321 4 to 1 -6 8 32 24 37 March 7 480 262 4 to 2-2 4 23 23 19 1 Lond. Med. Gaz. vol. xx. pp- IM, US, 129, 224. Y ' Ibid. p. 786. 322 EPIDEMIC OF 1836-37 It is apparent from this table, that the disease began in London about the 10th of January, attained its height in about a fortnight, and ceased after six or seven weeks from its first appearance. It is also observable that, whilst the deaths at all ages were increased, those of the old were most sensibly altered.^ The following return supplied by Dr. Graves, of the inter- ments in Prospect Cemetery, Glasnevin, in the suburbs of Dublin, conveys an idea of the severity of the epidemic in that locality : "In December 1835 . 352 January 1836 . 392 February ,, . 362 March „ . 392 In December 1836 . 413 January 1837 . 821 February „ .537 March „ . 477" " If, as is probable, less than a fourth of those dying in Dublin are buried there, three thousand persons died of in- fluenza in Dublin, besides those who, although they got over the immediate attack, sank under diseases induced by this epidemic." ^ Dr. Greenhow, of North Shields, who was at first inclined to attribute the disease to the influence of the weather, gave up that opinion on observing that comfortable lodging, warm clothing, and good food, afforded no protection against the attack. He adds : " In low situations near the river side, amongst narrow lanes and close alleys, the complaint w^as neither more fre- quent in its occurrence (in proportion to the population), nor more violent in its form, than it was in the upper town or in the adjacent country, amongst the villages and farmhouses. A gentleman who had been confined for some months to his chamber, the temperature of which never varied so much as one degree, was the only individual of the family who took the disease. " Those people whose occupations were carried on in high temperatures, as the pitmen, glass-blowers, forgemen, and founders, were amongst the first who sufl'ered from the epidemic, and great numbers of them were attacked while ' London Medical Gazette, vol. xx. p. 51. 2 Ibid. p. 787. DR. GRAVES'S OBSERYATIOXS 323 at work, and consequently when the skin was in a state of great activity ; from which we may fairly infer, that the morbid impression is exerted on the system through the medium of the skin. The people employed in the various soda manufactories, who work and live in an atmosphere impregnated with muriatic acid gas of such strength as to destroy vegetation in the immediate vicinity, enjoyed no exemption, but suffered in an equal proportion to the rest of the community, a circumstance calculated to make us a little sceptical as to the disinfecting power of any gaseous fluid. Of sailors, many were attacked at sea, but, as far as I can ascertain, not in harbour, who along with keelmen, w^atermen, and others, employed upon the river, suffered in a similar proportion to the rest of the inhabitants. The only class of people who enjoyed immunity from its attack were the dredgers, consisting entirely of females, amounting to about two hundred in number. Their occupation consists in wading up to the arm-pits in salt water for three or four hours at each ebb tide, to collect, with wooden rakes, the coals which fall into the river in loading the ships. These women enjoy a remarkable exemption from sickness, and generally ■ attain to a very advanced age. On the late occasion they escaped the epidemic entirely." ^ 2. DR GRAVES 2 " The epidemic rarely attacked persons labouring under acute diseases until the period of convalescence arrived, when their immunity ceased, and they became just as liable to its invasion as others. Thus patients labouring under typhus escaped as long as the fever continued ; biit frequently on the very day the crisis occurred, and symptoms of returning convalescence appeared, they were seized with influenza. " One of the most singular features ^ in the history of the present influenza is the extraordinary degree of dyspnoea wit- nessed in most cases where the lung is extensively engaged, but particularly where the patients had been previously sub- ject to pulmonary affection, and even in many cases where ' London Medical Gazette, vol. xx. p. 10. - Idem, p. 786. ^ Idem, p. 856. 32-t EPIDEMIC OF 1836-37 the bronchial mucous membrane is but slightly engaged the amount of dyspnoea is remarkably great. Indeed it might be said with much truth, that tlie dyspnoea was by no means pro- portioned to the extent of pulmonary inflammation. There is at present in the hospital a woman labouring under influenza whose chest sounds clear on percussion, and in whom every part of the lung is permeable, who presents nothing more than a few sonorous rales in the course of the larger bronchial tubes, and yet she is suffering from considerable dyspnoea, and the respiration amounts to forty-six in a minute. We cannot, therefore, attribute the difficulty of breathing to mere bron- chitic lesion, for it is not in proportion to this lesion. Another patient, admitted into Sir P. Dun's hosj)ital, exhibited a similar train of symptoms. He was a negro sailor, a native of New Brunswick, and was seized with the epidemic a few days after his ship arrived in Dublin. He was a man of Herculean form and finely-developed chest, and in the prime of life ; his suffering from dyspnoea was intense ; his chest heaved, he tossed about in bed in a constant state of agitation and restlessness, and yet the respiratory murmur was everywhere distinctly audible through the lung, and no rale could be heard, except here and there a few bronchitic wheezings. He also laboured under insomnia ; and, though he had but little fever, his debility was extreme ; indeed his pulse was so weak from the commence- ment, that I could not venture to treat him antiphlogistically, and I accordingly ordered extensive vesication over the chest, with the use of wine stimulants and narcotics. This man sub- sequently recovered, an event which could hardly have occurred under the plan of treatment adopted, had his dyspnoea de- pended on mere bronchitis. It should be also borne in mind that in many bad cases of influenza the dyspnoea is intermittent, or at least undergoes remarkable exacerbations and remissions at certain hours of the day and night. It would appear that the respiratory derangement depends on the same general cause which produces the whole train of symptoms, and that it might exist even where there was no bronchial inflammation at all. It is true, that where the bronchitis is present it adds to the distress of respiration, but the dyspnoea appears to be chiefly attributable to some impression made on the vital activity of the lung. That the lungs are endowed with an DR. GRAVES'S OBSERVATIONS 325 inherent vitality necessary to the aeration of the blood has been long acknowledged by the Germans, who have described a dyspncea from paralj'sis of the lungs ; and tliis opinion is now generally adopted in Great Britain since the results of the experiments on the eighth pair of nerves have been duly appreciated. We have abundant illustrations of this truth in asthma, in which the greatest dyspnoea is often present without any appreciable lesion of the lung ; and it would be a fortunate circumstance for the patients in influenza if this were not the case, for we could then treat the affection of the lung as ordinary bronchitis, and should expect to find it amenable to the ordinary remedies. You are aware that the mortality, in cases of ordinary bronchitis, is extremely small, if we except very young children and persons advanced in life. In adults, when met by prompt and appropriate treatment, it is in general a very manageable disease, and seldom proves fatal, unless combined with other unfavorable conditions. This, however, is not the case in influenza, nor is the pulmonary affection so easily treated, or the dyspnoea so readily controlled. I saw some time ago a fine young woman, servant to a gentleman in Fitzwilliam Street, for whom everything had been done which the best and most skilful practice could devise, — but her condition, when I saw her, was desperate, and she died the following day ; yet her chest sounded well on percussion, and we could hear nothing over the whole lung except a few sonorous and sibilous rales ; and the respiratory murmur seemed everywhere nearly as loud as natural. Of course such a lesion of the nervous influence could not last long without necessarily inducing pulmonary congestion, — an inevitable consequence of imperfect aeration of the blood. When the eighth pair of nerves is divided, the animal is slowly suffocated ; and on dissection, the lungs are found engorged, and the bronchial mucous mem- brane congested and inflamed. May not the affection of these parts in influenza be sometimes induced by lesions of nervous power in the lungs ? I am indebted to my friend Dr. George Green for the following results of his very numerous post- mortem examinations in this disease ; and I feel great pleasure in being able to give them, as such examinations, at least in this country, are very rare. Dr. Green observes : " ' In the cases which proved fatal at the House of Industry 326 EPIDEMIC OF 1836-37 during the late epidemic, influenza occurred principally among the aged inmates of both sexes. I had an opportunity of examining several of these cases, and the following were the principal post-mortem appearances observed : " ' The bronchial mucous membrane was found in every case more or less congested and inflamed. The colour varied considerably, being in some of a dull red, and in others of a much darker hue. The inflammation in most cases was found to occupy both the trachea and the bronchial tubes of both lungs ; in other instances it was confined to one lung alone. A sanguinolent frothy mucus occupied the area of the tubes, and increased in quantity as they were traced to their minuter divisions. The parenchymatous tissue of the lung was invariably discoloured, being generally of a dark or violet colour; its specific gravity was increased, and it did not crepitate, or at least very feebly, when pressed between the fingers. The surface of its section was not rough to the touch, and when pressed in the hand a quantity of the mucus described above was driven out. In some cases the postero-inferior portions of one or both lungs were very dark coloured, and the finger could be passed easily through its substance. When the surface thus torn was examined, it did not appear to be granulated, it re- sembled more a portion of gangrenous lung, except that there W'as an absence of foetor. This last appearance was found principally in very aged persons. It was rare to find any traces of the second or third stages of ordinary pneumonia in these patients ; but in the young and robust, wdio were received into the Hardwick Fever Hospital from the neighbouring streets, these degenerations of the structure of the lung were observed, together with the same inflammation of the bronchial mucous membrane. In most of the aged patients the blood was found dark coloured and fluid in both cavities of the heart and in every vessel where it was examined. The cases in which fibrous concretions in the cavities of the heart were found were very few, and these invariably in the young or middle-aged. In the former classes of patients, also, the lung occasionally appeared to be oedematous ; and, in one or two cases, a considerable effusion of serum had taken place into the pleural cavities. The signs of recent pleuritis were very rare, but old adhesions, as might be expected in such subjects, DR. GRAVES'S OBSERVATIONS 327 were very commonlj fouud between tlie pulmonary and costal pleume. In one case of a lunatic who sur^dved the immediate attack of influenza, tubercles appeared to have been rapidly developed in both lungs. In another lunatic two tuberculous cavities were found, in addition to the state of the lung and air-tubes already adverted to. " ' "With respect to the nature and duration of symptoms of those cases which came under my own management, I have little to say in addition to what is already so familiarly known. The physical signs afforded by percussion and auscultation were almost universally as follows : — Dullness, more or less decidedly marked in the postero-inferior portion of the lungs, sonorous, or some form of the bronchial rales throughout the chest ; or, what was more common, a mixed sonorous and crepitating rale ; or, in the latter stage, a muco-crepitating rale. The sputa were seldom rusty coloured or tenacious, but rather resembled those of bronchitis. In many cases, the want of power to excrete them appeared to be the immediate cause of death ; but in others, the morbid cause, whatever it might be, appeared to have affected the entire respiratory and circulating systems, producing great congestion of the venous system, and a state not unlike asphyxia. The latter cases were almost all among the aged inmates of the House of Industry. " ' The appearances of the other viscera were not such as could in any v\-ay account for the result so often fatal, so that, so far as one could hazard a conjecture, the morbid cause appeared to have made its primary impression on the respiratory mucous surface, thereby interfering with the proper aeration of the blood, and inducing the changes in that fluid, and in the structure of the lungs above detailed.' " Such are the appearances observed by Dr. Green in his numerous dissections of persons who died of influenza. They may be relied on as perfectly accurate, for no one is better acquainted with pathological phenomena than Dr. Green ; and consequently, no one better able to furnish valuable evidence with respect to the appreciable changes produced by influenza in the pulmonary and other tissues. I have already advanced the opinion, that we should not hastily assume that influenza consists essentially in the morbid changes which dissection reveals — we should examine every side of the question, and 328 EPIDEMIC OF 1836-37 consider whether it is not possible that the alterations in the pulmonary tissue may not be, to some extent at least, the con- sequences of the disease. Let us consider for a moment the method we pursue in reasoning about the progress and causes of the symptoms in ordinary bronchitis. Here a patient is seized with a pectoral affection, attended by cough, dyspncjea, and more or less of fever. We find certain rales, and the expectoration is altered in quality and quantity. Further observing a number of such cases, we remark that the danger is proportioned to the degree of dyspnoea, and the dyspnoea to the extent and nature of the rales, together with the quantity and quality of the expectoration. To these the general con- stitutional affection, and the probable results of the disease, have certain definite relations, a knowledge of which is soon obtained by experience. But these rales, and this state of the respiration and expectoration, we have reason to believe arise from the presence of bronchial inflammation, and to this we refer all the symptoms observed. On this supposition, too, we proceed in our treatment, and the result most commonly justifies its correctness ; and we have additional evidence of its truth furnished by post-mortem examinations. Now in such instances the chain of inductive evidence is complete ; and we feel a conviction, that our practice is founded on correct notions of the nature of the disease. But how different is the case when we assume that influenza is caused by bronchial inflammation ! In influenza, the dyspnoea is not always proportioned to the bronchitic affection ; nay, in som€ cases, we have seen that difficulty of breathing was most urgent, in cases where the air entered into all parts of the lung with facility, and where few and unimportant ralesl existed. Again, although the presence of a copious viscid! secretion in the bronchial tubes was sure to aggravate dyspnoea,] yet it often occurred in patients whose air-passages were very! little or not at all obstructed in this way. The effects of remedies, antiphlogistic, expectorant, and derivative, were veryj different from what they would have been, had the disease depended on a mere bronchitis. I have already stated mj conviction, that the poison which produced influenza acted on] the nervous system in general, and on the pulmonary nerves in particular, in such a way as to produce symptoms of DR. GRAVES'S OBSERVATIONS 329 bronchial irritation and dyspnoea, to which bronchial conges- tion and inflammation were often superadded. " In this view of the subject I am not singular, for I find that it has been advocated by Dr. Peyton Blakiston, in a short ' Treatise on Influenza,' as it occurred at Birmingham. He states, that his researches have led him to the conclusion, ' that influenza is an affection of the nervous system, with its concomitant derangements in the organs of digestion, circula- tion, etc., commonly known under the name of nervous fever, accompanied, throughout its whole course, by irritation of the pulmonary mucous membrane, which not unfrequently amounts to congestion and even to inflammation.' " This distinction between influenza and feverish cold, with bronchitis, is, in a practical point of view, of great importance, and should never be lost sight of in the treatment of influenza, for it prevents us from placing our sole confidence in remedies adapted to mere bronchitic inflammation. Thus Dr. Blakiston asserts, and most physicians will agree with him, in this point at least, that it was often necessary to have recourse to diffusible stimulants at the commencement, and to administer tonic medi- cines in an early stage of the disease. " In some cases, even where great dyspnoea exists, the cough is hard and dry, and the expectoration is copious, so as to cause constant efforts to cough it up ; and, indeed, it is melancholy to look at the distress which patients suffer in this respect. You will hear the wheezing of the phlegm in the throat and air-passages before you enter the room, and you will see the patient exhausted by successive paroxysms of cough and in- effectual attempts to expectorate. In other cases, where the vitality of the lung is less injured, and the general tone of the system less deranged, the sputa, although copious, are expec- torated with considerable facility. The sputa bear considerable analogy to those observed in ordinary bronchitis ; they consist, at first, of a greyish mucus, which, as the disease proceeds, exhibits a globular appearance, or assumes a puriform character, and does not coalesce ; in other cases they are extremely viscid and ropy, like solutions of gum or isinglass. A remarkable fact with respect to the sputa in influenza is, that they are very seldom mixed with air-bubbles. On mentioning this to- day to some persons attending my class, I was shewn some 330 EPIDEMIC OF 1836-37 sputa discharged by a patient lal30uring under influenza, in which there were some air -bubbles : this, however, is ex- tremely rare. " In a lecture which was delivered here some time ago, I took occasion to allude to the secretions of the bronchial mucous membrane, and stated my conviction that this subject had not received, as yet, the attention which its acknowledged import- ance demands. There is one point in particular, of which no adequate explanation has been as yet given, namely, why it is that in some cases of pulmonary inflammation the sputa are filled with air-bubbles, while in other instances there is no appearance of air-bubbles from the beginning to the end of the disease. The presence of the air-bubbles in the sputa has been explained, by supposing that air becomes incorporated with the mucus, while it is driven up and down in the bronchial tubes, during the acts of respiration and coughing, just as if you shake a solution of soap, or any other viscid fluid, in a half- empty bottle, it becomes impregnated with air-bubbles. There may be some truth in this, but I think it does not sufficiently explain the presence and intimate incorporation of air with the sputa, in certain affections of the lung ; and it appears to me that we can scarcely understand this, unless we suppose that the air and mucus are secreted together. You are aware that air is secreted by the bronchial mucous membrane, and that, in some cases, this secretion is morbidly increased, in others morbidly diminished. Now it is not very unreasonable to suppose, that the mucous membrane may secrete air and mucus together in abnormal quantity ; and that this, rather than any mechanical agitation, may be the cause of the intimate com- bination of air with the expectorated fluids. " I need scarcely make any observation on the cough of influenza. It is in general very troublesome, particularly at night. Many persons are not much annoyed by it during the day, but at night it becomes very harassing and prevents them from sleeping. When severe, it continues both night and day, and even when persons have recovered from fever and dyspnoea, and are able to go about, the cough will continue extremely troublesome : this I have observed in the majority of cases. In this state medicines prove of very little service, and one of the best remedies is to change to a mild country air. Cases DR. GRAVES'S OBSERVATIONS 331 of cough, in which I had tried every remedy without success, and which had resisted every form of treatment in the city, jdelded in a few days to the salubrious influence of change of air. " In influenza the urine is generally much loaded with lithates and superlitliates, and contains a large quantity of erythric or purpuric acid. It is red when voided, deposits a good deal of sediment, and tinges the vessel in which it lies, with a pink film. It bears some resemblance to the urine which accompanies arthritic and gouty affections. In very bad cases this state of the urine continues up to the period of death. You recollect what I stated with regard to the con- dition of the blood ; — it is generally buffed, even where there is scarcely any febrile excitement in the system, and thus affords a very fallacious indication. The same observation holds good with respect to the state of the urine and the temperature of the skin. I may observe here, that the heat of the skin is very variable ; it is sometimes very high, sometimes natural, in fact, like the pulse, it falls and rises in a very remarkable manner at certain times of the day. " I have already spoken of the affection of the mucous membrane of the bowels ; I may observe, that in some cases of influenza the morbid influence is translated to the brain, and symptoms of delirium and coma supervene. Thus, in two instances communicated to me by the surgeon -general, the patients fell into a state resembling coma, during the course of the disease. In three cases witnessed by IMr. Swift, the attack of influenza terminated in a train of symptoms bearing a close analogy to delirium tremens, and requiring the use of blisters to the head and neck, full doses of opium, purgative enemata, wine, and the occasional use of mercurials. The patients complained of great headache, noise in the ears, some intolerance of light, and more or less sleeplessness from the commencement, along with the usual pulmonary symptoms. After five or six days they became excessively nervous, lost all sleep, had continual subsultus and tremors, and talked very incoherently, particularly at nigiit. During the prevalence of the cerebral symptoms, the pulmonary affection partially or wholly disappeared, but returned again in some degree, after the subsidence of the delirium. All these cases terminated 332 EPIDEMIC OF 1836-37 favorably. I believe I have already remarked, that many persons who have laboured under very severe pulmonary symptoms, will struggle through the disease ; and I may men- tion here, that I have seen persons recover who have suffered from continued orthopnoea for three weeks. Still the mor- tality, peculiarly among the aged, is very great, and I fear that we shall shortly have but few octogenarians to tell the occur- rences of the last century. Indeed, the mortality has not been J confined exclusively to the aged, for many persons in the vigour of life have sunk under the attack. Tliere have been several deaths among the soldiers in our garrisons, notwith- standing the excellent health which our troops generally enjoy, and the skilful and judicious treatment of our present army- surgeons. The results of the medical treatment and necro- scopic observations in the different regiments in London, Dublin, and Edinburgh, will form a most valuable document, and I hope it will be made public for the benefit of the whole profession. ■ " It now remains for me to say a few words on treatment. 1 First, as to bleeding. A great deal was expected from general bleeding, because the disease was sudden and violent in its onset, accompanied by symptoms which seemed to require active measures, such as an inflammatory state of the bronchial mucous membrane, accompanied by a quick pulse, hot skin, and high-coloured urine. This led persons to expect much benefit from venesection. The results, however, of its employ- ment are, generally speaking, very unsatisfactory. Where venesection was employed promptly, and in the beginning of the disease, and where it seemed to be strongly indicated by the buffed and cupped state of the blood, even in such cases it failed to afford anything like material or permanent benefit, or to produce a decided amelioration of the existing symptoms. The general impression among practitioners in Dublin at present seems to be, that bleeding is doubtful in its effects, if not alto- gether improper. I am much inclined to think that bleeding, unless employed within the first twelve or twenty-four hours, will be likely to do as much or more harm than good. Bleed- ing on the second or third day, except to relieve congestion of the lungs, seems inadmissible. The same observation holds good with reference to other diseases. Thus, in scarlatina, if DR. GRAYES'S OBSERVATIONS 333 you happen to be called in when the rigor commences, and while the disease is beginning to form, you will often ac- complish much good by bleeding your patient ; but after eighteen or twenty -four hours, when the disease is fully formed, venesection will not do. On this point I can speak from experience. In scarlatina the difference of a few hours renders venesection inapplicable and even injurious. It is the same thing with respect to influenza ; general bleeding is use- ful, only in the commencement; and where the symptoms seem to demand it, it should be employed at least within the first twenty-four hours. Where I have been fortunate enough to find the disease just commencing, I bleed to the amount of twelve or fourteen ounces, order the patient to remain in bed and take some aperient, followed by the use of nitre. In this way, by timely bleeding, aperients, sudorifics, and confinement to bed, the attack generally passes over in two or three days. I could mention many instances of the success of this plan of treatment. In one family I treated all the individuals attacked in this way, and I have done the same thing in many cases of persons somewhat advanced in life. In the case of an old gentleman who was very severely attacked, I succeeded by these means in checking the disease at once. My experience therefore is, that bleeding is of service in the very commence- ment of the disease ; but as it seldom happens that a physician is called in at this period, I would qualify my statement by saying, that, as a general measure, bleeding in influenza is seldom admissible. When you are called in to attend cases, you wiU most generally find that the patients have been ill for two or three days or more, and then the only mode of abstracting blood, which you can have recourse to with safety, is by leeching. About eight or ten leeches applied over tlie noUow of the neck, just above the sternum, and allowed to bleed pretty freely, will prove very serviceable ; and if you apply them in the evening, you will often secure to your patient a good night's rest. This plan of leeching the hollow of the neck, in cases of tracheo-bronchial inflammation, is an excellent one: the leeches are applied at a spot which lies close to the trachea, and particularly to that point, to which the irritation accompanying bronchitic affections is chiefly referred. By the aid of leeching, the use of aperients, if necessary, and confine- 334 EPIDEMIC OF 1836-37 ment to bed, with sudorifics, you will frequently succeed in removing the fever and bronchial inflammation. You will derive much benefit, particularly in the early stage of influenza, from tartar emetic and nitre ; but I must say, that neither leeching, nor tartar emetic and nitre, prove as valuable and as efficacious in influenza as they do in ordinary bronchitis. Some of my friends who iised tartar emetic as a nauseant in the commencement of the disease, inform me that they have ■ derived benefit from its use, and others have told me that they have used tartar emetic and opium in the commencement and during the course of the disease with advantage. I have not employed the first of these, but I have the latter, and with favorable results. You may, therefore, after using antiphlo- gistics for a day or two, proceed to the use of opiates in com- bination with tartar emetic or nitre. In some cases the camphorated tincture of opium will answer very well ; in others you w^ill find the acetate or muriate of morphia better. A mixture composed of six ounces of almond emulsion, a drachm of nitre, and half a drachm or more of the liquor muriatis morphise, will be found very useful. The muriate of morphia, which possesses many of the valuable properties of opium without its defects, will serve to tranquillise the system and produce sleep, two most important points in a disease like influenza connected with increased nervous irritability. A gentleman, on whom I place much reliance, tells me, that he has treated many bad cases successfully with camphor mixture, tincture of opium, and tartar emetic. I need not mention the various remedies which have been recommended in this disease, as Mindererus' spirit, Hoffman's anodyne, ipecacuanha — alone or combined with extract of conium and blue-pill, — and many other remedies belonging to the class of diaphoretics or expectorants. They are all more or less serviceable, but they have all the common defect of producing less relief than they usually do in cases where the pulmonary affection is simple and idiopathic. Towards the end of the disease you find it necessary to give stimulant expectorants and light tonics, as decoction of polygala, senega, infusion of calumba, etc. etc. " One word about blisters before I conclude. They are useful in some cases, but in many of the severe ones they do DR. CLENDINNING'S OBSERVATIONS 335 little or no good, and only add to the patient's sufferings. They do not relieve the pulmonary symptoms, and particularly the dyspnoea, in the manner you would be prepared to expect. I do not know a more remarkable circumstance in the present disease than the failure of blisters, and in many cases I do not employ them at all. ^'omenting the trachea and chest with very hot water appears to be much more serviceable. This has proved extremely valuable in many cases of this as well as other affections of the air-passages ; and on referring to the late American journals, I find that the plan of treating croup in its onset, by means of very hot water apj)lied with a sponge to the throat, — a plan which I recommended some time ago in the Dublin Medical Journal — has been extensively employed in America, and with the most happy results. Sponging the throat and chest with water as hot as it can be borne, has been found, in many instances, capable of arresting all the threaten- ing symptoms of croup at once. Several cases are mentioned in the American journals, in which the lives of the little patients were evidently saved by this application. I may state also, that not long since a child was saved in Dublin by the same means. By the advice of Mr. Smyly, who suspected the threatened attack, the child's mother had everything pre- pared, and by her promptitude and care arrested the disease before it had sufficient time to form." 3. DE. CLENDINNINGi " Between Monday, January 9, and Saturday, February 4, 414 cases of influenza were admitted on the out-patient home list of the Marylebone Infirmary, as stated by Dr. Boyd, namely : "Week ending 14th January . . 161 ,, 21st „ . . 139 „ 28tli „ . . 84 ,, 4th February . . 34 and the workhouse practice and morning out-patients' room practice advanced numerically, and receded apparently along ^ Notice of the Influenza of January and February 1837, by Dr. Clendinning, in Loudon Medical Gazette, Feb. 18, 1837, p. 781. 336 EPIDEMIC OF 1836-37 with the infirmary and liome practices ; so that the epidemic would appear to have begun with January, and declined in about the usual period of from five to six weeks. " SymjJtoriis. — Of course amongst such a number, various combinations of symptoms must have happened. Confining my remarks to those that were admitted into the Infirmary, of whom only I had personal cognizance, I should say that the cases varied principally according as they were simple or com- plicated, — the former being tolerably uniform in their symptoms, the latter various as the complicating diseases. Of the former the symptoms are familiar, and require no detailed description from me ; namely, at first chilliness, lassitude, and depression or anxiety, followed in some hours by more or less of heat, gravedo, headache, coryza, pain of back and limbs, soreness, sometimes extreme of the chest and throat, with cough, smart fever, often coated tongue, nausea and vomiting, sometimes gastro-enteritic irritation, with diarrhoea, occasionally transient delirium, generally wandering pains of trunk, especially about the sides. Such were the principal symptoms of the uncom- plicated cases for twenty-four, thirty-six, or forty-eight hours after admission ; after which expectoration became easier, the skin softer and moister, and the cough and headache less troublesome, when the fever gave way, so that in three or four days nothing but weakness with a tiresome cough remained in the majority of instances, — a weakness, however, greatly dis- proportionate to the duration or danger of the disease. Two- fifths of the cases noted as influenza by the house surgeon, were of the kind just glanced at ; the remaining three-fifths were complicated as follows, namely : " With pleuropneumonia „ bronchitis, mostly chronic, and combined with 36 emphysema pulm., and morb. cord. 52 Phthisis .... 25 Pleuritis 5 Fever, in several instances typhoid 25 Rheumatism, chron. 2 Morb. chron. ventriculi 3 Croup .... Ptyalism Encephalitis Morb. chron. cord. 3 1 1 3 Pericarditis 1 DR. CLENDIXNING'S OBSERVATIOXS 337 " Of course the symptoms must have varied very much in the second class or complicated cases. In numerous instances the complicating diseases were at first so masked by the influ- enza as not to be easily recognisable, — without the aid of the pleximeter or finger and ear tube ; indeed, it appeared to me nearly impossible, in several cases, to arrive at a safe and satis- factory diagnosis, more especially in persons advanced in life. The irregularity observed in the course of the functional signs did not in any material degree of course extend to the physical signs, so that pneumonia, phthisis, diseases of the heart, and hypertrophy of the ramifications of the bronchus (or emphy- sema pulm. cum catarrh, chron.), which were the most frequent and formidable complications, were generally as easily identified as usual. In every case the influenza, if distinguished at all, was readily detected, whatever its complications, if attended to within the first day or two ; after that period, it often in bad cases became absorbed in the effects of the graver complicating disease. " Mortality. — The mortality with us or elsewhere, amongst populations embracing indifierently individuals of all ages, sound and unsound, was very considerable during the period so often specified above. I do not know that any simple case was lost from influenza unaided by previous disease or subse- quent compHcation ; but so large a portion of the subjects of our influenza had had previously tuberculated lung, diseased bronchial ramifications, or hypertrophy of the heart, and the instances in which pleuropneumonia was excited were so numerous, that we lost — " In the six weeks from the 31st December, altogether . 118 To which must be added deaths in the infirm wards of the workhouse, same period . . .21 In the out-door practice, also, there were some deaths amounting in the same period to . . .40 Giving a grand total mortality of .179 338 EPIDEMIC OF 1836-37 " TaUe of cases of all ages treated in the wards of the St. Mary- lebone Infirmary from, the 30th of December 1836, to the 10th of February 1837.^ Living. Dying. 1 Influenza in both sexes. Male. Female. Male. Female. Under twelve months One to five years Five to ten years Ten to twenty years Twenty to thirty Thirty to forty . Forty to fifty Fifty to sixty Sixty to seventy . Seventy and upwards 5 15 17 40 21 34 27 36 22 21 4 5 24 33 40 26 27 25 30 11 1 3 3 11 10 14 6 9 2 1 2 5 . 4 7 8 10 2 5 3 15 35 28 33 26 41 35 26 " Bemarks on the Table of Ages. — From the preceding table it would appear, that aged persons have enjoyed no such immuni- ties during the late epidemic, as they have been found, or, for want of counting, perhaps supposed to do, in former epidemics. More than half of the cases were above forty, while a fourth part nearly were above sixty. But the table represents the case too favorably of the other extreme of life, owing to the nursery and school children having usually not been so severely affected as to require hospital treatment. Another generally received opinion, however, is confirmed by our experi- ence, namely, the potency of pectoral disease as a predisposing cause ; this appears strikingly from the table of complications. For though the compKcated cases were received into the infirmary in much larger proportion, of course, than the simple cases, yet the number of the former is too considerable to be overlooked or attributed to universality of diffusion of the epidemic causes rather than to peculiar susceptibility in the subjects. I have added the deaths of all the diseases, but none for influenza separately, for the obvious reason, that influenza proper produced no deaths. Amongst the causes, I have seen no reason to reckon contagion ; perhaps I have not looked sufficiently, or inquired for it. Like all other epidemic diseases, the present, whether contagious or not, certainly com- menced at first without contagion, and has probably, as I think, ^ For corrected Table, vide ' Medical Gazette ' 1837, p. 819. DK. CLEXDINNINGS OBSERVATIONS 339 been exclusively reproduced and continued by recurrences of one or more of its first causes. What those first and essential causes are, I think with Pringle (Med. Observ. and Enq., vol. vi.), is still a problem for solution.^ "Morbid cq:)pearances. — During the epidemic numerous op- portunities presented themselves of investigating its anatomical characters ; and in every instance I found that the fatal result might be attributed to previous disease, or to organic deteriora- tion from lapse of years. The youngest was a female eight years old, who sank under double pneumonia, supervening on tuberculation. There were a male and a female between twenty and thirty ; a male and a female between thirty and forty ; a male and two females between forty and fifty; between fifty and sixty were five males and two females ; and between sixty and seventy, six males and one female. " The complicating diseases were : " Chronic disease, witli enlargement of the heart and bron- chial ramifications, without acute pulmonic disease . 9 Chronic disease of the heart and bronchia, with recent pleuro-pneumonia . . . .6 Chronic disease of the heart, with phthisis, or recent pericarditis Pneumonia and pericarditis . Phthisis with pneumonia Pneumonia . Pneumonia, with suppuration of the kidneys Pneumonia, morb. cord, and arachnitis " I observed nothing constant in the 'post-mortem appear- ances, but extreme injection of the trachea and all its branches, and in several places thickening of the mucous lining of the passages. But those are nothing more than are, according to my observation, to be met with in a greater or less degree in almost every case of asthma, chronic catarrh, and old disease of the heart. It may be thought singular, that disease of the heart should have occurred so often, much oftener than phthisis, being eighteen times out of twenty-two ; and I should probably, some twelve months or more since, have been struck myself by such a statement. But it is undoubtedly true, that disease of the heart frequently escapes the observer who trusts ^ Vide supra, p. 77. 340 EPIDEMIC OF 1836-37 to his eye as a means of admeasurement, when, as often happens, there is no pericarditis, nor any valvular disease, and when hypertrophy, if existing, is distributed pretty equally over the organ, there is a great chance of its escaping notice, unless very considerable ; more especially if the inspector have defective information respecting the health of the deceased. To guard against error from that quarter, I have for some time weighed every subject inspected on account of disease of the heart, entire in the first instance, and then, after careful examination of the pectoral viscera, weighed the heart separ- ately after washing, and in this way have satisfied myself that, amongst the labouring classes at least, hypertrophy of that organ is a still more common and fatal disorder than many or most physicians believe." 4. DR. BRYSON During the month of January 1837, influenza prevailed epidemically in nearly every British vessel of war stationed at the following ports : namely, Sheerness, Portsmouth, Plymouth, and Falmouth.^ In February it attacked the ships' companies of the vessels employed on the north coast of Spain and at Lisbon. In March it made its appearance on the south coast of Spain, and subsequently attacked the crews of several vessels at Barcelona. In April it reached Gibraltar, and in May, Malta. It appears, however, to have been prevalent also in January at Sm}Tna and at Trieste. With the excep- tion of the ' Thunderer,' there is no evidence of its having broken out in any vessel at sea, unless the crew had been recently exposed in an infected locality. In the above vessel it suddenly made its appearance while she was on her home- ward passage from Malta, four days before she arrived in Plymouth. The weather for some time previously had been wet, the wind varying from north-east to north-west. Catarrhal complaints had been for some weeks more than usually numerous amongst the crew, but they did not assume the epidemic form until the 3d of January. On that day, 3 ^ Compiled from ' Statistical Reports of the Health of the Navy,' 1837-43, and a MS. communication obligingly supplied by Dr. Bryson. ! DR. BRYSON'S REMARKS 341 unequivocal cases of influenza were placed on the sick list ; on the 4th, there were 7; on the 5th, 13 ; on the 6th, 11 ; on the 7th, 14 ; on the 8th, 17. After tliis the number of cases occurring daily began to decline until the 11th, when there were 2 only. On the following day, however, they again began to increase, and continued increasing until the 17th, when they amounted to 44. After this the number of cases gradually diminished, and the disease finally disappeared about the end of the month. It is rather remarkable that influenza did not appear in the ' Stag,' ' San Josef,' ' Talavera,' or ' Cornwallis,' all lying at the same port until about the 11th or 12 th of January, eight or nine days after its appear- ance in the ' Thunderer ' at sea, and four or five after her arrival in port. Fever, apparently of a catarrhal nature, broke out in the ' Sapphire ' about the middle of January, shortly after leaving Corfu, and while cruising to the southward, amongst the contiguous islands on the coast of Greece. It was supposed to have been occasioned by cold and moisture. The weather had been previously wet, and the awnings being much worn and defective, the whole of the main deck, and those parts of the lower deck near the hatchways, were almost constantly damp, thus proving a source of much discomfort to the men. Sixty- six cases occurred, all of which were cured on board.^ " Catarrhal complaints prevailed in an epidemic form, and with an unwonted degree of severity in almost every vessel of war stationed on the coasts of Spain and Portugal.^ In the majority of the returns these complaints have therefore been denominated influenza. It is first mentioned as having been prevalent at Lisbon, and amongst the merchant shipping, during the latter part of January. " Early in February it appeared in the ' Eussell ' (72 guns), then at anchor in the Tagus (the disease at that time being prevalent at Lisbon, both in the town and amongst the mer- chant shipping). The first man attacked had been exposed the ^ During the last quarter, 11 cases of what has been called typhus occurred in the ' Princess Charlotte ; ' two of these terminated fatally, after their removal to the hospital at Malta. Three of the ' Asia's ' men also died in that establish- ment from febrile disease. * Erysipelas also prevailed in the 'Caledonia' and ' Caiysfort.' 342 EPIDEMIC OF 1836-37 greater part of the day in a boat and on shore. The disease rapidly spread until the cases amounted to 84. The greater number of attacks occurred on the 7th day ; namely, on the 23d. The symptoms for the most part yielded readily to mild cathartics, sudorifics, and warm diluents. " H.M.S. ' Canopus,' 84 guns, with a complement of 650 men (writes Dr. M'William^), after being three years on the Mediterranean station, left Malta on the 1st January 1837 ; and having stopped twenty-four hours at Gibraltar and part of a day at Barcelona, arrived in Plymouth Sound on the 1st of February. The following day the ship proceeded into harbour. The weather was cold, rainy, and boisterous, and the influenza prevailed much on shore ; yet the crew, although daily exposed in unrigging the ship, in boat duty and at the dockyard, continued in perfect health until the 15 th, when the epidemic struck down two-thirds of the men in one day. Men in the prime and vigour of life and health, with their spirits in the highest degree elated at the prospect of being paid off, were in an hour or two prostrated in mind and body, as if by some sudden blow, or unexpected reverse of fortune. During the 16th and l7th, upwards of seventeen men were taken to the hospital at Plymouth. " I was labouring under the disease myself ; but the surgeon, and the other assistant -surgeon, being worse than I was, I managed to continue on duty, going to bed in the evening, and producing profuse diaphoresis by drinking plentifully of hot negus. Under this system, I got well in a week without confinement." In March the disease raged at Barcelona, so generally that the public business was greatly interrupted, and every place of amusement closed. On the 9th or 10th, it attacked the ship's company of the ' Ptodney,' then lying at anchor off the town. The seizures including cases of common catarrh, being at the rate of about three men per hour, for two or three days suc- cessively. After the 13th of the month it declined, and in eight more days ceased. At the same port it appeared in the 'Nautilus' on the 15th, culminated on the l7th, and dis- appeared on the 2 2d. On the 4th or 5th of April, it attacked the ' Childers,' ^ MS. letter to the Editor. DR. BRYSOX'S REMARKS 343 three or four days after she sailed from Barcelona, where the germs of the disease were undoubtedly contracted. On the 9 th of the month it reached its acme, and on the 14th ceased to extend. This vessel arrived at Gibraltar on the 9th, while the disease was at its worst, and anchored near the ' Jasseur,' the crew of which was then perfectly healthy. They purposely avoided as long as possible having any communication with the 'Childers'; but on the 12th, a signal was made by the latter for assistance (her crew being, from weakness, unable to weigh the anchor), when a party of men was sent on board. On the 15th the disease made its appearance in the 'Jasseur,' the first man that suffered being one of the party sent to the affected vessel, thus affording evidence of the propagation of the disease by personal communication. The greatest number of attacks took place on the 21st and 22d; after the 25th, but few cases occurred, and these were of a mild character. The crew of the ' Asia ' contracted the disease at Salamis, about the 15th of April. It attained the highest point of severity on the 2 2d, and ceased on the 29th. The vessel reached Malta on the 30th, but did not communicate the disease to the shore or shipping in the harbour. On the 15 th of May the ' Bellerophon ' was affected at Tunis. The disease was at the worst on the 23 d, and ceased after the 1st of June. A small vessel, called the ' Hind,' manned with a detachment from the crew of the ' Bellerophon,' was sent with despatches from the latter to Malta, where she arrived on the 16th, sailing again on the same day, in the course of which fifteen of her crew were attacked with the epidemic. It may be presumed that both these vessels con- tracted the disease at Tunis. Up to the 16th of May, Malta and the shipping in the harbour were unaffected. On the l7th, however, a case was entered on the sick list of the steamer ' Medea,' and the daily number of attacks occurring in her continued to increase till the 23d. After the 29th no fresh cases were entered. In the same anchorage the influenza attacked the crew of the 'Rapid' on the 20th; the daily number of attacks increasing, during the prevalence of tlie sirocco, until the 27th, when they began to decrease, and finally ceased about the 2d of June. On the 24th it attacked the ship's company of the ' Caledonia,' and acquired its greatest 344 EPIDEMIC OF 1836-37 intensity on the 29tli, on which day 73 cases were added to the sick list. After the 31st the daily number of attacks diminished, but the disease did not entirely cease before the 20th of June. The ' Volage ' (28 guns), on the 3d of May, sailed from the Bosphorus, arrived at Malta on the 19th, and again sailed on the 23d. On the 28th two cases occurred, thus marking a stage of incubation of at least five days, if the disease was contracted at Malta. Two days later it broke out suddenly in the 'Vanguard' (80 guns), which had sailed from the same harbour, and in the course of forty-eight hours attacked 200 men, so that the ship was obliged to return to Malta. The wind then changing from a bleak north-east to a mild north-west, was supposed to have occasioned a change for the better in the disease, the attacks becoming few and less severe. In July the disease prevailed in the island of Corfu, where it again attacked the crew of the ' Sapphire.' The first case occurred on the 14th. The number of attacks daily increased till the 26th, and finally ceased on the 30th. The influenza in the Mediterranean fleet was soon followed by diarrhoea and cholera. The ' Caledonia,' which suffered from influenza in May and June, was attacked with cholera, on the 7th of July, off the coast of Sicily, when 62 cases occurred. The ' Bellerophon,' during the same month, lost 10 out of 18 affected with this disease. Some of the facts here related may be viewed in reference to the idea of atmospheric origin. If we were to assume such a source of this disease at Malta, how could we explain its appearance in some of the vessels before it arose in others exposed alike to the same atmosphere ; or the fact, that some of the larger vessels, containing the greatest number of men and the greatest variety of constitution, were not the first to suffer ? The exciting cause of the disease did not reach the ' Caledonia ' till nearly a week after it invaded the ' Medea ' and ' Eapid.' It does not appear that any advantage was gained by the vessels leaving the ports where they contracted the disease. Both the ' Caledonia ' and ' Vanguard ' left Malta harbour two days after their crews became affected ; and while the daily number of attacks was on the increase, yet the change from a comparatively confined locality to the open sea, had not ¥ DR. BRYSON S REMARKS 345 the slightest influence in checking the progress of the malady or altering the symptoms. The proportional number of attacks occurring daily was nearly the same as in the ' Medea ' and in other vessels that remained at anchor, whilst the amount of morbid action, judging from the cases in the aggre- gate, was also the same. Contrary to what might be expected, the number of men and the size of the vessel had no very observable effect in modifying the disease. In the ' Medea ' and ' Eapid,' both small vessels, the former with a crew of 130, and the latter with about 60, the number of attacks, allowing for slight cases not entered on the sick list, was in nearly the same ratio as in the ' Caledonia ' and ' Vanguard,' having respectively crews of 666 and 598. Although the disease prevailed with different degrees of severity in different vessels, still it seems to have displayed about the same degree of severity in different places. In the ' Eodney,' of 9 2 guns, there occurred at Barcelona 232 cases ; whilst at Malta, in the 'Vanguard,' of 80 guns, there were 250, the number of cases in each vessel, including cases not entered, being about equal to half the crew. In the 'Nautilus,' a 10 -gun brig; in the steamship 'Salamander'; in the 'Tweed' (18 guns), on the north coast of Spain; in the ' Magicienne ' (24 guns), at Lisbon; and in the 'Pique' (36 guns), at Gibraltar, the same proportion of attacks obtained ; still there seems some reason to doubt whether it did not prevail with somewhat greater virulence in the vessels stationed in the ports of Spain and Portugal and in the Mediterranean, than in those stationed in the ports of England. The disease, although rife in the Medi- terranean station, was not very fatal. The number of cases of influenza and common catarrh amounted in 1837 to 3114, being 430-8 per 1000 of mean strength; 36*5 per 1000 were sent to hospital, but only 0-6 per 1000 died. The symptoms were headache ; a sense of tightness across the forehead ; pain in the eyeballs, much increased on motion ; lachrymation, coryza, and, in some cases, epistaxis ; pain of the back and limbs, with languor and debility ; inflammation of the fauces, with pain extending along the course of the trachea ; dyspnoea ; nausea ; vomiting. The cough was extremely trouble- some. In some cases, the bowels were constipated, in others, relaxed : rigors, alternating with flushes of heat, followed by 346 EPIDEMIC OF 1836-37 profuse perspiration. The state of tlie pulse varied : in general it was quicker tlian natural, soft, and easily compressed. The tongue had the appearance of being covered by cream. The treatment usually commenced with the exhibition of a dose of Calomel with Antimonial Powder, followed by a purgative, after the operation of which, Antimony with other diaphoretic and expectorant medicines was prescribed. In the ' Bellerophon ' different degrees of pneumonia so frequently accompanied the disease, that of 1 5 cases, bleeding was employed in 102, and sometimes repeated a second and a third time, it is said with the best effect. That venesection, and what is called the depletory system, were carried too far in several instances, may be inferred from the success attend- ing the opposite and palliative plan of treatment ; the im- mediate results thus obtained were at least equally satisfactory ; in the more remote, there was this remarkable contrast, that those patients who came out of the disease without great physical prostration from the means used, recovered rapidly and satisfactorily, while those who had been subjected to an opposite plan of treatment, and who had lost much blood, recovered slowly and unsatisfactorily. The epidemic influence of this year very much resembled that of 1831. The deaths in London were quadrupled during the preva- lence of the disease. In Berlin, during the month of January, they exceeded the births. The practitioners of the latter place found lemon-juice a useful medicine. In June, nervous and gastric fevers were rife. In the beginning of August, the gastric fever took the form of synochus ; and in the second , week of the month cholera appeared, to which those convalescent from other diseases fell an easy prey.^ In Prussia domestic animals, neat cattle, and horses, suffered at the same period from catarrhal and rheumatic affections. Eheumatism was especially prevalent amongst goats. At the end of the month there was much catarrhal ophthalmia and pleurisy. Horses were affected with quinsy and pneumonia, dogs and sheep with rheumatism. In April, goats were visited with gastric fever, and there was much disease among chickens ' Medicinische Zeitung, 1837. DR. BRYSON'S REMARKS 347 and pheasants. In May, complaints of horses took the form of tetanus, apoplexy, and low fever; in August, of colic and enteritis. On the continent, the spring equinox of this year was ob- served to be like the winter solstice. Cold, heat, dryness, and humidity, alternated previously to the \isitation of influenza.^ When the influenza was about to appear, the ordinary charac- teristic diseases of the season became less rife, but neuralgia and other diseases of the nervous system (in Geneva, rheumatism) prevailed ; but soon influenza reigned alone, as if it absorbed all pathological elements. At Galgou, cattle suffered from loss of appetite, weakness of limbs, injected eyes, and perspu-ation. In Medoc, horses were also affected.- Large populations suffered most. Geneva was attacked some days before the en\drons, and Lausanne before Morges. In Lyons, the St. Just district first. At Geneva, the military were first affected ; and the gendarmes, who are much exposed to the weather, before the artillerymen. The liability was modified by the elevation. In a prison at Geneva, in an elevated situation, only 6 out of 35 in- mates suffered ; in another prison near the water, 23 out of 60. At Paris, Piedagnel observed more men than women affected. The duration and fatality of the disorder increased with the age of the patient. Petrequin, who suffered from the disease at Paris, subsequently got it again at Lyons. Strangers coming to Lyons were frequently attacked on the same or the next day. The epidemic catarrh, as it appeared in Paris, was described under four varieties, Adz., the anginose, bronchial, pneumonic, and gastro-enteric.^ During the month of April 1836, Capt. Burnett observed, to the west of Africa, between the 4th and 8th degree of north latitude, an extensive shower of red dust. In February 1837, the same observer remarked, for four consecutive days, a fall of dust resembling that of red bricks, attending the north-east trade wind, and prevailing over an extent of 300 miles from 4° 20' to 8° north latitude, and in 27° 20' west longitude. The shower commenced as the wind, which had been south- east, veered by E.S.E. to N.E.^ ^ Gazette McJicale, p. 82. - Journ. de ^ledecine Pratique de Bourdeaux, Avril 1837. ■ ' Gazette Medieale. * Nautical Mag., 1837, p. 291. Dannn, in 'Geological Transactions,' 1845, p. 30. 348 EPIDEMIC OF 1836-37 <. 8 5-i i-^i ^8 1^ X 55^ 8 ^ 1 1 1 1 1 1 1 1 1 1 ^ A ""ja" rH 1 1 1 1 1 1 1 1 1 CO CO 1 1 1 1 1 1 1 1 1 -* si -f -Hill 1 1 1 1 kO 1 t-l ^ •e ■* 1 1 1 1 1 1 1 CO 1 •^ '^ 1 1 1 1 1 1 1 1 r 1 I 1 rH urS (N < CO 1 ' 1 A 1 '-' 1 1 m CO # 00 (N O T*( 00 CO «> ^ CO <£> t^ rH 00 (N I-H CS I-l ■* s 1 CO Tt* I^ CO Tj( to ^ CO CO 00 ^ 1 CO 1 1p s '3 j3 'T3 -tJ r ID CO '^ :;3 ^ "0 p^^ rt r^ S ^ f§ 0^ =« ^ fls =« ^ DR. PEACOCK'S ACCOUNT 349 EPIDEMIC OF 1847-48 DR. PEACOCK'S ACCOUNT INTRODUCTOKY NOTICE OF EPIDEMIC IN LONDON " The influenza of 1847-48 first became epidemic in London in November 1847, between the 6th and 2 2d of that month, the date of the attacks differing widely in different parts of the country. During the summer and early autumn of 1846 dysenteric affections were unusually frequent, followed, later in the season, by typhoid fever, connected with intestinal disease, and characterised by prolonged duration, great pros- tration of strength, depression of the vital powers, torpor of mind, and tendency to coma. At the same time there was catarrhal complication, and a more than ordinary tendency to idiopathic bronchitis, pneumonia, and other chest affections. Throughout the summer intermittent fevers were common, purpura, and hepatic disorders. The latter, combined with pulmonary affections, continued to the end of the winter of 1847-48. " During the months of October and November, cases of chest affection, distinguished by an unusual degree of febrile disturbance, Avere frequent amongst the out-patients of the Royal Free Hospital. Up to the 1 8 th of November, however, the number of applicants labouring under those symptoms, though larger than usual, did not attract much attention ; but it was otherwise on Monday the 2 2d, when the fresh recommenda- tions rose from an average of 50 or 60 to 126, and a great proportion of these proved cases of influenza. On the subse- quent Thursday, the 25th, the new patients amounted to 137, and on Monday the 29th, to not less than 166. The applica- tions now began to decline in number, and the new patients on Thursday, December 2d, were only 111 in number, and on Monday the 6th, 95. " Mr. Stone informs me, that the disease first showed itself among the boys at Christ's Hospital, on Sunday the 21st November, and that for three or four days previously, catarrhal affections, with fever and headache, had been unusually numerous. 350 EPIDEMIC OF 1847-48 On the 21st, 9 boys labouring under the ordinary symptoms of influenza, were admitted into the infirmary; on the 2 2d, 32 ; and on the 23d, 43. The disease maintained its activity during eight days, in the course of which 112 boys were received either into the infirmary, or into a ward set apart for their treatment, while a much larger number were more slightly affected. Cases of influenza continued to occur till the middle of December, and in all about 350 of the boys suffered more or less from its attacks. " By information with which Mr. Carey has favoured me, it appears that at the Infant Orphan Asylum, at Wanstead, eight miles north-east of London, the disease commenced on the 14th November, and lasted till the 26th, during which time 44 of the children, and 11 of the adults in the establishment, were attacked. The greater number of cases occurred between the 18th and 24th. " It is clear, from the preceding statements, that the epidemic in the metropolis was most active from the 2 2d to the 30 th of November, having commenced about the 16 th or 18th of that month, and ceased to be very prevalent by the 6th or 8th of December. Though, however, the disease in its intensity may thus be said to have raged more particularly during this period, it continued its ravages throughout the whole of December 1847, and the early months of 1848. To the end of the winter quarter, indeed, various febrile and inflammatory affections, having more or less of the peculiar features which characterised all the forms of the epidemic dis- ease during its prevalence, were constantly presenting themselves. " The report of the Registrar-General shows that mild weather characterised the opening of the year 1846, and that the rate of mortality was considerably below the average, and continued low to the beginning of summer, when there was a slight excess of deaths, chiefly from diarrhoea, dysentery, and other intestinal disorders, owing to the warm, moist season. This summer, in fact, was remarkable for heavy rain and thunderstorms. The weather continued warm and damp until the middle of November, when the winter set in suddenly. Both summer and autumn showed great increase in mortality, from the various forms of eruptive fever, diarrhoea, and dysentery, and, later in the season, from acute affections of the lungs. Typhus, DR. peacock's account 351 also, was unusually fatal. The weather continued cold from 'November until the following May, intensely so from the 8th to the 13th of February; and the spring of 1847 was as unhealthy as the preceding summer and autumn, and the diseases were of a similar character, and equally fatal. May and June of 1847 were unusually warm, while July opened cold, but became warmer, and the mean temperature in August was 62°. September was cold throughout and dry, and the mortality in London during the quarter exceeded that of previous years. The temperature was high through October and half of November, and the weather calm and dry. Between the 15th and 19th of November the temperature fell from 54'3° to 32*1°, while on the 20th a dense fog covered the Thames. On the 21st the air was moist, and the wind changed from north to south-east. On the 2 2d the mean temperature had risen to 44*7°, and the wind was south-west. The air was damp, and rain fell on the 2 2d, 23d, 26th, and 27th, the temperature being still high, but becoming very low on the last of these days. For the next week, ending December 4th, the average temperature was 47'9°, the wind generally south-west, with much rain. During part of the following week the weather continued similar, but there was a remark- able fall in the barometer, which on December 7th stood at 28"381, or lower than at any period since the great storm of January 13th, 1843. On Monday the 20th the weather again changed, the wind shifted from south-east to north-east, and the temperature fell to 38*1°, continuing low to the end of the month. For the month of November the average tempera- ture had been 46'9°, for December, 42-8°; both considerably above the mean of several years. The amount of rain which fell in the quarter was two inches less than in the same period during previous years. The whole year, indeed, was unusually dry. During September, October, November, and to the 20th ff December, the amount of electricity was very small. A brilliant aurora was visible on October 24th, and on several other occasions during the quarter. " In the beginning of October the deaths registered scarcely exceeded the average. In early November, however, the mortality slightly exceeded the average, and kept advancing until the week endincf November 27th, when it suddenly rose 352 EPIDEMIC OF 1847-48 from 1086 to 1677 deaths. For the week ending December 4th, the deaths registered amounted to 2454 ; and for that ending December 11th, they were 2416. For the following weeks, ending December the 18th and 25th, 1847, and January 1st, 1848, the numbers registered were 1946, 1247, and 1599. The high mortality with which 1847 thus ended continued to characterise the early part of 1848. The deaths registered in the week ending January 8th were 1364, and there was little variation in the numbers till the end of February. For the week ending March 4th, however, a rapid decline in the mortality was perceptible, the registered deaths having fallen to 1114, and for the following week to 1070 ; while the average for the quarter in the six previous years had been 1107. "The proportion of deaths registered as from influenza, during each week of the six months, commencing October 1st, 1847, and terminating on the 1st April 1848, afford a good criterion of the relative prevalence of the epidemic. The number of deaths attributed to it, from the commencement of the quarter to the week ending November 20th, are registered as in the whole 14, and for the last week only 4. In the week ending November 27th, the deaths are 36 ; and in those ending December 4th, 11th, 18th, and 25th, and January 1st, 1848, they are stated as 198, 374, 270, 142, and 127. On the 8th, 15th, 2 2d, and 29th of January, and the 5th of February, the weekly returns are 102, 89, 56, 59, and 47. In the month of February, the decline was still more per- ceptible, the deaths registered in the weeks ending the 12th, 19th, and 26th, and the 4th of March, being only 27, 33, 18, and 1 8. March exhibited the furtlier reduction, for the weeks ending the 11th, 18th, and 25th, and the 1st of April, of 11, 10, 6, and 8 respectively. The deaths registered, as from influenza, amounted, for the entire six months, to 1739. The Registrar-General has however remarked, that during the six weeks the epidemic was at its height, not less than 5000 persons died, in the metropolitan districts, in excess of the average mortality of the period, an excess which shows itself in nearly every class of disease ; the local maladies which had been the most predominant affections being doubtless, in many cases, assigned as the cause of death. DR. peacock's account 353 " There was also, during the period of the influenza, a great increase in the number of deaths from the various descriptions of eruptive fever, small-pox, measles, and scarlet fever, as like- wise from hooping-cough and different forms of combined cardiac and pulmonary disease, asthma, hydrothorax, etc., with affections of the fauces and larynx. The deaths from erysipelas and rheumatism, and from different forms of cerebral disease, were considerably augmented in number, as were those from childbirth, consequent on the frequency of puerperal fever. It would appear, however, that diarrhoea and dysentery were less extensively fatal during the epidemic than previous to its breaking out, unless, as is probably the case, those affections, being generally combined with other manifestations of the reigning disease, have been registered under other designations. " The facts cited from the Eegistrar-General's report, if the ordinary period of death be regarded as from the seventh to the tenth day, are confirmatory of the date previously assigned as that of the first appearance of the influenza in its epidemic form. It will be observed that the earliest marked increase of the mortality is shown in the week ending November 2 7 th ; that it went on increasing up to December 4th ; that it became somewhat less in the course of the third week, ending December 1 1th; and that by the termination of the fourth week, December 18th, it had fallen off considerably. The excessive mortality continued, however, throughout the remainder of December, the whole of January, and to the middle of February ; nearly six thousand persons beyond the ordinary number of the period having died in the course of the nine weeks, from November 20th, 1847, to January 22d, 1848. " From the notes of the Eegistrars of the sub-districts, and from other facts embraced in the Eeport, it appears that there was considerable variety in the period at which the epidemic commenced its attacks in different parts of the country. In some places it was at its height previous to its outbreak in the metropolis, in others not till long afterwards ; and others again seem altogether to have escaped. We are informed by Dr. Stark that the disease was raging in Edinburgh on the 18th and 28 th November. In Bradford, Yorkshire, it prevailed during the ten days commencing November 27th. In Cheshire, Lancashire, and Derbyshire, it was most felt during the last 2a 354 EPIDEMIC OF 1847-48 two weeks of December, In Northampton, it was committing its ravages when the Eegistrar's notes for the quarter were written. In Bath, Bristol, Brighton, Plymouth, and Penzance, it prevailed during December. " The epidemic was raging at Constantinople in August, and it affected the south of France and the shores of the Mediterranean in October. In Paris,^ it commenced about November the 27th, and was at its height on December the 4th; in Madrid, it was very general on the 11th and 19th of January; and in Geneva,^ it appeared as a casual disease in the first week in December, suddenly became very prevalent about the 20 th, declined during the course of January, and had almost disappeared by the commencement of February. m " It would be highly interesting to ascertain the proportion of the population of the metropolis who were attacked with the disease during the recent epidemic : for the full elucidation of this question we are not, however, in possession of the requisite information. It has been already stated, that about 350 of the 1000 boys at Christ's Hospital, or about one- third, were more or less affected with the disease. At the Infant Orphan Asylum, 44 of the children, out of the 275 resident, were attacked, about the proportion of one-sixth; and 11 adults, or about one-third of the 38 at the time in the Institution, also had the disease. In the City Police Force, out of 470 adults, between 25 and 50 years of age, 100 were affected, being in the proportion of more than one-fifth. " In the report of the Eegistrar-General, it is stated that, taking the deaths at two per cent — the rate of mortality deduced from observations on the epidemic of 1837 — it may be estimated that 250,000 persons were more or less affected by the disease in the metropolis ; but this, the writer suggests, is probably not more than half the true number, the total pro- portion being probably one-fourth of the whole population. In Paris,^ between one-fourth and one-half of the population is said to have been attacked by the recent epidemic ; and in Geneva,^ the proportion affected is stated to have been not 1 Gazette Medicals de Paris, 1847, p. 958. ^ ibi^j. 1848, p. 472. 3 Ibid. 1847, p. 958. * Ibid. 1848, p. 372. DR. peacock's account 355 less than one-third. The epidemic of 1837, we are informed, affected fully half the inhabitants of London ^ and Paris ; ^ and in the prison at Eennes, M. Toulmouche ^ states that one-third of the inmates were attacked. In Geneva, the different epi- demics which have preceded that of 1847 are said to have variously affected from one-tenth to two-thirds of the inhabit- ants. So far, therefore, as calculations based upon observa- tions of the disease in another locality and during another epidemic can be depended upon, the estimate of the Eegistrar- General may probably not be far from correct. " In the boys at Christ's Hospital, and the younger children at the Infant Orphan Asylum, as also in the adults at the latter institution, and in the City Police Force, the disease was uniformly of a mild character, and in no single instance proved fatal. In fact, notwithstanding the mortality occasioned by the influenza was so formidable, it was chiefly confined to persons who were previously in unsound health, or of advanced age. This not only appears from the above statement, but more conclusively from calculations contained in the report of the Eegistrar-General. In the three weeks, ending November 13 th, which preceded the outbreak of the disease, the number of deaths in persons under 1 5 years of age was 1553; in the three weeks of the prevalence of the epidemic it rose to 2846. In the same two periods, the deaths of persons from 15 to 60 were 966 and 1970; and at the age of 6 and upwards, 576 and 1999. The mortality in childhood was, therefore, raised 83 per cent, in manhood 104 per cent, and in old age 247 per cent. "SIMPLE CATAREHAL FEVER " In this form of the complaint, the attack was most usually Budden, the patient experiencing a sense of cold down the back and between the shoulders, lapsing into general chilliness or complete rigors, and succeeded by flushes of heat and dryness of the skin, pain in the head, chest, and extremities, and prostration of strength. Generally these symptoms followed ^ Holland's Notes and Reflections, p. 198. 2 Gazette Med. 1837, p. 81. ^ ibjd. isij, p. 801. 356 EPIDEMIC OF 1847-48 some exposure to damp and cold, but occasionally they appeared without being traceable to any immediately exciting cause, and more rarely, the attack came on gradually, with a general feeling of indisposition of two or three days' duration. "At first, there was dryness of the nostrils, and soreness of the throat, with a sense of tightness or constriction of the chest, and a dry hard cough. As the disease advanced, copious defluxion from the nostrils took place ; the throat was generally more decidedly affected, and the cough more frequent. The expectoration was at first scanty, and consisted chiefly of a pale glairy fluid ; but at a later period, there was a more copious discharge of the usual opaque mucus. At the same time, some degree of difficulty of breathing and soreness at the chest were experienced, and occasionally slight lividity of the face was perceived. The respiration was, in most instances, accelerated, and, on auscultation, the respiratory sounds were usually dry and harsh, especially in the posterior and inferior regions of the chest, and sibilant and sonorous rhonchi were audible on forced inspiration. In some instances, no morbid sounds were detected, and the vesicular murmur was extremely indistinct. " Throughout the course of the disease there was distressing headache, particularly in the forehead, across one or both eye- brows, and in the balls of the eyes, increasing ordinarily in severity towards evening, and often undergoing considerable intermission during the day. With these symptoms there was commonly much mental depression, listlessness, inability for intellectual exertion, and nocturnal restlessness. In some cases, epistaxis occurred and produced alleviation of the symptoms. The tongue was usually moist, and covered with a whitish creamy fur, but occasionally it was morbidly red at the tip and edges, and thickly coated towards the centre and root, with a fur of the colour popularly termed whity-brown ; — more rarely, it was dry. In the greater number of cases, entire loss of appetite, with some little nausea and a confined state of the bowels, was experienced at the commencement ; but, occasion- ally, diarrhcea was observed at an early period, and not un- frequently, it came on during the progress of the disease. A sense of weight, tenderness, or pain, in the right hypochon- drium were frequent symptoms, and were generally combined DR. PEACOCK'S ACCOUNT 357 with some degree of icteroid tinging of the conjunctivse, or of the general complexion. " Prostration of strength was throughout one of the most marked and distressing features of the complaint, accompanied as it was with a general feeling of soreness and lassitude, and with dull aching pains in the chest, back, and limbs. The pulse was but little increased in frequency, generally ranging from eighty to ninety, and rarely exceeding a hundred beats in the minute. Though occasionally full, it was uniformly very compressible, and, after the first day or two, feeble. The skin was seldom very hot or dry, or, if so at the commencement of the disease, it soon became cool and moist, and generally the complaint subsided with free perspiration. A sense of chilli- ness, alternating with transient flushes of heat, was a very constant symptom in every stage of the disease. At first, the urine was usually somewhat scanty and high coloured, but after a day or two, it flowed more copiously, and deposited, more or less, sediment. " The cases of simple catarrhal fever were usually too slight to require much medical aid, so that though the number of persons prescribed for, at the Eoyal Free Hospital, from the 2 2d November to the 6th December inclusive, could not have been less than several hundreds, only twenty persons thus affected were admitted into the wards, during the three or four months in which the disease was prevalent, and these were all cases either of unusual severity, or of persons utterly destitute. The patients were under treatment in the hospital, on an average, nine days ; two were detained for four days only, three for five, and three for six days ; but in one case, the period of residence was extended to seventeen, and in another, to twenty days, the remainder being resident between seven and fourteen days. Owing to the difficulty of collecting correct histories of the illness of hospital-patients before they come under personal observation, it is difficult to give a satisfactory estimate of the probable total duration of the disease in these cases. Of thirteen, however, in which the length of illness, previous to admission, seems to have been ascertained with exactitude, it averaged six days, so that the total duration of the cases may be stated at fifteen days. In three instances, the patients were only ill seven days, and in tlie three others, 358 EPIDEMIC OF 1847-48 the illness extended to twenty-one, twenty-two, and twenty-five days. In the police force the average period of invaliding from service was three days, and in eleven only, out of one hundred cases of the epidemic, which occurred in about two months, did the period of illness exceed a week. The ordinary duration of indisposition in this form of influenza may, there- fore, be stated at from three to five days in the milder cases, and at from seven to ten, in those of a more severe descrip- tion. The disease, however, on its subsidence, usually left the patient for some time much reduced, and suffering from general debility, inaptitude for exertion, either of body or mind, with loss of appetite, or entire distaste for food, and a troublesome cough ; and in this state there was a great tendency to relapse. " Not unfrequently, towards the termination of the com- plaint, the transient pains, which had been troublesome during its course, increased in severity, and rheumatic affections of an obstinate and painful character supervened. These often as- sumed a distinctly intermittent type, returning regularly at the same hour for several days in succession, and not unfrequently affecting one side of the head, or one eye-brow, or eye-ball, and occasionally the intercostal muscles of one side of the chest. " Among the children at Christ's Hospital, the disease was much milder than in the cases just described, and probably assumed the form which characterised it in most instances. The attack usually commenced with a sense of cold, sometimes amounting to actual shivering, followed by heat of skin, and the ordinary symptoms of fever. In several cases, the disease was ushered in by nausea and vomiting, and in one or two by diarrhoea and gastrodynia. At an early period, there was usually a hoarse, barking cough, with intense frontal headache, much prostration of strength, a hot dry skin, and quick pulse. About the third day, the disease began to subside, and generally passed off with perspiration. The most frequent complications were affections of the throat and larynx. The laryngeal affection usually assumed the form of a croupy cough, and in three cases was developed into decided croup. In two cases, slight erysipelatous eruptions appeared on the face. The boys were not ordinarily detained in the infirmary more than four or five days ; but the three affected with croup were under treatment eleven, fourteen, and eighteen days. All the cases DR. peacock's account 359 terminated favourably ; but in several instances, the attacks were succeeded by considerable debility and a troublesome cough. The cases at the Infant Orphan Asylum, and in the police force, were likewise of a mild character. "CATAERHAL FEVER WITH PULMONARY COMPLICATIONS " 1. Acute Capillary Bronchitis " The mode of invasion in cases of influenza complicated with acute capillary bronchitis, was very similar to that in the other severe forms of the epidemic. In eight cases the disease commenced suddenly, for the most part with a feeling of cold between the shoulders and down the back, increasing to slight shivering or severe rigors, and followed by heat of skin, more or less intense, and in some by perspiration. To these symp- toms succeeded pains in the head, chest, and loins, a sense of tightness across the chest, difficulty of breathing, and cough, with usually some soreness of tlie throat. " The symptoms in the early stage, of the cases complicated with capillary bronchitis, differed in no material point from those characterising the more severe forms of influenza. There was usually increased frequency, and some difficulty of breath- ing, and constriction of the chest, with soreness or stiffness of the throat. The cough, though slight, was troublesome from its frequency. The expectoration, if any, was scanty and of a glairy character. The tongue was usually red at the tip and edges, and covered with a creamy mucus, or with a whity- brown fur ; occasionally, it was morbidly red throughout. The pulse was accelerated, beating generally from 100 to 112 or 1 1 6 in the minute ; but in one case, it rose to 132 on the third day of the disease. The skin was not usually hot, or if so at first, the heat declined after two or three days. " With these symptoms, there were the marked prostration of strength, the severe frontal headache, the pain in the back and limbs, and the general soreness of the body, which char- acterised the ordinary cases of influenza. Herpetic eruptions 3G0 EPIDEMIC OF 1847-48 appeared in three eases around the mouth ; in two, on the second day from seizure, and in the other, on the fifth day. In three other cases, in which emetics had been given at the commencement of the attack, obstinate vomiting continued for two or three days. " When the chest was examined in this stage of the disease, the only morbid phenomena detected, were a rough character of the inspiratory sound, particularly when a forcible inspiration was drawn, with some slight crepitation, audible more espe- cially towards the lower part of each dorsal region, and general feebleness of the vesicular murmur, with sibilant rhonchus occasionally heard in other parts of the cliest. The respira- tion was, however, quicker and shorter than natural, averaging 28, 32, or 40 respirations in the minute; the dyspnoea was greater than could be explained by any apparent physical signs, and most generally there was some lividity of the face. " In the, second stage, all these symptoms were much ag- gravated. There was great difficulty of breathing, and the respiratory acts were performed quickly and imperfectly, the respirations in the minute varying from 30 to 40 or 50. The cheeks were much flushed, and the lips were of a purple colour. Generally there was no acute pain in the chest, but rather a sense of constriction and soreness ; and the cough, though frequent, and often occurring in paroxysms, was not usually severe. The expectoration still continued scanty, and consisted of small, yellowish-white pellets, forming tenacious masses of a peculiarly nodulated or botryoidal form, very nearly re- sembling, when floating in water, some of the larger oolitic limestones. The tongue, mostly covered with a thick whity- brown fur, was somewhat dry and often red at the tip and edges, or morbidly red and glazed. The pulse was much accelerated, beating 120 to 130 or 140 times in the minute; but was generally small and very compressible. In some instances, after being low and feeble at the outset of the disease, it acquired a more sthenic character at the commence- ment of the second stage. The skin was rarely very dry, or much above the natural temperature, and the hands and feet were generally cool. The former were much congested, so that when the skin was blanched by pressure, the colour did not readily return. There was, in most cases, an increase of DR. PEACOCK'S ACCOUNT 361 the general prostration in this stage, much headache and often transient delirium, especially during the night. "On percussion, the chest did not present any alteration in the degree of resonance proper to its several regions, unless when there existed other disease of the lungs or heart. On auscultation, crepitation of a more or less fine character was audible with the inspiration, first, in the inferior part of one or both dorsal regions, and thence spreading rapidly higher up in the back, and towards the bases of the lungs, laterally and anteriorly, while occasional sibilant rhonchus was heard in other parts of the chest, especially on forced inspiration. During this stage the patients usually lay on the back, with the head more or less elevated, and slightly inclined to one side ; occasionally the difficulty of breathing prevented their lying down with ease. " The third stage of the disease was marked by the dyspnoea becoming so severe, that the patients were compelled to sit constantly upright in bed, or to lean forwards, resting on their arms and elbows. At intervals, the respiration became even still more laborious. The lividity of the cheeks, lips and hands increased, the eyes became prominent, and the expres- sion of countenance extremely anxious. The cough was frequent, and of a short abortive character, giving the im- pression of the presence of viscid secretion in the lungs, which the patient had not the power to expectorate. Its frequency also occasioned much fatigue, and it often caused pain in the head and great general distress, and during the paroxysms, the lividity of the face was much increased. The sputum was generally expectorated in large quantity. It was of a greenish yellow colour, of a very viscid consistence, contained little air, and was occasionally streaked with blood. The respirations amounted to 50, 60, and in one case to 72 in a minute, and the expiration was difficult and prolonged. The pulse, uniformly very feeble, was either extremely quick, 140 to 150 or 160 in a minute, or intermittent, so as to number only 100 or 120 beats. The tongue was covered with a thick yellowish, white, or brown fur, and was generally dry ; sordes also formed on the teeth. The general surface of the body now became cool and bathed in perspiration, and the hands and feet were decidedly cold. The transient delirium before 362 EPIDEMIC OF 1847-48 noticed grew more constant, and in one case there was active mania at the earlier period, lapsing, with the progress of the disease, into low muttering delirium, with deafness and tend- ency to coma. With the decreasing strength, the cough became slight, the expectoration nearly or entirely ceased, and the patients died, either gradually from increasing exhaus- tion, or suddenly from suffocation. " With the progress of the disease, the physical signs under- went a corresponding change. The chest, which had been naturally resonant on percussion, now yielded a morbidly clear sound, almost tympanitic, except when portions of the lungs were the seat of old or recent condensation. The crepitation gradually extended over larger portions of the lung, being of a finer character in the parts more recently involved, and giving place to sub-crepitant and mucous rhonchi, in the situations in which it was first heard, and, finally, becoming of a gurgling character in the neighbourhood of the larger bronchial tubes. The sub-crepitant rhonchus towards the later stages of the disease, when the respiration was very laborious, became audible with the expiratory, as well as with the inspiratory, act. When there was any local condensation, more or less decided bronchial respiration was also heard in the parts so affected. " Such was the course of the disease in the cases which proved fatal ; in those which terminated more favourably, the improvement took place in three instances, after the disease had reached the stage of secretion, as evidenced by the presence of fine crepitation in the dorsal regions, and in three others, after effusion had taken place, so extensively, that crepitant and sub-crepitant rhonchi were audible in all parts of the lungs. " The amendment was marked by the respiration becoming less hurried and laborious, by the expression of countenance appearing less anxious, and the face less livid, and by the diminution of the general prostration. The pulse beat slower and stronger, and the paroxysms of coughing were less severe. The sputum lost its viscid character, and became more muco- purulent, having a greater tendency to coalesce into a homo- geneous mass, involving the presence of more air, in the form of large bubbles. At a still later period, the mucopurulent H DR. peacock's account 363 secretion was combined with serous and spumous fluid, occa- sionally slightly streaked with blood. Subsequently, it consisted chiefly of this fluid, and finally declined in quantity. " The improvement in the general symptoms was attended by an alteration also in the character of the physical signs. The mucous and sub-crepitant rhonchi gave place to crepitation of a finer character, and the space over which the morbid sounds had been audible gradually contracted. The latter disappeared, first, in the upper parts of the chest, then, in the lower portions of the front and sides, and, lastly, at the lower dorsal regions, until they were at length merely audible even there on forced inspiration. A considerable period, however, elapsed in all cases after amendment was visible, before con- valescence could be regarded as fully established, during which the patients continued to suffer from cough and dyspnoea, and were subject to sudden returns of the difficulty of breathing and pain in the chest. The muco-crepitating sounds could still be detected, on examination, long after the general symptoms had in a great degree disappeared ; and at a later period, after decided crepitation had ceased to be audible, the inspiration continued to possess a somewhat harsh or rough character, especially at the bases of the lungs, and the expira- tory sound was more distinct and prolonged than natural. The unusual clearness of the resonance on percussion, especially in the dorsal regions, was also observed for some time after the more marked physical signs had disappeared, and then gave place, in some cases, to a slight degree of general dulness. " After the subsidence of the general symptoms, rheumatic affections not unfrequently appeared, most commonly in the form of pains in the head and face, or in the intercostal muscles; and in some cases materially prolonged the con- valescence. " 2. Epidemic Catarrhal Fever complicated with Pneumonia " The cases ia which the predominant local complication of influenza assumed the form of pneumonia were seven, or excluding one for reasons afterwards specified, only six in number. 364 EPIDEMIC OF 1847-48 " The disease, in these eases, assumed a very different character from that which pneumonia ordinarily presents, being attended by an unusual degree of depression of strength, and combined with various indications of disorder of the chylopoetic viscera, and more or less general bronchial in- flammation. " Five out of the six cases of pneumonia treated in the hospital commenced with symptoms common to the more severe forms of influenza, chilliness or actual rigors, followed by heat of skin, pain in the head, and, in three patients, with pain also in the chest, and difficulty of breathing. In four | cases the period of attack preceded that of admission by from two to four days ; in another, the patient had been ill thirteen days before application ; and the sixth had an attack of the more ordinary form of influenza six weeks previous to his reception, from which he recovered sufficiently to resume his employment as a dock-labourer, when the symptoms of inflam- mation of the chest re-appeared, and he was admitted after an interval of four days. " In all of these six cases the pneumonia co-existed with more or less general bronchitis. Where pain in the chest existed from the commencement of the disease, the patients shewed decided evidences of pneumonia when received into the hospital, while the bronchitic symptoms were slight, and did not become marked till after the disappearance of the local condensation ; in these cases, therefore, the disease may be inferred to have commenced in the parenchyma of the lungs. In the remaining three cases, tlie catarrhal symptoms probably preceded the occurrence of inflammation in the tissue of the lungs. In four instances, the disease extended to the production of more or less extensive consolidation of one lung, and in two there were evidences of condensation in portions of both lungs. When observed throughout their whole course, the cases presented the usual physical signs of pneumonia. First crepitation without material impairment of the natural sound on percussion, and subsequently bronchial respiration, and increased resonance of the cough and voice, with more or less decided dulness. The process of amendment was marked by the re-appearance of crepitation of a coarser character, the gradual disappearance of the dulness on percussion, and the DR. PEACOCK'S ACCOUNT 365 return of natural vesicular breathing. With these signs were also combined those of bronchitis of the smaller tubes. " Of the general symptoms by which the cases of pneumonia were characterised, the cough was one of the most troublesome. In three patients, all young persons from eleven to fifteen years of age, and in whom there was extreme prostration of strength, there was throughout no expectoration ; while in the others the matters expectorated combined the characters of the sputa of pneumonia with those of bronchitis, consisting of brownish coloured and viscid masses, containing small air- bubbles, intermixed with glairy fluid, either transparent or opaque, and with large bubbles of air. " Pain in the chest, though in three cases experienced at the invasion of the disease, was not generally present to any great extent, or only induced complaint during the paroxysms of coughing. Dyspnoea, also, could not be regarded as a very decided symptom. In two cases, however, in which the disease was combined with extensive bronchial inflammation, there was considerable difficulty of breathing, and lividity of the face ; while two patients continued to lie in the recumbent position, either on the back or partly turned to one side, with- out experiencing material dyspnoea, though the local disease was very extensive. The respiratory acts were not generally much accelerated, having only ranged from 28 to 44 in the minute. In one case, the respiration was remarkably slow, and the sounds so feeble as to be scarcely audible. " The pulse was usually, but slightly, quicker than natural, numbering not more than 80, 90, or 100 beats in the minute. In one case, however, it was 144 at the commencement of the disease, and, in a second, 136 during a relapse. It was uniformly either soft and compressible, or decidedly small and feeble. The skin was rarely dry or very hot, and if so at the earlier periods, as in the other forms of influenza, soon became cool and moist. During a relapse, in one case, the skin was, however, intensely hot and dry, and in one or two others, though the temperature was not above the natural standard, there was a peculiar dryness and harshness of the skin. "The cases of pneumonia occurring during the epidemic of influenza, were very generally complicated with evidences of gastro-enteric and hepatic disease. The tongue was usually 366 EPIDEMIC OF 1847-48 red at the tip and edges, with a whity-brown fur at the centre and root ; it was moist in the early stage and became dryer with the progress of the disease : in one case only was it very dry or brown. In two cases, there was decided jaundice, and in the others some degree of tinging of the conjunctivae, and of the surface of the body generally. Loss of appetite, nausea and vomiting, in various degrees, were also early symptoms ; to which diarrhoea, with tenderness and inflation of the abdomen, succeeded. The prostration of strength, which was much greater than in ordinary cases of pneumonia, was also usually present at the commencement of the attack, before thei local affection had attained much importance. In several' cases, particularly in two where relapses occurred, the depres- sion of strength was extreme, while in two others it was com-i bined with great and peculiar torpor of mind, almost amounting ' to coma. " Notwithstanding that the cases of pneumonia observed i during the epidemic presented a most threatening character, from the severity of the local affection, the complication with| serious disease of other organs, and the extreme depression and prostration of strength with which they were attended, their result cannot be regarded as unfavourable, since of the seven cases one only proved fatal. " 3. Laryngeal Complications of Influenza " In the notice of the epidemic as it prevailed among the! children in Christ's Hospital, I have mentioned the frequent occurrence of some degree of laryngeal affection, indicated by a hoarse barking cough, and ending in three cases in decided' croup. Among adults, too, a degree of sore throat, with a harsh cough and hoarseness, were very general symptoms. Though no case came under my own observation in which the patient laboured under acute laryngitis, or other severe affec- tion of the throat, it would appear that these affections were prevalent at the time. From the tables of mortality, it will be seen that the deaths from croup, quinsey, and laryngitis, were during the epidemic much more numerous than usual. The deaths from the former disease, instead of 8 per week, the DR. PEACOCK S ACCOUNT 367 quarterly average, were only 6, 9, 5, and 7, in the several weeks during November, and rose to 11, 16, and 10, in the weeks ending December the 4th, 11th, and 18th; and those from quinsey and laryngitis rose from the average 4, to 11, 8, 6, and 9, on the 6th, 13th, 20th, and 27th of November; and to 7, 12, 11, and 12, on the 4th, 11th, 18th, and 25th of December. This fatality, however, appears to have been chiefly among children. " 4. Eesults of Catarrhal Fever with Pulmonary Complication " Mortality. — In the following table all the cases of the pulmonary form of the disease are arranged, without reference to the precise kind of local complication, so as to show the mortality in each sex, and at the several periods of life. Age. Cases. Deaths. Males. Females. Cases. Deaths. Cases. Deaths. 11 and 14 15 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 2 12 14 10 3 4 3 3 1 1 2 1 1 7 3 7 2 3 1 1 1 1 1 5 11 3 1 1 2 2 1 1 1 1 48 9 24 3 24 6 " The remark made in reference to the respective frequency of the two forms of the disease, applies equally to its fatality. Though from the very general prevalence of the disease, the mortality in the whole population was very greatly increased, yet, there can be no doubt that the proportion of deaths rela- tive to the number of cases which occurred, was far from large. The facts here collected do not, it is true, appear to counte- nance this assertion, one-fifth nearly of the cases admitted into the hospital having proved fatal. It must, however, be remembered that the persons under treatment, were either such 368 EPIDEMIC OF 1847-48 as presented the disease in its most severe form, or who were in a state of entire destitution before their reception, and, consequently, that no inference as to the ordinary mortahty of the epidemic can be deduced from the result of the disease under such circumstances. The cases are, also, too few to form a satisfactory basis for generalisation, and a reference to the preceding statements will show that all those which proved fatal were either complicated by organic disease, or by the presence of other serious affections. The facts can, indeed, only be regarded as showing the very unfavourable result of the disease when it attacks those previously in unsound health, or who have long been suffering from depressing causes. On the other hand, the character of the epidemic in the young children at the Infant Orphan Asylum ; in the boys at Christ's Hospital ; in the adults at Wanstead, and in the police force, sufficiently demonstrates its mildness under favourable cir- cumstances. " It is obviously extremely fallacious to apply inferences, deduced from observations in one epidemic, to explain the rate of mortality in another ; yet it is probable that the recent disease was not ordinarily more fatal than the epidemic of 1837, and certainly were an approximative statement to be made, founded on the whole of the cases under my own observation, it would be, that the mortality of the epidemic of 1847 did not at the highest estimate exceed 3 or 4 per cent. " Of the cases complicated with different forms of acute pul- monary inflammation, the class in which the disease assumed the form of acute capillary bronchitis was the most numerous : eight examples of the idiopathic affection, three in which it appeared as a complication of phthisis, and two in which it was combined with ileac typhus, in all, thirteen cases of that form of disease, having fallen under my notice during the period of greatest prevalence of the influenza, or between the 19 th of November and the 15th of December. Subsequently, four other cases were admitted into the hospital, in which the disease assumed the sub-acute form, and which dated their commence- ment from the same period, as did several cases visited in my private practice. These details show the remarkable tendency to the occurrence of this form of disease, as a complication of influenza, a fact not without interest, when the extreme in- DR. PEACOCK'S ACCOUNT 369 frequency of acute capillary bronchitis as a sporadic affection, at least, among adults, is considered. M. Fauvel's researches show, that in Paris the disease very rarely occurs in ordinary seasons ; and during the period of nearly two years preceding the appearance of the influenza epidemic, with my attention specially directed to the subject, I met with but seven cases, in my hospital practice, and of these, three only were examples of the acute idiopathic type. Pneumonia, on the other hand, does not appear to have been a frequent complication of the epidemic, only six cases of it having fallen under my view, during the period specified ; three of which were preceded by more or less general bronchial inflammation, while in the three others, the disappearance of consolidation in the pulmonary tissue was followed by general capillary bronchitis. It will also be seen, that the inflammation of the mucous membrane of the smaller bronchial tubes, was invariably a most alarming, and, in a large proportion of cases, a fatal malady ; while all the cases of pneumonia which occurred, however threatening in appearance, were readily amenable to treatment, and termin- ated favourably. "EPIDEMIC CATARRHAL FEVER WITH ABDOMINAL COMPLICATION " 1. Catarrhal Fever, with Disorder of the Gastro- enteric Mucous Membrane " Patients affected with this form of disease, in a mild degree, usually stated, on their admission, that they had been more or less indisposed for periods varying from three or four, to ten or fifteen days. The symptoms, in these cases, were throughout of a slight character, or if at first more urgent, generally subsided into a mild form at the end of a few days. The pulse was seldom materially accelerated, unless at the commencement of the attack. The skin was not generally very hot or dry, and soon showed a tendency to become moist. The tongue usually continued moist, and was covered with a creamy mucous, or whitish fur, and was red towards the 2b 370 EPIDEMIC OF 1847-48 extremity. There was generally some slight cough and diffi- culty of breathing. The bowels were usually torpid, but occa- sionally, and especially when the disease was about to subside, there was slight diarrhoea, which sometimes also appeared at an early period. There was often troublesome vomiting. With these were combined the ordinary febrile symptoms, prostration of strength, pain in the head, back, and loins, loss of appetite, restlessness, etc. This form of disease was ordinarily of sliort duration, the convalescence being established from four to seven days from the commencement of the attack ; so that of fifteen cases under treatment in the hospital, the mean period of detention was between seven and eight days. " The more severe cases of this description usually com- menced very gradually, so that it was difficult to ascertain 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 witli yellowish brown sordes. The skin was hot, dry and harsh, and con- tinued 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. " Some degree of pulmonary disorder, characterised by hurried respiration, cough, and the usual signs of febrile bronchitis, was also very generally observed. " 2. Catarehal Fever, with Affection of the G astro -enteric Mucous Membrane and Liver, and characterised by tendency to relapse or to assume a remittent character. " These cases were usually ushered in by severe febrilej symptoms, such as rigors, followed by great heat of skin anc DR. peacock's account 371 depression of strength, which led the patient to appl}^ early for admission into the hospital, as on the third or fourth day. In some instances, however, the invasion was more gradual, one or two weeks having elapsed from the com- mencement of indisposition, before the symptoms became urgent. * " When the attack was sudden, the symptoms usually assumed a sthenic type, the pulse being full and bounding, 110 to 120 or 130 in the minute, the skin hot and dry, and the mouth and tongue dry and parched. There was thirst and loss of appetite, with often bilious vomiting, pain in the head and loins, and general oppression and prostration of strength. When these symptoms had continued for an interval, varying from a week to ten days, improvement began to take place, and the patient became so rapidly convalescent, as to be able to leave the bed in a much shorter time than, from the urgency of the previous symptoms, could have been supposed. After the lapse of a few days, however, in different cases, on the eleventh, twelfth, thirteenth, and fourteenth days from the commencement of the attack, sudden relapses occurred. The patient was seized with violent rigors, followed by pungent heat of skin, dryness of the surface, throbbing and pain in the head and loins, and a full bounding pulse, to which succeeded profuse perspiration, continuing from a few hours to a day, or a day and a half, and attended with extreme prostration of strength. The pulse then became small, feeble, and faltering, and was often unusually slow, not numbering more than 60, 50, or even 40, beats in the minute. The tongue aeain acquired a dryish and thick whity-brown, or yellowish coating. The skin became cool, or absolutely cold, and assumed, with remarkable rapidity, a jaundiced hue of varying intensity, and there was pain or tenderness, on pressure, in the right hypo- chondrium. The abdomen was generally distended, and most frequently diarrhoea supervened, with copious liquid stools, often containing considerable quantities of more or less altered blood. These symptoms continued for three or four days or more, when the patient would again begin to recover, and usually regained his strength rapidly. In some cases, relapses of this description occurred two or three times, with well- defined intermissions of one or two days' duration ; in others, 372 EPIDEMIC OF 1847-48 the febrile symptoms, though slighter in the intervals between the paroxysms, never entirely intermitted. " In the cases of remittent fever, in which the febrile symptoms were more gradually developed, the disease gener- ally assumed a low type. The skin was at an early period cool, but not particularly dry, and from the first slightly jaundiced. The tongue was covered with a thick fur of a yellowish white colour, and was somewhat dry. The pulse was feeble and quick, numbering 130 to 140 or 150 in the minute, and there was great prostration of strength, with a torpid and oppressed state of mind. . , . Diarrhoea was very generally present, and large quantities of nearly pure blood were often voided by stool; epistaxis was also a frequent symptom. " 3. Catarrhal Fever, with Affection of the Gastro- enteric Mucous Membrane and Liver, complicated with Eheumatism. " The only remaining class of cases observed during the recent epidemic, to which I shall have occasion to allude, is that in which the low form of fever, with hepatic and enteric disorder, was complicated with severe rheumatic symptoms. " In these cases the pains in the head, back, loins, and ex- tremities, which were present with more or less severity in all the forms of influenza, were from the first of a severe character, or increased with the progress of the disease, till they con- stituted its predominant feature. The pain was usually most distressing in the head, especially in the forehead, and in some cases was limited to one temple, or to one eyebrow or eyeball. It was generally of an intermittent or remittent character, coming on every night, after a more or less distinct intermission during the day, and attended with singing in the ears, distress- ing restlessness, agitation, and inability to sleep. Delirium was most generally present. In some cases, it only amounted to a little excitement or incoherence during the evening exacerbation ; but, in others, it was so active as to require the employment of restraint to retain the patient in bed, and con- tinued, with little intermission, for many hours. With these symptoms, there was usually much tremor of the hands, and I DR. peacock's account 373 the eye was pale and glassy. . . . Diarrhoea, with discharge of blood, was very general, and epistaxis frequently occurred, in one case to an alarming extent. " In the cases which assumed a paroxysmal character the collapse succeeding the exacerbations was often extreme, the perspiration being so profuse as to soak through the bedclothes, whilst the hands and feet became cold and livid. " On referring to the reports of the Eegistrar- General, I find that the deaths from rheumatism, during the period of prevalence of influenza, exceeded considerably the average of the previous six years. In the weeks ending November the 6th, 13 th, 20th, and 27th, and December the 4th, 11th, 18 th, and 25 th, the deaths registered under this head were 6, 9, 6, 7, 6, 6, 7, and 5 respectively, while the weekly average for the quarter amounts to only 4'1. " Otitis. — Among the complications of the several forms of febrile affection, that of purulent discharges from the ears must also be mentioned as of frequent occurrence, particularly where there had been erysipelas of the head and face. They also, however, happened independent of any such eruption. In these cases, the formation of matter was preceded by singing in the ears, deep-seated pain extending thence to the forehead and face, tenderness on pressure beneath, and in front of, the ear, and deafness, with, in some cases, delirium or torpor of mind. These symptoms occasionally occurred without being succeeded by any discharge ; but more frequently they were followed by an escape of yellowish fetid pus in considerable quantity, a day or two after their commencement. Sometimes the discharge was confined to one ear, in others it affected both, and it generally continued for several days. "REVIEW OF THE TREATMENT ADOPTED IN THE DIFFERENT FORMS OF THE EPIDEMIC " 1. Treatment of the cases of Simple Catarrhal Fever " Of the method of treatment pursued in the cases of simple catarrhal fever, it is not necessary to say much. The patient 374 EPIDEMIC OF 1847-48 was usually directed to be confined to the room or bed, to take some form of antimonial or diaphoretic medicine, to use the foot-bath, and to restrain himself to a low diet. At the end of a day or two, according to the urgency of the symptoms, a more nutritious diet was allowed, and some form of tonic, or slight stimulant medicine, with anodynes and expectorants, was prescribed. Under this treatment, the attack commonly passed off readily, with more or less decided diaphoresis. If, however, at the commencement of the complaint, the chest- symptoms were of a more urgent character, the cough being hard and painful, and the breathing mucli affected, au emetic of the potassio-tartrate of antimony and ipecacuan, followed by a full dose of opium, or by a diaphoretic, consisting of Dover's powder and nitrate of potash, not unfrequently arrested the severe symptoms, and the disease pursued a mild course. When the attack was succeeded by rheumatic pains, small doses of colchicum were usually prescribed in combination with a tonic remedy, quinine being especially given when the pains assumed a. periodic character. " On the whole, the treatment adopted was similar to that which would be enjoined in a case of severe catarrh, with this difference, however, that tonics and stimulants were employed more freely, and at an earlier period, than would in simple catarrh have been either necessary or desirable. " 2. Treatment of the cases of Influenza with Pulmonary Complication " Of the cases complicated with acute capillary bronchitis. — Of eleven cases of this form of affection, which fell under my observation, in which the disease was, so far as is known, free from any serious organic complication, two only w^ere bled from the arm, and in both of these, the depletion was practised before they came under my care. ... In each instance, the general depletion was accompanied with, or preceded by, the exhibition of contra-stimulant remedies, such as calomel and opium, and antimony. " The depression occasioned by the loss of blood was extreme, and the free employment of stimulants was shortly after had recourse to, but without success. I DR. PEACOCK S ACCOUNT 375 " Besides cupping, the remedies resorted to were, calomel with opium, or Dover's powder, which were exhibited so as slightly to affect the mouth, iu five out of the nine cases. In some instances, 2 or 4 grains of calomel, with 1 grain of opium, were given immediately after the cupping, and repeated once or twice a day : in others, smaller doses of opium, as one-third or one-quarter of a grain, were given with the calomel at shortei' intervals. Of the cases in which this treatment was followed, one proved fatal, but in this instance, the specific action of the mercury was not developed. A sixth case also terminated fatally, where one dose only of calomel and Dover's powder had been taken. " In most of these cases, anodynes, expectorants, anti-spas- modics and diffusible stimulants, such as the compound tinc- ture of camphor, or hyoscyamus, Dover's powder and camphor, ipecacuan or squills ; the sesqui-carbonate or aromatic spirits of ammonia ; the compound sulphuric sether, and the alcoholic or setherial tincture of lobelia, and brandy, with the infusion or decoction of bark, were given in the later stages ; and in three cases, where depression was from the first very great, these remedies were persisted in throughout, though only one of the three reached a favourable termination. Counter irritants, consisting of blisters and mustard cataplasms, were employed in all cases, and were generally several times re- peated. " The great tendency of inflammation in any portion of the bronchial mucous membrane to become diffused over the whole of the lungs, and the general obstruction to the circulation which results, renders it most important that a correct view should be early taken of the nature of the affection, and an appropriate system of treatment speedily adopted. The ex- perience which I have had of this form of pulmonary disease, both recently, in its epidemic shape, and previously, as a sporadic affection, justifies I think the conclusion, that it may, iu a large proportion of cases, be entirely arrested, if appro- priately treated in the early stage. At this period, effusion has taken place only to a limited extent, and the disease is merely indicated by a slight roughness or harshness of the respiratory sounds in the posterior regions of the lungs, with fine crepitation at their bases, and sibilant rhonchus in other 376 EPIDEMIC OF 1847-48 parts, on forced inspiration. If, however, the first signs of pulmonary disorder be misconceived or neglected, and the disease be allowed to proceed to extensive effusion in the smaller bronchial tubes, before an efficient course of treatment is pursued, it becomes almost necessarily and unavoidably fatal. " As in the earlier periods of all forms of inflammation of the pulmonary tissue, antimonial medicines appear more effectual than mercury, I would commence the treatment of cases of acute capillary bronchitis by the exhibition of an anti- monial emetic ; and so long as the strength of the patient permitted, and the local inflammation required it, would con- tinue the use of antimony, either as an occasional emetic, or in smaller doses, more frequently repeated, as a nauseant. I am inclined to believe that while in the sthenic form of pneumonia, the frequent repetition of small doses of antimony, so as to keep up continued nausea, is the most efficacious mode of employing that medicine ; in capillary bronchitis, in which there is so great a tendency to depression of strength, the occasional administration of emetics is preferable, and that the use of antimony in this latter mode may be continued when its constant nauseating operation could not be borne by the patient. " In the second stage of the disease, when crepitation is extensively audible over different parts of the lungs, the pros- pect of recovery becomes small, and the available means are necessarily very limited. The depression of strength precludes the employment of antimonials ; but an attempt may still be made to get rid of the redundant secretion from the bronchial tubes, by the exhibition of emetics ; and this seems effected, with the least exhaustion to the patient, by the combination of sulphate of zinc with ipecacuan. . . . The strength must be supported by animal broths and jellies ; and wine, brandy, or other form of stimulant be administered. " Of pneumonia as a complication of Influenza. — In the cases of pneumonia which occurred as a complication of influenza, depletion was practised in only one case, in which, though the patient was much prostrated, and exhibited great torpor of mind, 8 ounces of blood were abstracted by cupping between the shoulders on the eighth day from the DR. peacock's account 377 commencement of the symptoms. The bleeding was followed by a full opiate with calomel, and nauseating doses of anti- mony were given as long as the patient's strength admitted ; the calomel being continued till slight salivation was produced : subsequently stimulants were had recourse to. In two other cases, emetics of antimony were first given, and nauseating doses repeated at intervals ; and in a third, small doses of antimony were employed from the first. In one other case only, that in which a circumscribed pleurisy supervened on the pneumonia, was any form of mercurial prescribed ; and then small doses of mercury with chalk were given for a secondary disease, and for the relief of a diarrhoea. In two patients, one of whom was jaundiced, the treatment was throughout of a stimulant and expectorant character; and in all others diffusible stimulants, anti-spasmodics and anodynes, were given in the later stages, a nutritious diet being at the same time ordered. Counter irritation, by blisters and sina- pisms, was employed in all cases. " A review of the treatment pursued in this form of the disease, and of the success which attended its employment, for the only case which proved fatal, was not sufficiently long in the hospital to be subjected to any specific treatment, fully supports the assertion already made, that the pneumonic com- plication of influenza during the late epidemic was by no means so serious as the cases in which the local disease assumed the form of capillary bronchitis. The facts, though too few in number to be regarded as conclusive, tend nevertheless to show that this form of inflammation of the lungs is mostly a very tractable disease ; a remark previously made by M. Lassere when describing an epidemic of a similar kind, observed by him in one of the Parisian hospitals, and of which he has published an account under the name of Catarrhal or Broncho Pneumonia. " 3. Eemaeks on the Nature and Causes of the Epidemic " Though the catarrhal form was undoubtedly that most characteristic of the recent epidemic, there were various co- temporaneous affections, of such frequent occurrence, and of so 378 EPIDEMIC OF 1847-48 peculiar a character, as, on the most superficial view, to suggest that the connexion between them and the more typical forms of the epidemic was other than accidental. " By reference to the reports of the mortality of the metro- polis, it has previously been shown, that when towards the end of November, the total number of deaths registered became much larger than usual, the increased mortality was scarcely greater from pulmonary diseases than from typhus, remittent fever, erysipelas, rheumatism, etc. If it be true, that in some cases the pulmonary mucous membrane was almost the sole seat of disorder, and that in others the abdominal organs were the leading parts involved, still, so far as my observation extended, these cases were comparatively few in number, and trivial in their nature, while in all those of any severity, both the pulmonary and abdominal organs were implicated. " The close analogy perceptible amid the variations of the individual cases is, however, a feature not confined to the recent influenza. The records of former visitations clearly indicate, that in them also the coincidence of the pulmonary with the various other affections referred to, was not less fre- quent. So common indeed has been the combination of the epidemic with enteric disorder, that Dr. Hancock remarks : ' It is scarcely possible to look over the histories of influenza without perceiving a connexion between this disease and morbid affections of the mucous membrane of the stomach and intestines.' Dr. Hooper, also, in a small treatise on the epidemic of 1803, which I have only recently met with, suggests a classification of the several forms of the malady, very similar, in some respects, to mine. "Extensive and carefully conducted investigations of the phenomena of fever, during life, and of the morbid appearances visible after death, in the bodies of persons who have fallen victims to that malady, have clearly established : — " 1st, That though in certain localities and seasons, the solitary and aggregate glands of the intestine are very con- stantly diseased, yet, that in the fevers of other localities, and in other seasons, they are but rarely affected ; and, further, that when disease of the intestine is detected, it does not always bear a proportionate relation to the intensity of the symptoms during life. ¥- STATE OF PUBLIC HEALTH IN AUTUMN QUARTER 1847 379 " 2ndly, That evidences of true inflammatory action, in any organ, are by no means generally observable after death from fever, which may have raged in such intensity as to destroy life, without leaving a trace of morbid action behind. The only cliange which may invariably be predicated of such cases, is an alteration in the qualities of the blood, by which it loses more or less of its power of coagulating. " Srdly, And, consequently, that decided evidences of morbid action, when found in the bodies of those who have died from fever, can only be regarded as accidental complications, afford- ing no explanation of the essential nature of the disease. The only supposition, therefore, which is applicable to the explana- tion of the phenomena of fever, is that of a deleterious influence operating upon the nervous system, deranging all the vital powers, and so poisoning the blood as to excite a predisposition to local congestion or inflammation in different organs. " These views, if applicable to the phenomena of the more intense forms of febrile disease, no less apply to those of a slighter description." STATE OF THE PUBLIC HEALTH IN THE AUTUMN QUAETER OF THE YEAPt 1847 (OCTOBER, NOVEMBER, DECEMBER). "57,925 deaths were registered in the quarter ending December 31st. The average number of deaths deduced from the returns of the corresponding quarter of nine pre- ceding years, and corrected for increase of population, is 46,549. There is consequently an excess of 11,376 deaths in the quarter. The deaths registered in the December quarters of 1845, 1846, and 1847, are 39,293, 53,055, 57,925 ; the mortality in the first is to that of the last quarter nearly 2-3. The mortality was below the average in the autumn quarters of the 5 years 1841-5 and above the average in the 5 years 1838-40, 1846-7. " A slight increase in the mortality was noted in the returns of the June quarter, 1846 ; the mortality in the following hot summer, when the potato crop failed, was excessive : cholera 380 EPIDEMIC OF 1847-48 and diarrhosa were epidemic: in the autumn of 1846, as well as the winter and spring quarters of 1847, the mortality was still higher : scurvy prevailed in the beginning of the year, but in the summer the public health appeared to be slightly improved. Epidemics of typhus and influenza, however, set in; and made the mortality in the last quarter of 1847 higher than in any quarter in any year since the new system of registration commenced. "Deaths registered in each of the four quarters of the nine years 1839-47, in 117 of the districts of England and Wales. Years. 1839. 1840. 1841. 1842. 1843. 1844. 1845. 1846. 1847. Qtr. ending March 42,410 46,376 46,967 44,903 43,748 46,136 '49,996 43,850 56,105 June 41,244 42,074 39,133 38,569 40,343 38,977 40,847 43,737 51,585 September 37,317 39,498 36,058 39,409 36,953 38,933 36,139 51,405 49,479 December 41,740 44,186 39,292 39,662 42,608 44,080 39,293 53,055 67,925 Total . 162,711 i 172,134 161,450 162,543 163,652 1 168,126 166,275 192,047 215,094 "The deaths in the year 1845 were 166,000; in 1847, two hundred and fifteen thousand. The excess in 1847 is forty -nine thousand! or not less than 35,000 over the corrected average of 1839-45. The districts from which the Quarterly Table is made up, have hitherto returned less than half the deaths in England ; but it is not probable that the country districts have suffered to the same extent as most of those in the return. " In London the deaths registered in the quarters ending December 1845-6-7, were 11,838, 13,221, and 18,553 (13 weeks). The greatest number registered in any quarter of the nine previous years was 14,686 in the severe winter of 1845. " It was shown in the last Quarterly Eeport on the State of the Public Health, that if the chance that a child in Dorset- shire under 15 years of age will die in the summer quarter be represented by 1, the chance that a child under 15 in London will die in the same time is represented by 2. It was also shown that the chance of dying among men above 35 in London, is to that in the country as 3 to 2 : and it was remarked that ' if the chance of dying is increased from 2 in the country to 3 in London, the liability to suffer from epi- STATE OF PUBLIC HEALTH IN AUTUMN QUARTER 1S47 381 DEMICS is raised still more.' The truth of this proposition has unfortunately been too soon exemplified. The population was inadequately supplied with potatoes, and scurvy was prevalent in the beginning of the year. Meat and bread were dear, distress was rife; vagrants flocked in from the country, the poor Irish came to their kindred, the workhouses were crowded. In April and May typhus became epidemic; instead of the average 34, fifty died weekly in London; it steadily spread and burnt on until it killed a hundred and eleven victims in a single week. Diarrhoea, dysentery, and cholera had been a little more fatal than usual throughout the year : 1 7, however, only died of these diseases in the first week of July ; the mean temperature of the air was above 60°; the number of deaths rose to 38, 47, 67, 125, 128, 188, by the middle of August, and then gradually subsided. Notwithstanding the continued prevalence of typhus and scarlatina, the deaths in the last week of October were only 945 ; one person died of influenza, 36 of bronchitis '(inflammation of the air-tubes), and 62 of pneumonia (inflammation of the substance of the lungs). In the three weeks following, ending November 20, the total deaths were 1052, 1098, and 1086; of which 2, 4, and 4, were by influenza; 49, 58, and 61, by bronchitis; 68, 79, and 9 5, by pneumonia. The wind had generally been blowing S.S.W. and S.W. since the first week of October ; the weather was unusually warm ; a brilliant aurora was observed, and shook the magnets on Octobea" 24 ; it appeared eight times during the quarter; on Tuesday, November 16, there was a remarkable darkness ; the wind changed to N.W., and amidst various changes still blew from the north over Greenwich at the rate of 1 6 and 250 miles a day. The mean temperature of the air suddenly fell from 11° above, to 10° below the average; on Monday it was 54°, Friday 32°; the air on Friday night was 27°; the earth was frozen; the wind was calm three days, and on Saturday evening a dense fog lay over the Thames and London for the space of five hours. No electricity stirred in the air during the week. All was still : as if Nature held her breath at the sight of the destroyer, come forth to sacrifice her children. On Sunday the sky was overcast, the air damp, the wind changed in the night to S. by E., and passed for four days over Greenwich at the rate of 382 EPIDEMIC OF 1847-48 200 and 300 miles daily ; the temperature suddenly rose, and remained from 2° to 9° above the average through the week ending November 27th: when the deaths of 1677 persons — 819 males, and 858 females — were registered in London; 771 persons under 15 years of age, 518 aged 15-60, and 388 of the age of 60 and upwards. Influenza was epidemic. On the first week of December two thousand four hundred and fifty-four persons died: 1141 were males, 1313 females; 1012 children, 712 persons in the prime of life, 730 of the age of 6 and upwards. On the week following two thousand four hundred and sixteen persons died: 1175 males, 1241 females ; 1016 under the age of 15 ; 698 at the age of 15-60, and 702 at the age of 60 and upwards. The deaths in the weeks ending Saturday, December 18, December 25, and January 1, were 1946, 1247, and 1599. 11,339 persons died in six weeks, and altogether the epidemic carried off more than 5000 souls over and above the mortality of the season. The epidemic attained the greatest intensfty in the second week of its course; raged with nearly equal violence through the third week ; declined in the fourth, and then partly sub- sided ; but the temperature falling, the mortality remained high not only through December, but through the month of January. " The epidemic was most fatal to adults and to the aged : thus in the three weeks ending November 13, the deaths under 15 years of age were 1553 ; in the three weeks of the epidemic ending December 18, the deaths under the age of 15 were 2846. In the same two periods the deaths at the ages 15-60 were 966 and 1970; at t-he age of 60 and upwards, 576 and 1999. The mortality in childhood was raised 83 per cent, in manhood 104 per cent, in old age 247 per cent. From the age of 4 to 25, however, the mortality was com- paratively not very much increased; at the age of 10 to 15, the healthiest period of life, it was scarcely increased at all in girls. "During the 7 years 1838-44, the deaths of the males in London were more numerous than those of females in the proportion of 1749 males, to 1677 females; in the second week of the influenza epidemic the proportions were reversed, for 1141 males, and 1313 females died; in the six weeks STATE OF PUBLIC HEALTH IN AUTUMN QUARTER 1847 383 ending January 1, the deaths of 5580 males and 5759 females were registered. Looking, however, at particular ages, the deaths in the six weeks under 5 years of age were — 2321 males, 2009 females; from 5 to 55, males 1580, females 1507; 55 and upwards, 1678 males, 2241 females. At all ages there are more females than males living in London ; at 55 and upwards the males in 1841 were 71,021, the females 90,143; at 75 and upwards, males living 6754, females 11,124. A disease much more deadly in the old than in middle-aged and young people, therefore necessarily increases the total deaths of females more than the total deaths of males, without for that reason being more fatal to the female than to the male sex. The difference in the mortality of males and females from the epidemic is but slight, and can only be determined by nice calculation — into which I shall not enter here. " Influenza attacked those labouring under all sorts of diseases, as well as the healthy. The vital force was extin- guished in old age and chronic diseases. The poison, per- meating the whole system, fastens chiefly on the mucous membrane lining the sinuses of the face and head, and the air-tubes of the lungs. Hence it is fatal to the asthmatic ; the deaths directly ascribed to asthma in October and November were 12 weekly; in the six weeks of the influenza epidemic, 77, 86, 78, 52, 14, 26, besides the numerous cases classed under influenza. 36 deaths were ascribed to bronchitis in the week ending October 30th, and 49, 58, 61, 196, 343, 299, 234, 107, and 138 in the nine following weeks. 62 deaths were ascribed to pneumonia in the same week, and 68, 79, 95, 170, 306, 294, 189, 131, 148, in the nine weeks following. In some of these cases the inflammation specified was the primary disease, in others secondary, and in many it was purely influenza — misreported. There is a strong disposition among some English practitioners, not only to localize disease, out to see nothing but a local disease ; hence although it is certain that the high mortality on record was the immediate result of the epidemic of influenza, the deaths referred to that cause are only 1157; namely in the first week of November, 2, and in the eight weeks following, 4, 4, 36, 198, 374, 270, 142, 127; and these include nearly all the cases in which 384 EPIDEMIC OF 1847-48 influenza was returned, whether as primary or secondary in conjunction with other diseases. A similar defect has hitherto been found in the returns of all great epidemics ; in 1665, the Great Plague year, 97,306 burials were returned in the London Bills of Mortality, only 68,596 of which were ascribed to plague. Influenza attacked persons labouring under other zymotic diseases : thus the deaths from hooping-cough rose from 12 and 25, to 65 and 71 during the epidemic; the deaths from measles rose from 43 to 96, 89, 69, 75, during the first four weeks of the epidemic, and then subsided to 37 and 58, Typhus, which had been fatal to 70 and 80 weekly, rose to 132, 136, and 131, in the second, third, and fourth weeks of the influenza epidemic, and then fell to 83 and 74. Although influenza is not mentioned in these cases it is in others, and there can be little doubt that two or more zymotic processes do often go on simultaneously in the blood and body; a fact of profound interest to the pathologist, and worthy of attentive investigation. " The epidemic was much more fatal in some districts of London than in others. To show this, I take the deaths in each of the London districts during the six weeks from November 21st, 1847, to January 1st, 1848, and comparing them with the population, obtain the relative mortality. It! was at the rate of 46 per annum to 1000 living in London; the mortality in the seven years, 1838-44, was at the rate of 25 annually to 1000 : the mortality was consequently raised for 6 weeks, by the epidemic, about 80 per cent above the average. Lewisham, including Blackheath, Sydenham, and Eltham, is one of the healthiest districts in London ; the ordinary rate of mortality is 17 annually, during the epidemic it was 27. St. George in the East is one of the unhealthiest districts ; the ordinary rate of mortality is 29 in 1000, the rate of mortality during the epidemic was 73 : the increase in Lewisham was 1 ; in St. George in the East 44 ; the latter district suffered four times as much from influenza as the former. Excluding districts which contain hospitals or the workhouses of other districts, we have the following result : — STATE OF PUBLIC HEALTH IN AUTUMX QUARTER 1847 385 Deaths to 1000 annually. Mean Annual Rate of Mor- tality 183S-44. Annual Rate of Mortality during the last 6 weeks of 1847. Difference in the Mortality ascribable to the Epidemic. LEAST rXHEALTHT DISTRICTS OF LONDON. 6 Districts of London in which the ordinary mortality of Fenoales is low TJNHEALTHIEST DISTRICTS OF LONDON. 6 Districts of London in which the ordinary mortality of Females is high '. 20 27 38 61 18 34 "The epidemic of influenza killed twice as many people in the insalubrious parts of London as it did in those less un- healthy : its fatality in Lewisham and St. George in the East was, as we have seen, 1 to 4. The annual average rate of mortality for London, in 1730-39, was 41 in 1000 ; the rate in the 6 weeks of the epidemic of 1733 was 72 in 1000; the increase was 31 in 1733 ; the increase in 1847 was 21, " Let us look to the few country and small town districts in the present return. The deaths in St. Albans (population 17,000 in 1841), during the last quarters of the four years 1844-47, were 94, 75, 91, and 76. The Eegistrar of the sub- district of St. Albans says, ' ISTo epidemic has visited this district.' The deaths in the Kendal district (population, 35,000) during the last quarters of the four years were 160, 213, 268, and 155; in Anglesea (population 38,000) the deaths were 155, 163, 206, 158. The Eegistrar of Lland- dausaint, Anglesea, says, ' Latterly influenza has been preva- lent,' but it was, as has been seen, not very fatal. In the Isle of Wight (population 43,000), the deaths in the December quarters of the last four years were 235, 167, 201, l79. The Eegistrar of the Godshill sub-district says, ' The district would be healthy but for influenza, which has just made its appear- ance ; but no case has as yet been fatal.' Epidemic influenza is mentioned in the notes by the Eegistrars of Maidstone, Brighton, Portsea Island, Xorthampton, Cambridge, Norwich (mild — ' fatal to few '), Yarmouth, Exeter, St. Thomas (this is 2c 386 EPIDEMIC OF 1847-48 the district ronncl Exeter ; influenza has just made its appear- ance at Topsham), Plymouth (very fatal in St. Andrew's sub- district, deaths in October, 48 ; November, 49 ; December, 103. Charles the Martyr, sub-district, deaths in October, 17; November, 26 ; December, 63), Eedruth, Penzance, Bath (Landsdown, sub-district, deaths in the three months, 16, 21, 47; the Abbey, 18, 19, 58), Bristol, Clifton, Stroud, Hereford City (' influenza is just appearing '), Shrewsbury, Walsall, Wolverhampton, Burslem, Birmingham, Aston, Coventry, Leicester, Lincoln, Nottingham (St. Ann, sub-district, deaths in three months, 35, 33, 76), Basford, Derby, Stockport, Maccles- field, Great Broughton, with Chester, Liverpool, West Derby, Preston (' influenza prevailed during the last two weeks of December'), Bury, Bolton, Wigan, Prescot, Chorlton, Man- chester (Ancoats, deaths in October, 169; November, 135; December, 270), Salford, Ashton and Oldham, Sheffield (West sub-district, deaths in October, 27; November, 27; December, 85), Huddersfield, Halifax, Bradford (Horuton sub - district, 'no particular disease, except in 10 days commencing November 27, when influenza was prevalent'), Leeds, Hunslet, York (Walmgate, sub-district, deaths, October, 6 1 ; November, 52 ; December, 99), Sunderland, Tynemouth, Newcastle-ujDon- Tyne, Carlisle ('no epidemic disease prevalent at present in Dalston, Carlisle '), Pontypool, Wrexham, Angiesea. The Quarterly Eeturn includes few of the country distri'cts ; but it is evident that influenza pervaded England generally; in many places it appeared later than in London ; some places it has not yet reached at all, or its visitation has been so slight as^ not to attract attention. The mortality was raised in the unhealthiest towns ; but, on the whole, much less in the mixed' town and country districts than in London. The deaths ii the December quarters of the four years 1844-47 were in the district of London, 13,819, 11,838, 13,221, 18,553 (thirteen' weeks): — in the other districts, 30,261, 27,455, 39,834, and 38,320. In the latter districts, notwithstanding the epidemic influenza, the mortality on the whole was lower in 1847 than in 1846. The weather did not differ much in any part of the country. " Edinbuegh. — Dr. Stark, to whom Edinburgh is indebted for tables of mortality, states that in that city influenza STATE OF PUBLIC HEALTH IX AUTUMX QUARTER 1847 387 suddenly attacked gi'eat masses of the population twice during the course of Kovember ; first on the 18th, and again on the 28 th day of the month. It appeared, in both cases, during keen frost, and an excessively damp, thick fog, which came on rather suddenly after a few days of very mild weather. The total deaths returned, exclusive of still-born, were in October 521, November 728, December 1001. The mean tempera- ture of Edinburgh in December was 39°; the highest 57°, the lowest 21°.i " Our knowledge of the progress of the epidemic in other countries is necessarily imperfect, as no weekly tables are yet published in any of the great continental cities. We learn, however, from the medical and other journals, that the 'grippe,' which had prevailed for a week, was at its height in Paris about December 4th, w^hen one fourth or one half of the popu- lation were ill (' un quart, si non la moitie de la population est couchee.' — Gaz. Medicale). It is stated that 50,000 of the inhabitants of Madrid were in bed, suffering from influenza, on January 11th. The epidemic still prevailed on the 19 th, and was exceedingly fatal. London was probably attacked a few days before Paris ; Madrid a month later. In a former epidemic (1782), influenza attacked London at the end of May, France in June, Italy in July, and Spain in August. It travels faster now. The present epidemic reigned in Piennes October 30th (Prof. Toulmache, in Gaz. Med.) _ Influenza attacked the crew of the 'Lousquor' French packet in the Mediterranean in October, and was so general that, in difficult circumstances, the surgeon believes the vessel must have lieen lost. The epidemic did not prevail in Marseilles when the ' Lousquor ' left. The ' Albatross ' and ' Nile ' had cases at sea, but the epidemic was in full force at Toulon and Marseilles when they left port.^ Dr. Laval, a member of the Council of Health at Constantinople, states that influenza broke out in that city towards the end of August (1847), and prevailed, though not to a very great extent, for a month or six weeks.^ A slight epidemic of cholera broke out in October, and still 1 Report by J. Stark, M.D. 2 Bulletin de I'Acad. Royale de Med. T. 13, n. 12, 13. Mem. from Dr Renault, Surgeon of the ' Lousquor. ' 3 Letter dated 25th Nov. 1847, in the Ga.-^ette Medicale. 388 EPIDEMIC OF 1847-48 reigns in Constantinople. Eespecting the influenza epidemic in Germany, Eussia, and Italy, no authentic information has come to hand. " By returns already received at the office of the Medical Department of the Navy, and with which I have been favoured by Sir William Burnett, it appears that epidemic catarrh or influenza prevailed on foreign stations during the year 1847, as under noted : — In January and February, on the coast of Portugal and south coast of Spain ; January, February, March, in Newfoundland and New Zealand ; February, March, at Valparaiso ; April, coast of Syria ; July, August, September, west coast of Africa south of the equator ; August, Hong-Kong. " Coryza, gravedo, destillatio, and other forms of catarrh are described by the ancients. The disease is called Pose by old English writers, from the Anglo-Saxon Gepose (heaviness, stupor). Epidemic catarrh is mentioned by Targioni Tozzetti in the Cronica Meteorologica of Tuscany under the years 1323, 1328, 1358, 1387. Cullen cites other instances in his Nosology 1 under the years 1510, 1575, 1580, 1591, 1658, 1675, 1679, 1708-9, 1712, 1729, 1732-33, 1737, 1742-43, 1748, 1758, 1762, 1767, 1775, 1779-80. Ozanam adds the years 1239, 1311, 1327, 1400, 1403, 1438, 1482, 1505, 1557, 1597, 1627, 1669, 1691, 1695. Some of these epi- demics, and others which he describes, were apparently local.^ " The disease, when severe, runs into inflammation of the lungs and pleurae, and there can be no doubt that several of the epidemic pleurisies and pleuro-pneumonias of the middle ages were what is now known as influenza. The malignant pleurisy at Venice in 1535, which pervaded Brescia and Lombardy in 1537, as well as the epidemic pleurisy of Switz- erland and Upper Italy in 1551, are examples.^ The more celebrated epidemic of 1564 is said to have appeared first in England ; to have spread thence to the Netherlands, Holland, and Switzerland. Patients died in 3-6 days, after violent delirium, coma, apoplexy. Vast numbers were victims of the epidemic, and physicians, who at that time began to examine bodies after death, learnt that ' inflammation of the substance 1 Art. 39, Catarrhus a contagio. ^ Histoire Med. des Maladies epidemiques, tome 1, pp. 93-218. ^ Sprengel, Histoire de la Med., vol. iii. p. 88. And authors cited. STATE OF PUBLIC HEALTH IN AUTUMX QUARTER 1817 389 of the lungs may be combined with pleurisy.' Sydenham notices that peripneumonia and pleurisies committed great slaughter at the end of March 1665 — the year of the Great Plague.^ The winter had been excessively cold, and with a dry frost lasted till spring ; a sudden thaw took place in March. Influenza was epidemic in England in 1657; it broke out in April (Willis, de Febrihus). Influenza, described tolerably well by Sydenham as 'Tusses epidemicae anni 1675, cum pleuritide et peripneumonia supervenieutibus,' and dis- tinguished by him from pure pleurisy, spared scarcely anybody, attacked all ages and temperaments, and seized whole families, together — ' integi^as simul familias pervadentes.' It was dangerous. The previous years 1674, 1675, are referred to as a period of great dearth; the harvest of 1673 proved defective, and wheat, which was 36 s. per quarter on Lady- day 1673, was 64s. on Lady-day 1674. The epidemics of 1709 and 1729-30 in Germany appear to have been well described by Hoffman. Epidemics in 1728, 1733, 1742, 1758, 1762, 1775, 1782, 1788, 1803, 1831, 1833, and 1837 have been mentioned ; several have been fully described by English writers. An abridged account of them is given elsewhere from the original accounts. Tlie symptoms in these epidemics only differed in severity, and from complications with other maladies. " Influenza, like small-pox, probably always exists ; in ordi- nary circumstances it is confounded with inflammation of the air-tubes, yet in London from one to five deaths have been directly referred to it nearly every week since the new Loudon tables were published. Like other zymotic diseases it becomes, at intervals of some years, epidemic ; that is, it attacks the people generally of all classes. Its epidemics are distinguished by the numbers they assail ; by affecting the same persons more than once ; by being most fatal to the aged of both sexes, and, therefore, where there are more old women than old men, causing the deaths of females to exceed those of males during their prevalence ; by great difference in the severity and fatality of their attacks ; by the rapidity of their course, and passage from place to place. After the mortality they occasion becomes apparent in London, it attains a maximum in ' Syd. Opera Obs., sect. 2, cap. i. ; sect. 4, cap. v. 390 EPIDEMIC OF 1847-48 the second or third week ; and the mortality falls to the average in the sixth or seventh week. (See table, p. xlii.) Influenza appears to be generated in ill-organized camps, in crowded ill-cleansed cities, and to be most fatal among people who have for some time before been depressed, ill-fed, or ill- supplied with vegetables, as after hard winters and in war.^ It rages in cold and hot, moist and dry weather, but most frequently breaks out after a thaw, or with violence after a fog, generally the result of cold streams of air mixed with warm air, and a calm. The saturation of the atmosphere favours the transformation of all organic matters ; and those of a zymotic character among the rest. Extreme cold alone never raises the weekly mortality in London above 1500 ; extreme heat still less. Intermediate changes affect the mortality but slightly under ordinary circumstances. November fogs occur every year without giving rise to influenza. In November 1847, the weather was nearly the same all over England, yet influenza did not break out simultaneously. When once generated, the epidemic spreads through the air. The great epidemics generally travel from (1) Eussia, over (2) Germany; (3) Denmark, Sweden, England, France ; (4) Italy, Spain, in from three to six months ; and then reach America. Influenza is often associated with other epidemics. It appears to have preceded, or accompanied the Plague, in the Black Death of the 14th century;^ it preceded tl>e Great Plague of London (1665); it followed epidemic typhus in London 1803, pre- ceded it in 1837, occurred in the midst of the typhus epidemic of 1847, preceded and followed the epidemic cholera in 1831- 32-33. It carries off asthmatic persons, and those suffering from chronic disease ; it affects those labouring under other zymotic ^ ' ' Morbi praesentes a praeterita temporum conditione flunnt accipiinit vero etiam differentiam a conditione prsesentis : quare utriusque oportet habere rationem." The first part of this profound Hippocratic aphorism, which applies to revolutions as well as epidemics, is often overlooked. - See Hecker ('Epidemics of Middle Ages'). The symptoms were not, as he assumes, those of simple bubo plague. The pulmonary symptoms are always dwelt on by the contemporary writers ; and Fracastorius, referring to the Black Death, specifies them exclusively : — • " Insolita exarsit febris, quae pectore anhelo, Sanguineum sputum exagitans (miserabile visu !), Quarta luoe frequens fato perdebat acerbo. " — Fracastorius, Syph. Lib. i. v. 189. STATE OF PUBLIC HEALTH IN AUTUMX QUARTER 1847 391 diseases ; in the healthy it quickens the seeds of other maladies, particularly of the lungs. The fatality and duration of attacks vary with age. In some of the late epidemics 2 in 100 cases attended by medical men are said to have died.^ If 2 per cent was the rate of mortality in London, for 5000 deaths there must have been 250,000 cases of sickness of not less than seven days' duration. This would be little more than one in eight of the population ; but nearly all were affected more or less, and without taking slight instances, it is probable that not less than 500,000 persons in 2,100,000 suffered in London from the epidemic of 1847. "The English physicians of the 18th century agreed in pro- nouncing influenza contagious. They did not mean that it was propagated by contact, but that it was introduced into cities, institutions, and houses in England by persons actually affected by the disease. This notion is, however, too exclusive ; the word ' contagion,' applied to influenza or cholera, is apt to mislead, and to have practically a bad effect. When people ask if a disease is contagious, they generally mean, ' Are we more likely to have influenza or cholera if we touch or go near persons labouring under these diseases ? ' Now if the matter of contagion is very diffusible, and is distributed equally through the room, the house, the street, the city in which a patient is lodged, no one living in the house, street, or city is much more likely to be infected if he approach the sufferer than if he remain in absolute solitude, shut up like the grocer of "Wood Street in the Plague. The matters which excite influenza and cholera are evidently highly diffusible ; in a few days influenza spread all over London ; it met you every- where : nobody, therefore, has attempted to show that medical men, nurses, or others in attendance on the sick suffered more than other people. If such should ever be the case, either in influenza or the cholera epidemics, it will be in rare circum- stances, and should never deter the most timid from discharging their duties to the sick. ^ See a return by Dr. Dain of the mortality at different ages among 317 per- sons, and a lucid description of the epidemic of 1837, as it appeared in London ; British Annals of Med., vol. i. p. 265 ; and the able Report on the Influenza of 1837, by Prov. Med. Assoc. Trans., vol. vi. Data might now be procured for determining the exact mortality at different ages of complicated and uncompli- eati'd cases. 392 EPIDEMIC OF 1847-48 " The earth, it is well known, is surrounded by an atmosphere of organic matter, as well as of oxygen, nitrogen, carbonic acid, and watery vapour. This matter varies, and is constantly undergoing transformations from organic into inorganic ele- ments : it can neither be seen, weighed, nor measured. The chemists cannot yet test its qualities. Liebig, with all the appliances of the Giessen laboratory, cannot yet detect any difference between the pure air of the Alps and the air through which the hound can tell a hare, a fox, or a man has passed ; or the air which observation shows will produce small-pox, measles, scarlatina, hooping-cough, dysentery, cholera, influenza, typhus, plague. These matters may either be in a state of vapour — that is elastic, or they may be inelastic ; or like water, they may exist in both states. They are most probably in a state of suspension — hang, like the smoke in cities, over the places in which they are produced, but are spread and driven about like vesicular water in clouds. A stream of aqueous vapour of the same elasticity from the Atlantic — passing over England — is, in one place, perfectly transparent ; in another, mist ; in another, rain ; so clouds of infectious matter may fleet over the country, and in one place pass harmless by, in another (as influenza in London) destroy thousands of lives. The emanations from the living, the graves, the slaughter-houses, the heaps of filth, the Thames — into which the sewers still empty — raise over London a canopy which is constantly pervaded by zymotic matters — in one season this, in another that, preponderating ; and the epidemic influenza may easily be conceived, either to have broken out spontaneously, to have been conveyed here by ships, or to have been carried over by the winds ; — as the cases of the ludiaman infected in the Chinese seas, our own fleets, and the ' Lousquor ' in the Mediterranean, seem to imply that influenzine may be carried great distances over the ocean from the place of its origin. " ' Proinde ubi se ccelutn, quod nobis forte alienum est Commovet, atque aer inimicus serpere coepit ; Ut nebula ac nubes paulatim repit, et omne Qua graditur, conturbat et immutare coactat ; Fit quoque ut in nostrum quiiin venit denique ccelum, Corrumpat, reddatque sui simile, atque alienum,' STATE OF PUBLIC HEALTH IN AUTUMN QUARTER 1847 393 " The zymotic hypothesis, here so well stated, explains the phenomena to a certain extent. Still epidemics afford a vast field for research ; for much remains to be investigated.^ The mariner, however, steers his ship without knowing whence the winds come, wdiither they are going, or why they are blowing ; so, as the returns adduced above established beyond a doubt the fact that influenza was four times as fatal in one part of the population of London as it was in another, and that it is much more fatal in a part commonly insalubrious than in a part usually healthy, the course to be pursued is plain. If the means which improve the public health are applied with intelligence and energy, the general mortality can be reduced ; and the ravages, either of any future influenza, or of the coming cholera,^ can be rendered inconsiderable. " The piety of the ancients, and of our ancestors, made them consider all plagues the immediate visitation of God's wrath.^ And there can be no doubt, that though as affecting individuals there is nothing now judicial in plagues, they are the results of great national violations of the laws by which the Almighty is pleased to govern the universe. It has been shown, year after year, that the impure air of London destroys thousands of lives — that it makes ejjidemics fatal : the causes of the excessive mortality have been pointed out ; and it has been proved that they admit, to a considerable extent, of removal. Yet the efforts of Her Majesty's governments to introduce sanitary measures were strenuously opposed up to the close of the last session of Parliament. The population of London was left at the mercy of any epidemic that should break out in any part of the world. During six weeks influenza interrupted business, afflicted hundreds of thousands by sickness, implanted fatal diseases in the breasts of many, and destroyed five thousand of the inhabitants. Are the men who opposed sanitary measures, and declared so loudly that the ' City of 1 The inquiry would be greatly facilitated if such meteorological returns as the Astronomer-Royal now supplies, and weekly tables of the causes of death were published on a uniform plan in Paris, Berlin, Stockholm, Petersburgh, Moscow, Vienna, Venice, Rome, Naples, Madrid, Lisbon, Cairo, Constantinople, and Calcutta. '^ Asiatic cholera broke out in October 1848 : it will be recollected that this passage was written in January 1848. ' " Morbos turn ad iram Deoram inimortaliuni relatos esse." — Celsus. 394 EPIDEMIC OF 1847-48 London, for health, cleanliness, effective drainage, lighting, and for supply of water to its inhabitants, cannot be surpassed,' satisfied ? or will they fight against the public good till cholera drive away their best customers, and decimate their own families ? Let us hope that, instead of pursuing such a course, they will assist in supplying London with the necessaries of city life, which they have enumerated, and which they now know are wanted. "Influenza was slightly epidemic from February 20th to April 24th, 1841 ; but the weekly deaths by the new tables never exceeded 1079, and ranged from 780 to 1079 during that time. Influenza prevailed to a slight extent at the end of 1846 and the beginning of 1847. Deaths from all causes returned in each of five series of Nine Weeks tvhen Influenza was Epidemic and most fatal. No. of Week. 1733. 1T43. 1S33. 1S37. 1847. 1. 529 478 321 228 1098 2. 531 579 587 284 1086 3. 783 1013 796 477 1676 4. 1588 1448 961 871 2454 6. 1166 1026 940 860 2416 6. 628 629 874 598 1946 7. 591 537 575 558 1247 8. 613 500 311 350 1599 9. 507 423 479 321 1364 Weekly average return 502 501 429 429 980 INTRODUCTORY REMARKS 395 Numher of Deaths that would have been returned in each Week if the Po2mlation had been the same as in 1847, viz., 2,139,209. Xo. of Week. 1733. 1743. 1833. 1837. 1847. 1. 1767 1561 684 486 1098 2. 1773 1891 1251 605 1086 3. 2615 3309 1696 1016 1676 4. 5304 4730 2047 1856 2454 5. 3894 3351 2003 1832 2416 6, 2097 2054 1862 1274 1946 7. 1974 1754 1225 1189 1247 8. 2047 1633 663 746 1599 9. 1693 1382 1021 684 1364 Weekly average retui'n . 1677 1636 914 914 980 Total deaths in 9 weeks . 23,164 21,665 12,452 9688 14,886 Number of deaths that would have happened if the average mortality had prevailed in the 9 weeks .... 15,093 14.724 8226 8226 8820 Difference 8071 6941 4226 1462 6066" EPIDEMIC OF 1889-90 INTRODUCTORY REMARKS In endeavouring to give a concise and accurate account of the epidemic of 1889-90, it has been thought best to give a faithful statement of facts and figures, incorporating such observations as are suggested by the circumstances, to enable observers to collate for their future guidance the main features of the epidemic, in respect of both nature and incidence, and to form conclusions of their own. The statistics given have been selected on account of their representative character, and they are substantiated in every instance by the name of their author. We have not abstained from recording suggestions and hypotheses merely on the ground that they did not fit in 396 EPIDEMIC OF 1889-90 with our own views ; but, on the other hand, it must not be assumed that their mention involves any expression of opinion as to their vahie or merits. NOMENCLATUEE The nomenclature of the disease now definitely known as influenza is not of the clearest. It is said that the word was originally introduced by the Italians at a time when less was understood of its nature and origin than at present, if, indeed, this be possible. Stellar pathology being then current, they attributed the capricious and astonishing rapidity with which it spread (though we do not desire by speaking of its spreading to infer that it really does spread in the usual sense of the term) to some peculiar " influence " of the stars. Hence the word, in common with so many others of a like nature, reflects faithfully the erroneous tenets of departed schools of thought. Although not in any sense a scientific appellation, yet the word influenza would have answered its purpose well enough had it not come to have a totally different meaning in damp cold climates where coryzal symptoms are common. Owing to the accidental association of these coryzal symptoms in previous epidemics, the term has been cur- rently employed to designate an acute catarrhal condition of the mucous membranes of the eyes and nose, assumed to be con- tagious, and possibly infectious. Hence, when the epidemic first broke out, its victims often declined to believe that their malady could rightly be called influenza, seeing that the most salient features of the English aftection of that name were con- spicuous by their absence. For some years to come, at any rate, we shall have learned to disassociate the name from any necessary connection with a cold in the head. We need not do more than allude to the names which have been assigned to it in different countries according to its prevailing characteristic or based on its supposed geographical source. The Eussians call it the " Chinese distemper," while other European nations call it the " Eussian influenza." Some further confusion has been caused in this country by DIFFERENTIAL DIAGNOSIS 397 the careless use of such expressions as " epidemic catarrh," etc. This is distinctly ill-chosen, since catarrh is not necessarily pre- sent. On the whole, perhaps the term " influenza," or epidemic catarrhal fever, is open to least objection pending definite knowledge as to its pathology. DIFFEEEXTIAL DIAGNOSIS While there can be little doubt as to the identity of the disease in this country with that of previous epidemics, as well as with that which has overrun Europe during the last months of 1889, the comparative absence of catarrh of the conjunc- tival and nasal mucous membranes, the occasional appearance of a measly or scarlatiniform eruption, and other circumstances, gave rise for a time to a doubt as to whether the epidemic was really one of influenza. It has been pointed out that for the last eighteen months a widespread epidemic of dengue or dandy fever has prevailed in Asia Minor, Smyrna, and south- east Europe, and it has been suggested that the epidemic which reached our shores via Eussia and France was dengue modified by conditions of environment. The symptoms of dengue fever do occur with the same curiously sudden onset, hence the appellation of " knock-me-down " fever which has been applied to it, and, as in influenza, pains in the eyeballs and limbs and headache soon follow. The tongue in dengue is furred, and there is sometimes vomiting and diarrhoea. On the other hand, the fact that influenza did not spare regions in which dengue fever had recently prevailed, tends to negative the idea of their being the same disease, for although isolated cases of repeated attacks in the same individual have been noted, this is distinctly unusual. The points of difference between the two maladies are clearly made out in a com- munication from Dr. Limaricis, of Constantinople, reproduced in the British Medical Journal of January 1890, which we have modified so as to correspond to influenza as observed in this country : — 398 EPIDEMIC OF 1889-90 Covryparative Table of Characteristics of Dengue lever arid Influenza. Localisation. Duration of Epidemic. Extension. Commencement. Temperature. Kervous symptoms. Larynx and Trachea. Dyspnoea. Gastric symptoms. Exanthema. Headache. Complications. Convalescence. Prognosis. Lower animals af- fected. Incidence as to age. Dengue. Hot countries. 3 to 5 months. Slow, and fi'om scribed areas. Always sudden. Always very high. head Lassitude, pains and limbs. Seldom affected. Seldom or never. Violent and persistent. Constant, beginning in face and descending — erythem- atous, followed by des- quamation. Feeling of tension. Rarely the heart, liver, or kidneys. Lungs may be affected. Very tedious. Always favourable. Dogs and cats. All ages indifferently. Influenza. All latitudes. 1 to 2 months. Rapid, and invading large tracts at the same time. Usually sudden — sometimes strikingly so. Uncertain — not usually very high. Same, often with tendency to somnolence. Frequently affected. Frequent. Often absent. Seldom — irregular in pre- sence and description. Sharp, internal, often neu- ralgic in character. Lung affections frequent — principally bronchitis and broncho-pneumonia. Usually quick — sometimes protracted. Usually favourable in ab- sence of complications. Horses especially, but also dogs, and jjossibly cats. Principally adults — more rarely children. The resemblance to malaria reposes on even less plausible bases. The mode and rapidity of propagation, the prevalence of the disease in districts far removed from any possible source of malarial poisoning, its non-amenability to the influence of quinine, and the general course of the affection, distinguish it clearly from all known malarial diseases. Moreover, the spleen is only occasionally enlarged in influenza, and the tendency to relapse, so marked in diseases of malarial origin, is far less so in influenza. SYMPTOMATOLOGY 399 SYMPTOMATOLOGY The onset of the malady is usually sudden, and marked by shivering. The victim thinks he has " caught a cold," to use the consecrated expression ; he experiences the same aching lassitude as that which characterises the " bad cold," and there is an intense feeling of depression, both mental and physical. The face feels flushed and uncomfortable, and little shudders creep up the spine, the integument wrinkling up into the condition known as "goose skin." Before very long, perhaps even coincidently with the sliivering, violent headache, with giddiness, supervenes, more or less limited to the frontal region and behind the eyeballs, often of a neuralgic character. In rare cases this preliminary shivering assumes the aspect of a typical rigor. The prostration is immediate and extreme, and in the majority of cases it is the most salient clinical feature of the affection. The sensation of cold is persistent and dis- tressful. The temperature is very variable. In some cases the attack begins with, or shortly attains, a high degree of fever, but during the first twenty-four hours it does not usually exceed 100° or 101°. The pain in the limbs is general, and seems more of the nature of an ache, though it may be associated with local neuralgic manifestations. The muscles feel sore on pressure, but the tenderness is not localised to any particular structure, partaking of the nature of a general cutaneous hypersesthesia. It is always well marked and severe in the back, and the backache is often one of the earliest indications of an attack. The pulse is small and rapid. Coryzal symptoms, so commonly known under the name of influenza in this country, have been comparatively little marked during the last epidemic, and have only been observed in from a third to a half of the cases, though conjunctival hyperemia was sometimes present. The tongue is furred and tremulous, and there is, for a time, complete anorexia. Thirst, however, is not marked. The bowels are usually confined, and the urine high coloured, scanty, loaded with litliates, and with an occasional trace of albumen. While these symptoms re- present the average type of the disease, there has been an "xtreme and remarkable diversity in the manner of the onset, 400 EPIDEMIC OF 1889-90 as well as in the subsequent course, of the malady. In a number of recorded instances a violent attack of pain has been the first intimation, so severe sometimes as to cause the person to fall down under the impression that he has been struck. In others, wild transient delirium has ushered in the symptoms ; indeed, a very interesting chapter might be written on the eccentricities of the disease in this respect. In cliildren, delirium was almost the rule. However the malady commences, within a few hours the patients are unable to be still on account of the aching, and unwilling to move on account of the pain. The prostration becomes very intense, and the patient manifests indifference to his surroundings and is wrapped up, so to speak, in the contemplation of his own misery. The back pain simulates a severe attack of lumbago, while that in the limbs has been mistaken for rheumatic fever. On the second day the temperature sometimes rises to 103° or 104°, and occasionally veritable hyperpyrexia has been noted, the thermometer marking 107° or 108°. Sweating occurred in about half the cases, and when present was " cold " and abundant, necessitating several changes of linen during the night, and adding greatly to the discomfort of the patient. In a second category of cases this phenomenon was conspicuous by its absence, the skin remaining hot, harsh, and dry. The bronchial mucous membrane and the lungs were not, as a rule, aflected during the early stages of the disease, though the presence of tonsillitis, laryngitis, and hoarseness was noted in a certain proportion of the cases. Occasionally a few sibilant sounds were detected on auscultation. As the disease progressed, however, a dry hacking cough supervened, unaccompanied by expectoration, and presenting, in its irritat- ing iteration, some resemblance to that of whooping-cough. There was sometimes herpes labialis or nasalis, erythema or urticaria, and, more rarely and as a later complication, meningitis or pneumonia. In a certain but variable proportion of the cases a rash of some kind has been noted, resembling that of measles or scarlatina, erythematous or papular in character, and generally described as " rose-coloured," disappearing on pressure, and lasting for from one to four days, usually followed by some desquama- SYMPTOMATOLOGY 401 tion. A rash only appears to have been noticed in a com- paratively small number of cases, and when present it has occasionally been the means of causing an error in diagnosis, only cleared up by subsequent events. Even in mild cases in which auscultatory signs were absent, urgent dyspncea of an asthmatic character with cyanosis has been remarked. The liver and the spleen were found to have undergone enlargement in a small and uncertain proportion of the cases, and in some rare instances symptoms of a paralytic nature were noted. The temperature continued high (102° to 103°) for a period variously stated as from three to five days, when it subsided more or less suddenly. In the majority of cases, however, the temperature had returned to normal by the third day, at which period the pains began to diminish in severity. At the expiration of from seven to ten days the patient was well, save for the physical prostration which the attack almost invariably left behind it. Considering the mildness of the disease in general, the loss in weight which resulted in so short a time is remarkable. The rash most frequently made its appearance on the second or third day, affecting the face (cheeks) and neck, sometimes extending to the trunk and the inner aspect of the limbs (especially the legs), and desquamation commenced within 48 hours of its appearance. The amount of desquamation varied exceedingly, in some being so slight as hardly to be noticeable, in others rivalling and even surpassing that following a severe attack of scarlet fever. In some cases the rash has been of a papular character, more or less closely set, and associated with a good deal of itching on the chest, back, arms, and legs, lasting for two or three weeks, and followed by desquamation. Dr. H. P. Hawkins, of St, Thomas's Hospital, has recorded seven interesting cases of rash in the course of influenza, of which over 1000 cases applied at St. Thomas's Hospital for treatment. Of these a large number were carefully examined, and all were asked if they had had any rash. As the result, six cases have been seen with an eruption presenting a certain degree of similarity in appearance and position, and the patient in a seventh case described an eruption which seems to have 2d 402 EPIDEMIC OF 1889-90 been of the same nature. One man was covered with well- marked urticaria, and a large number had labial herpes. Case 1. J. C came to the hospital as an out-patient. He had a roughly circular patch slightly raised over the back of each elbow, passing at its periphery into patches and spots of similar appearance, especially numerous along the back of the forearm. The colour was bluish-red, such as is seen on the cheeks in measles, disappearing completely on press- ure. A similar condition existed on the legs ; there was a large patch on the patella, with smaller patches and spots down the shins. There was a slight blush on the chest, but nothing more than is often seen in fever from any cause. This patient had had eighty grains of salicylate of soda before the rash appeared. A few days later, while the rash on the arms was fading, a crop of spots arose on the backs of the hands, of urticarial appearance, considerably raised, and paler than the surrounding skin, but not attended with itching. Case 2. W. B had a similar rash to Case 1 on the front of the knees and shins, with a slight blush on the chest, but nothing on the arms ; he had no medicine before its appearance. Case 3. H. D. L . The arms showed the same rash, but it was on the flexor surface, and there were a few spots on the legs. The patient had had no medicine. Case 4. H. S . The chest, abdomen, and back of this patient were covered with a continuous bluish-red rash, which, judging from the edges and outlying spots, was probably com- posed of confluent patches ; it ceased abruptly at the level of the clavicles. The elbows and knees had the same appearance as those of Case 1 ; there was the same patch on the olecranon and patella, with discrete spots around ; the colour was the same, but it was rather fainter. This patient had had a saline draught, but no quinine, antipyrin, or salicylate of soda, the three chief erythema-producing drugs. Case 5. H. T . The elbows and backs of the fore- arms exhibited an eruption having the colour, appearance, and arrangement described under Case 1 . This patient had had no medicine. Case 6. N. B . The elbows and backs of the fore- arms were spotted as in Case 1. From the middle of the SYMPTOMATOLOGY 403 front of the thigh to the ankle on both sides, having its greatest intensity and degree of confluence over the patella, was a livid, slightly raised hsemorrhagic eruption in spots and patches ; there was not a single spot to be seen on the backs of his legs. This patient had had no medicine, and had never suffered from purpura before. Case 7. This patient, a woman, did not come to the hos- pital until she began to suffer from the secondary bronchitis. She said that on the day after the onset of the illness her chest and abdomen became covered with large " red blotches and spots," without itching ; but she had noticed nothing on her arms or legs. Dr. Hawkins adds that these seven cases certainly bore a family resemblance, but observes that their number (7 out of 900) is so small that one would hesitate to admit for the rash any relationship to the specific disease influenza, in the absence of further observations. A curious fact was elicited, in reply to a suggestion made in the British Medical Journal by Dr. Barnes, bearing on the influence exerted by sex upon the malady. Dr. Evershed of Hampstead states that in a home for girls of which he is the medical officer, out of 36 girls of the age of 15 and upwards, 10 were attacked between January 15th and 27th, of which number, 8 were either menstruating or menstruation appeared during the attack. The other 26 inmates who were not attacked were not at the time menstruating. In these cases a high temperature (101° to 105° Fahr.) was the rule. The difference in the manner of onset of the malady is not more remarkable than the variation in its severity as experienced by different individuals. In a few it has manifested itself solely by an extreme somnolence, and after one or two days' complete repose the attack has passed off. In some of these cases a tendency was noted to the occurrence of muscular pain and lassitude at periodical intervals after the first attack, continuing for two or three weeks. Dr. Farbstein, of Hull {Lancet, February 2 2d, 1890), claims to have remarked the coexistence, in the early stages, of high temperature (101° to 103° Fahr.) with a slow pulse (80 and under). He says he made it a rule to take the tempera- ture in all cases seen within twenty-four hours of the onset of 404 EPIDEMIC OF 1889-90 symptoms, and in no case did he find a temperature below 100° "4 Fahr., or a pulse above 88. After the first twenty- four hours the pulse-temperature ratio becomes variable, and may have returned to normal. He suggests that this curious departure from the normal ratio may serve as a diagnostic guide in doubtful cases. Sir Peter Eade, M.D., in a contribution on " The Influenza in East Anglia" {Lancet, February 1st, 1890), dwells upon the fact that in one respect this epidemic would seem to differ from preceding ones in that it appears to have travelled and spread irrespective of winds and uninfluenced by temperature or the mild weather ; whilst certainly on some former occa- sions it has broken out so suddenly upon the giving way of a frost or the melting of snow as to point to the probability of a close connection between the two circumstances. He insists that the morbid influence was more especially exerted upon the nervous system, and secondarily on the pul- monary apparatus. He points out that in many cases in which thoracic oppression and diaphragmatic pain were com- plained of, the dyspnoea was much in excess of that warranted by the amount of lung tissue involved, and he ascribes it to " pulmonary paralysis." He noticed, too, in respect of the decubitus, that even when a considerable part of one lung or portions of both has or have been choked by congestion, and when the difficulty of breathing has been considerable, he had seen patients lying almost flat down upon the bed, perspiring, pale, and evidently thus seeking relief from the cardiac asthenia and difficulty, more than from the effects of the pulmonary in- flammation. He observes that in most cases of fatal influenza the post- mortem appearances have been those of broncho- or catarrhal pneumonia. The lungs were studded with patches of congestion, from which, on section, exuded a yellowish, purulent, or dark red material. The mucous membrane lining the bronchi was usually swollen and hypersemic, and in some cases there was oedema of the lungs and hyperaemia of the pleuras. Engorge- ment of the spleen and liver were noted in some cases, but this was by no means constant or even frequent. RELAPSE AND RECURRENCE 405 EELAPSE AND EECUEEENCE Eelapses have occurred in many of the cases, especially when due care has not been taken to provide against exposure during convalescence, hence they have occurred more fre- quently in males. When this has been the case the liability to pulmonary complications has appeared to be markedly in- creased. The temperature rises again, and the shivering, headache, and pain return, and the symptoms thus revived do not tend to resolution as promptly as at first. The protection afforded by one attack against subsequent attacks does not appear to have been so complete as is usually the case with specific fevers generally. A few instances of a second or even a third attack at varying intervals of from four to eight weeks, after an interval of complete restoration to health, have been reported, but the proportion has been extremely small The case is reported of one aged gentleman who was known to have had, and to have survived, three well-marked attacks during the last three epidemics, 1837, 1848, and 1890. COMPLICATIONS The complications have been numerous and varied, and so much has this been the case that it is difficult to avoid the conclusion that the malady has a tendency to graft itself on to other maladies, so to speak, and to seize upon the idiosyn- crasies of the patient. By far the most frequent and serious complications have been catarrhal or inflammatory affections of the air passages and lungs, and most of the deaths have been due to a peculiar creeping form of lobular (catarrhal) pneumonia. This, though frequently the result of exposure during convalescence, has, in spite of every precaution, in elderly or enfeebled persons, directly determined a rapidly fatal result. Apart from the cases in wliich the poison appeared to concentrate itself on the respiratory apparatus, the pulmonary affection rarely 406 EPIDEMIC OF 1889-90 became serious before tlie fourth day, and often only declared itself much later. The signs and symptoms were those of catarrhal pneumonia, with rapid shallow breathing, a small rapid pulse, cyanosis, and prostration, culminating in a comatose condition followed by death. Laryngitis and bronchitis were also fairly common, espe- cially among those unable to protect themselves from atmospheric vicissitudes, or who returned too early to their work. In rare cases, meningitis, pleurisy, chorea, etc., have super- vened. Hfemorrhages from the nose, lungs, and stomach, either during the period of invasion or during convalescence, were noted as less common complications. From an examination of cases reported by practitioners who saw a good deal of the epidemic, pneumonia occurred in about 1 6 per cent of the cases, bronchitis in 2 per cent, rheumatic and gouty complications in 6 per cent. The conjunctival irritation, which was a common symptom of the disease, not unfrequently left after it a chronic condition of inflammation requiring special treatment for its relief. The catarrhal condition occasionally extended into the ears and nose, but seldom to the extent of causing more than passing discomfort. Not unfrequently some congestion of the kidneys has been present, the urine being scanty, more or less (generally less) albuminous, and in rare instances suppression of urine for several hours has been noted. Neuralgic troubles were frequent, both as a complication and as a sequel. Complications were most frequent in persons between the ages of 30 and 40, and rather more in males than females. A special feature of the recent epidemic was the great heart weakness occasionally present, especially in elderly or middle-aged patients. Cardiac failure was moreover the im- mediate cause of death in many cases of relapse. In one case under the care of the author recovery had taken place from a second and severe relapse occasioning gastro-intestinal, as well as pulmonary symptoms. When convalescence was setting in the patient got out of bed for the first time without per- mission and immediately fell dead. In another instance the VARIETIES 407 cardiac weakness was so great, and the action of the heart so rapid, that rest in the recumbent position had to be rigidly maintained for weeks. It has been a subject of general remark that a large number of cases of phthisis, apparently consecutive to influenza, have come under notice, but it is only fair to assume that the attack of influenza, like any other debilitating influence, only precipitated a latent tendency or aggravated a condition which had until then escaped attention. VAEIETIES A tendency has been noticed on the part of the virus to attack particular parts of the organism, thus giving a special aspect to the attack. The varieties have been roughly classi- fied according as the maximum effect was produced on the nervous, the respiratory, or the digestive system. A more accurate subdivision may be made, as suggested by Dr. Norman Kerr, as follows — 1 . The general type, witli acute heaclaclie, pains in limbs, and fever. 2. The catarrhal variety, attacking the mucous membranes of the nose, eyes, and bronchi. 3. A gastro-intestinal form, in which nausea, vomiting, diarrhoea, and abdominal pain prevail. 4. The nervous type, characterised by extreme depression and som- nolence, followed by harsh dry cough. 5. The arthritic variety, in which joint pain was the prominent symp- tom. TEEATMENT Although, if properly attended to, influenza is usually a mild and ephemeral malady, we have abundant evidence that it is not to be trifled with. The first and most important part of the treatment is rest and warmth — two conditions with which sufferers are usually very willing to comply. Antipyrin, salicin, aiul the salicylates have been very exten- sively resorted to, often by the patients themselves, and not 408 EPIDEMIC OF 1889-90 rarely with the effect of producing inconvenient and even disquieting symptoms. We have not, however, heard of any fatalities due to the abuse of such drugs as antipyrin and the salicylates, possibly because a becoming prudence had been en- gendered in the public and among dispensing chemists by the serious mortality (17 cases) directly attributed to overdoses of antipyrin in Vienna. The general consensus of opinion is in favour of a laxative, followed by a stimulating diaphoretic, though antipyrin and the salicylates have not been without benefit when judiciously administered for the relief of the pain and ■ headache. Dover's powder was also much used to relieve the ^ distressing insomnia, but opium in any form seems to have been badly borne. On the second or third day, and during recovery and convalescence, quinine was unquestionably of service, and markedly hastened the return to a normal con- dition of health. The comphcations had of course to be treated secundum artem, the only principle to be borne in mind being the necessity for the use of sustaining rather than lowering remedies. Alcohol, undesirable in the early stage, was sometimes taken with advantage when the febrile symptoms had subsided. It is worthy of note that the bronchial catarrh was not relieved by the ordinary expectorants, and the cough, dyspnoea, and wheezing were best controlled by the iodides or bromides, or a mixture of the two. No special precautions appeared to be necessary in regard to diet, and the greatest difference existed in the degree of anorexia present, the appetite indeed being often but little affected. During convalescence a tonic preparation containing iron and quinine gave the best results, and was as a rule highly appreciated by patients. As is invariably the case during the prevalence of an epidemic, a large number of so-called specifics were brought before the public, but though some of them, such as menthol, eucalyptol, pumiline, etc., may have been useful in virtue of their disinfectant properties, no known drug or method of treatment proved to be possessed of the power to cause the attack to abort or be sensibly abridged. MORTALITY 409 The Turkish vapour baths failed to afford the relief they may usually be relied upon to procure in ordinary " cold," and attempts to procure diaphoresis by active exercise — a variety of treatment which very few sufferers had the courage or the resolution to put to the test — culminated in acute and even dangerous prostration. MORTALITY The mortality in this country, so far as one can judge, does not appear to have exceeded, even if it attained, 1 per cent of the cases. ISTo deaths were registered as due to influenza until the week ending January 4th, when four were recorded, the mortality from respiratory diseases having risen from 5*6 per thousand deaths, which is below the average, to 9*9 per thousand, which is considerably above it. The following week (ending January 11th) the number of deaths from influenza was 67, and that of diseases of the respiratory organs 12 '6 per thousand — more than double the average. The deaths directly attributable to in- fluenza attained their maximum during the week ending January 18th, their number being 127, the deaths from respiratory affections having declined to 11*9 per thousand deaths. During the week ending January 25th, there were 105 deaths from influenza, and the proportion of deaths from respiratory diseases, 8*7 per thousand. During the same period the total mortality per thousand for the twenty-eight large towns rose from 21 "9 per thousand for the week ending December 28th to 28*1 for the week ending January 11th. The following week it was 27 per thousand, falling to 24*2 during the week ending January 25 th. 410 EPIDEMIC OF 1889-90 The following are the returns of the Eegistrar- General for the five weeks during which the epidemic was at its height : — Eegisteak-General's Eeturn for London. Week ending o o Mortality due to 1 fl Respir 1 Bronchitis. Diseases. ' Pneumonia. Total. > i 3 Total. ^ ' Total. 6 4 o O Total. >- s Jan. 4 . Jan. 11 . Jan. 18 . Jan. 25 . Feb. 1 . 26-5 32-2 30-2 25-2 20-9 2,371 2,747 2,720 2,227 1,849 1947-6 1937 1955 1967-1 2059-8 4 67 127 105 75 843 1069 1010 736 550 532 547 546 569 630 530 715 630 468 339 350-8 332-5 335-7 372-6 426-6 215 253 281 a93 145 118-8 122-9 116-8 117-8 128-0 Totals . 11,914 9866-5 378 4208 2824 2682 1818-2 1087 604-3 During these five weeks, therefore, 378 persons died of influenza, many no doubt of some respiratory complication, and, in addition, no less than 1384 persons succumbed to some affection of the respiratory organs who would not under normal conditions have perished, and of this excess 844 -per- sons died of bronchitis and 483 of pneumonia. The Kegistrar-General's returns for the first quarter of 1890 showed the same remarkable general increase in the rate of mortality in the larger towns, which cannot be accounted for by the meteorological conditions. Excluding the death-rate from zymotic diseases, which was only 2-04 per 1000, the rate from all other causes was 22-7. Compared with the recorded rate in the first quarter of 1889, which was excep- tionally low, the mean rate in the twenty-eight towns during the preceding quarter showed an increase equal to 1 8 per cent ; in London the increase was 21 per cent, whereas the mean rate of increase in the twenty-seven provincial towns did not exceed 16 per cent. In three of these towns the death-rate during that quarter showed an actual decline from the rate in the first quarter of 1889 ; the decrease being 5 per cent in Birkenhead, 9 per cent in Cardiff, and 12 per cent in Blackburn. The decline in Blackburn, it should be pointed out, was from 32-3 to 28-5, INCIDENCE 411 and was more than explained by a marked fall in the zymotic death-rate. In each of the twenty-three other provincial towns under notice the death-rate last quarter showed an increase. The increase was, however, less than 10 per cent in Oldham, Nottingham, Salford, Preston, Huddersfield, Norwich, Leicester, and Liverpool; it was between 10 and 20 per cent in Derby, Sunderland, Newcastle-on-Tyne, Plymouth, and Manchester ; and between 20 and 30 per cent in Birmingham, Halifax, Sheffield, Portsmouth, Bolton, Wolverhampton, and Leeds. The highest proportional increases were .30 per cent in Brighton, 32 per cent in Bradford, 33 per cent in Bristol, and 37 per cent in Hull. To what extent this varying increase in mortality corre- sponds to the intensity of the epidemic, we are at present unable to ascertain. Although the above high death-rates have been surpassed during non- epidemic times in London, under exceptionally unfavourable climatic conditions (third week of 1880, 46-7; sixth week in 1882, 34-5), it must be noted that the mortality was then chiefly among the very young and the old, and not, as during the recent epidemic, between the ages of 20 and 60, the increase being 70 per cent between the ages of 20 and 40, and 93 per cent between 40 and 60. This extraordinary rise in the mortality was due almost entirely to an increase in the deaths due to disease of the respiratory organs. In spite of the fact that the proportional mortality was exceedingly small, it is worthy of note, as showing how deadly the disease has proved in the aggregate, that there is no other disease except cholera which has so serious an effect on the death-rate while it lasts. INCIDENCE The epidemic does not seem to have evinced any predilection for sex — males and females suffering in about the same propor- tion, though the former seemed to be the first to contract the malady. With respect to age, the greater number of patients were between 15 and 40, children and infants being apparently less amenable to the action of the poison, though in 412 EPIDEMIC OF 1889-90 this respect the returns show the most curious differences. Numerous cases, however, have occurred among the aged, and of these a large proportion proved fatal. On the other hand, neither youth nor extreme infancy appears to have afforded more than a relative immunity. Dr. Kingston Barton, of South Kensington, rej)orted a fatal case of an affection which bore every appearance of being influenza in a new-born child, delivery having taken place on the fourth day of a well- marked attack of influenza on the part of the mother. It has been remarked during this epidemic that even when persons did not, properly speaking, contract influenza, any existing malady assumed an influenzoid character. Thus a person who contracted a cold in the head, proved very apt to experience lassitude, etc., out of proportion to the local affec- tion, and a greater tendency existed to subsequent bronchial catarrh. There is every reason to believe that measles and scarlatina have in exceptional cases coincided with influenza and thus caused the medical attendant a good deal of anxiety and uncertainty. BACTERIOLOGY Notwithstanding the sensational announcements which from time to time found their way into the public press, it is more than doubtful whether the relationship of any particular micro- organism, or organisms, to influenza has been satisfactorily proved. Most of the best known bacteriologists of the world devoted themselves to the task, and many of them succeeded in isolating an organism whose presence strongly suggested that it was " loitering for the purpose of committing a felony." The verification experiments, however, did not in any case, so far as we are aware, conclusively demonstrate the pathogenetic properties of the incriminated microbe. Dr. JoUes, of Vienna, noted numerous capsuled cocci in the sputa of patients who had suffered from influenza, and by isolation and cultivation he claimed to have demonstrated their identity with the bacillus of Friedliinder. Professor Weichselbaum, of the Vienna Bacteriological Institute, examined the sputa of eighteen living persons BACTERIOLOGY 413 suffering from influenza, and found in them, as well as in the diseased organs of patients who have died from the disease, a micro-organism resembling Frankel's diplococcus of pneumonia; but he was unable to detect in any of the pathological products of the disease, Friedlander's pneumococcus. The same micro- organisms have been found by Professor Weichselbaum in the intestines of a girl who died from enteritis during the epidemic, but he was unable to establish the connection of these micro-organisms with the spread of influenza to his satisfaction. He expressed the opinion that influenza may be caused by a microbe as yet unknown, and that the complications of the disease may be due to the micro-organism of pneumonia finding favourable conditions for development in the diseased body. The results of Professor Weichsel- baum's investigations have been corroborated by the ex- aminations of sputa made during the epidemic at the Vienna Hygienic Institute. Professor Klebs, the well-known pathologist of Zurich, found in the blood of influenza patients great numbers of monads similar to the organisms credited with giving rise to the symptoms of malarial fever. In a critical article on this subject in La Province, Mklicale of February 1st, Dr. G. Eoux calls attention to the fact that in 1884 Otto Seifert described a streptococcus in the nasal secretions of influenza. Dr. Pdbbert asserted that he had found a streptococcus in eight cases of influenza, six of which were suffering from pneumonia, identical in every respect with the streptococcus pyogenes, and his observations are in part con- firmed by those of M. Vaillard of the Val-de-Grace Laboratory. None of these researches, however, have been able to satis- factorily explain the cause of influenza, but it may be that the presence of such micro-organisms is favoured by antecedent conditions induced by the general " influence," and that the key to the varying degrees of intensity of the disease, the variety of its manifestations, and its complications, is to be found in this suggestion. 414 EPIDEMIC OF 1889-90 tETIOLOGY The erratic aud always unexpected outbreak of the disease, and the promptness with which it appears and disappears, may- account for the fact that we are still strangely ignorant of the causes wliich preside over its origin and dissemination. We are not even in a position to affirm authoritatively whether or not it is transmissible, or whether, if transmissible, the virus is conveyed through the air, the water, or other vehicle. Careful inquiry points to the disease being in the first instance depend- ent on some general condition — though whether atmospheric, electrical, or miasmatic, we know not — which affects populations in their entirety, and either confers the disease or prepares the way for it. The theories advanced to explain what has always been mysterious, are as numerous as some of them are ingenious. Several of them merit attention, and it may not be unprofitable to briefly discuss one or two of the more striking. It has more than once been noticed by Italian physicians that the incidence of the disease has appeared to vary according to the proportion of ozone in the atmosphere, and attempts have been made to trace a distinct relationship between the presence of an excess of ozone and the prevalence of the affection. In Nature of January 24th, 1890, Mr. Augustus Harvey mentions a case in support of this view. He says that forty years ago he paid a visit with a friend to the laboratory of the celebrated chemist Professor Schonlein, the discoverer of ozone. Just prior to his visit the Professor had obtained some ozone and had inhaled it " for the purpose of giving himself influenza," and they both distinctly observed most of the ordinary symptoms of the malady. Ozone, it is true, even in attenuated proportions, acts as a powerful irritant to the bronchial mucous membranes, but it is preposterous to pre- tend that its inhalation would give rise to an affection which has every appearance of being a specific malady. More- over, the epidemic has been most marked in cities and large towns where ozone is rarely present in perceptible quantities. Moreover, were such the case, sporadic cases of influenza would be of common occurrence among employees ETIOLOGY 415 in electrical works, where the smell of ozone is invariably very marked. Eather more to the point — for it has at any rate some elements of possibility, not to say probability, in its favour — is the suggestion that dust may be the vehicle which serves to transmit the contagion, whatever its nature may be. It is well known that the dust swept up by the sirocco or thrown into the air by volcanoes may be, and has been, blown incredible distances over land and sea. If, then, it can be shown that the disease, or something analogous to it, was prevalent in the country whence the dust is derived, and, secondly, that the occurrence of the disease elsewhere coincided with the distribution of the incriminated dust, then we have data which admit of serious discussion. This theory was well brought forward in a long and interesting letter addressed to the Times in January 1890 by the Hon. Eollo Eussell, who points out that "in the Times of January 11th, 1888, it was reported that a great flood had occurred in China through the bursting of tlie banks of the Hoang Ho, or Yellow Eiver, and that an immense extent of thickly inhabited country had been inundated, causing a loss of life by drowning estimated at between one and seven millions. A letter from the Professor of Chinese at Oxford and others, appeared on February 24th, 1888, calling attention to the famine following this disastrous calamity, and estimating the flooded area as fully equal to that of Wales. On October 9th, 1888, it was reported that the new embankment, constructed at enormous cost, had been swept away by a summer flood, and that the low-lying fertile land had for a second time been inundated. On January 1st, 1889, news arrived of terrible floods in Manchuria, by which 2000 lives were lost, and of an outbreak of cholera at Quilon. In the Times of April 26th, 1889, it was stated that 170,000 persons were receiving relief in the desolated province, and that there was much illness and fever. During the winter an epidemic had been feared among the vast stricken population of the flooded districts {Times, January 6th, 1889), and in the follow- ing summer there was great distress in the towns and villages elevated above the plain and spared by the flood, but deprived of their means of living, the fertile land having been covered by the yellow mud brought down by the swollen river. The 416 EPIDEMIC OF 1889-90 heat of summer is intense in this region, and the great level area was dried up, but had ceased to be capable of supporting a teem- ing population, so that the survivors lived upon roots, grasses, and anything that could be picked up, until the relief provided by the famine fund and native aid came to minister to their most pressing wants. In the Loess district, which seems to have been partially subject to the floods, the fine powdery yellow soil is carried up during the dry winds of summer in such quantities into the atmosphere as to obscure the landscape and almost hide the sun. Something of the kind probably occurred when the province, covered by the same thick yellow deposit, lay under the burning heat of the summer of 1889. Countless millions of organic spores, developed in the marshy water of the flooded area which must have been saturated with the dejections and refuse of a dense population, would thus be carried into the air and disseminated by the strong winds which there prevail. It would not have been surprising if some malarious disease had been strongly developed in these unusual conditions, and the peculiar character of the rich earth from which the Yellow Eiver derives its name would be likely to give rise to infective organisms differing from those common to marshy districts in tropical and temperate climates. Whether any distinct disease of an epidemic character fastened upon the distressed population in China at this time does not clearly appear. But there does seem to be some reason — slight, perhaps, at present — for supposing that the present epidemic of influenza has its source in the dried-up surface of the sodden soil of the province of Honan. . . . There are only two distinct records of the dates of great deluges in that part of China; these occurred in the few years preceding 1833 (Davis's Chinese, vols. iii. and iv. p. 180) and in 1851-53 (Keith Johnston, Physical Geogrofphy). In 1832-33 and in 1854-55 Europe was to some extent affected with influenza (see Eeynolds's System of Medicine; also article on influenza in Health, by Dr. Wilson, January 3d, 1890)." The writer concludes by suggesting that " it might be desirable to investigate further the possible connection of floods in China with epidemic in- fluenza, for present data barely sufiice to mark out China and Siberia as the breeding-ground of the disease." This suggestion called forth some statements from a writer ETIOLOGY 417 in Nature, to the effect that the Hoang Ho could not burst its banks, as it ran at a lower level than the surrounding country, that the soil was all sand, devoid of vegetation or cultivation, and that, as a matter of fact, malaria was not prevalent there. The author, in a communication to the Medical Press and Circular (May 7th, 1890), found it necessary to disclaim the credit of this " dust theory," as also for entertaining the sugges- tion that the micro-organism of influenza was generated in China and thence conveyed by winds, by upper currents, or by cyclonic or anticyclonic action. He admitted, however, having been bold enough to throw out the suggestion that dust in the air, whether Chinese dust or meteoric dust, might supply the " raft " for the conveyance of the microbe, and that the presence and diffusion of dust in the air might be the condition which determined the prevalence of the disease, and might be adequate to convert a local epidemic into a universally distributed or pandemic wave. These data, interesting as they are, are scarcely sufficient to do more than stimulate investigation and inquiry in this direction. They open up a wide field for original research for epidemiologists and sanitarians. The dust which is always present in the atmosphere inland is largely composed of organic particles which, even if not themselves possessed of pathogenetic properties, are admirably suited to serve as a vehicle for spores or poisons of a different kind. Many diseases are known to be thus conveyed, and it may be that further inquiry will elicit information of value in this respect. Although we are not in possession of data which permit the exact nature of influenza to be accurately defined, a large number of clinical observations are now available which throw further light on a problem which has always been remarkably obscure. Graves held that the symptoms of the disease were referable to the action of some virus on the nervous system, and it must be admitted that many of. the features of this affection are more readily to be explained on that hypothesis than on any other. This, however, even if admitted, does not help us to elucidate the nature of the poison, its source, or the patli by whicli it enters the organism. Dr. Bezley Thorne has carried this theory a step farther, and has made out a very plausible 2e 418 EPIDEMIC OF 1889-90 case in favcur of the view that influenza is essentially an inflammation of the cerebro-spinal meninges. In a communi- cation on this subject addressed to the Lancet, he says : " The signs of local inflammation commencing in the eyes, pass backwards, possibly through the medium of the optic nerve, to the cranial nerve centres, and within a few hours portions of the spinal cord, notably the lower lumbar and sacral portions, are sensitive to deep percussion. The pains in the limbs, which are felt early in the attack, are characteristic of central irritation. On the subsidence of the fever and even before, the following symptoms, all or some of them, become manifest : insomnia, mental depression and confusion, with impaired power of mental concentration, neuroses of both arms and legs with pains and twitching at night, hyperses- thesia and a sense of intense cold, intercostal neuralgia and myalgia of the scapular, dorsal, and lumbar muscles, feebleness of the hand-grasp, with perspiration and sense of exhaustion on making the effort to increase its force, marked alteration in the handwriting, which becomes juvenile and straggling, feebleness of gait and tremor of the muscles of the lower extremities, prsecordial distress, with a sense of faintness and even syncope, and the occasional secretion of abundant so-called ' hysterical ' urine." The epidemicity of influenza is a difficulty which has to be grappled with from another point of view. We have to ask ourselves how it is that it sometimes spreads with such wonderful rapidity while at others it remains confined for a time within a more or less narrowly circumscribed area ? Evidently the only possible explanation is that there must be something in the conditions of environment which either favours the evolution of the virus or renders persons abnormally and unusually susceptible to its influence. Something analogous in the vegetable kingdom has been observed in certain districts of South Africa, where plants exist the flowers of which only make their appearance at odd times, and seldom much oftener than once in a decade. This means that they can only develop under certain coincident meteorological and physical conditions, failing which they remain dormant. Given the required moisture, heat, or what not, forthwith the country is covered with the blossom, and persons who have ETIOLOGY 419 been but a few years in the country are surprised to see a flower which they do not remember to have met with before. There are many circumstances in the history of the present epidemic which suggest the possibility of a similar condition of things in regard to the spread of influenza. There is every reason to believe that isolated cases of the disease occur in districts which, later on, are ravaged, but in which, it is to be assumed, the conditions are not such as, for a time, to favour its evolution or distribution. Another interesting fact is, that a malady which affects many points of resemblance with influenza in human beings has been observed in the lower animals. This has been repeatedly noticed in past epidemics, more particularly with regard to horses, in which it is known among veterinary surgeons as "pink-eye." A good deal of trouble has been taken to investigate this point, and careful inquiry has been made among veterinary practitioners with the view of ascertain- ing what was the exact relationship in point of dates and symptoms between the existence of " pink-eye " in horses and the prevalence of influenza among human beings. Mr. W. Burr, who was thus applied to, writes as follows : — " A serious outbreak of that form of equine influenza which has received in America the name of ' pink-eye,' appeared in the west of England in September of this year (1889) and in Glasgow a little later. The outbreak has been characterised, as was the case with many of its predecessors, by the sudden- ness of its appearance, the epizootic rapidity of its spread, and by its attacking all classes of horses under all manner of sur- roundings. " The onset of the disease is sudden. An animal may be at work one day, to be the next discovered with legs filled and stiff, eyelids swollen, the conjunctivae exhibiting the character- istic congestion and discoloration ; rapid nervous and muscular jarostration ensue, and the patient is languid and depressed ; the heart's action is feeble, the appetite fails, and the secretions of the skin, kidneys, and bowels are impaired ; the temperature rises sometimes to 104° or 106°; the pulse is nearly double the ordinary rate, remaining so for several days. The loss has been about 5 per cent. Some patients have died from exhaustion, others apparently from the oedematous swellings 420 EPIDEMIC OF 1889-90 about the head and throat interfering with respiration. We have no sufficient information as to the first cases, nor have we learned whence the malady came. Cart, carriers', and omnibus horses have suffered most. Much checked since recent frosts. Fatal cases only happen when work is continued after the disease has appeared. In 1881 it was much more severe, and accompanied by violent diarrhoea, which seldom yielded to treatment. This year there is very little catarrhal disturbance, no sneezing or cough, and but slight sore throat. "When the malady gets into a stable it tends to spread, but seldom is a whole stable affected at once, " A healthy horse, if placed in an affected stable, will in most instances take it ; but in my opinion a diseased animal will not communicate it to others in a healthy situation." In the address on " Influenza " delivered by Professor W. T. Gairdner at the annual meeting at Glasgow of the Glasgow Branch of the British Medical Association, he alludes to the recent occurrence, both in Glasgow and Edinburgh, of a " very severe and widespread epidemic of influenza, or ' pink eye' in horses for a month or more prior to the outbreak of the disease in man, whole stables holding large studs having been down with it, as, for instance, was the case with the largest railway carriers and tramway companies." It is, however, only fair to add that, according to Dr. Eussell, the medical officer of health, in the large establishment of Messrs. Wylie and Lochhead, while there has been abundance of " pink eye," the men who had to do with their very extensive stables were almost exempt from the disease, and certainly in no degree specially prone to the epidemic. According to Bollinger, the horse is subject to three different affections, all of which are known as influenza: 1, a catarrhal form, which affects the mucous membrane of the nose, larynx, trachea, and bronchi, and may go on to a fatal termination from bronchitis or broncho-pneumonia ; 2, epidemic erysipelas, or horse typhoid, which in some respects stands in closer relationship to anthrax or splenic fever ; and 3, pectoral influenza, or contagious pleuro-pneumonia — i.e. horse influenza in the old and large sense. The last two forms are never communicated to man, and it is the first only that stands in any possible relationship to human influenza. Yet it would be hazard- ETIOLOGY 421 ous to say that thei:e is any direct relation between the human and the equine malady, for influenza is very often rife among horses when there is none in man and vice versd, while the occasional coincidence of the two, of course, proves nothing of itself. In the great horse epizootic which in 1872-73 spread over the w^hole of Northern America, the symptoms were like those of human influenza and bore a close resemblance clinic- ally to the recent epidemic, but, as at that time there was no similar epidemic among human beings, Bollinger believes that the two affections are essentially distinct. Still it seems that in November of last year there was an epidemic catarrh raging among horses to a greater extent than at any period since 1882. It was attended with very great prostration, so that the horses could hardly stand, and if worked during the first day of illness they were very likely to die. The pulse was so feeble as hardly to be felt, and there was a little catarrh. The affection lasted about a month, and that at a time when the ordinary winter catarrh was not specially prevalent among horses. Although veterinary authorities, therefore, are inclined to believe that horse and human influenza are distinct, it is at any rate certain that human influenza may spread to some of the domestic animals. Horses, dogs, cats, and even birds have been described as suffering in previous epidemics, and in the present several fairly conclusive cases have been recorded, but chiefly among cats. Domestic animals are said to have suffered coincidently from influenza, and Dr. John J. Redfern of Croydon records a typical instance of possible contagion from man to animal. On January 7th last, the elder daughter of a family he was attending was suddenly prostrated with a typical attack, from which she recovered without relapse. On the 14th (seven days later) her father was struck down, and had a serious relapse. On the 21st (seven days later) the son was attacked, but after a slight illness resumed work. On the 16 th their cat was taken with violent running from the eyes and general depression and apparent illness, which in the course of a few days subsided. The cat had never suffered from anything of the kind before. These facts are interesting, inasmuch as both the daughter and son ex- cluded the cat from their rooms entirely, but the father permitted the cat to lie on his bed during the greater part of the day. 422 EPIDEMIC OF 1889-90 Dr. Eegius Thornton, of Canterbmy, reports {Lancet, March 29th, 1890) that "in this part of the country, as early as October 1 4th, lambs began to suffer from a malady ' tlie like of which ' has certainly not been known for more than twenty years. In one farm not one lamb out of 500 escaped, and at first, until skilled treatment was brought in, more than twenty died. This epidemic amongst the lambs having finished, every horse on the farm was seized with undoubted influenza. The horses having finished, then the owner, his wife, his son, and his servants were all ill with the influenza, and this sequel of events was the same on two adjoining farms." If the influence of contagion be admitted in this case, the converse would also be likely to hold good, and it would be very desirable to possess comprehensive and accurate data as to the existence of the disease in domestic animals hefore its appearance in human beings. So strongly impressed were we with the intimate connection between " pink eye " in horses and human influenza, that in the early part of December 1889 — some weeks before the disease had gained a footing in London — the author wrote to the British Medical Journal, calling attention to the prevalence of an epidemic among horses, and suggesting that it would not improbably prove the forerunner of an outbreak in man. Subsequent events fully justified this forecast, and though it would not be wise to attach too great an importance to what may later prove to be a mere coincidence, the association is one which ought to be borne in mind. We know that the virus of certain diseases can be attenu- ated or intensified at pleasure by their passage through the organisms of different animals, and possibly the virus of influenza, at first unable to attack man, may by spontaneous cultivation in the organisms of the lower animals become endowed with increased virulence until, under favourable circumstances, it is enabled to overcome the resistance offered to its entry by the human tissues. The disease is asserted by Dr. Norman Kerr to be endemic in the territories bordering the lower Danube, with occasional exacerbations, as we have already pointed out. Hence he re- gards it as essentially of a malarial nature. The objections to this view are numerous and weighty. In the first place, no METEOROLOGY 423 known malarial affection is transmitted or spreads in the way which is characteristic of the spread of influenza, and the disease fails to show that amenability to quinine which is so marked a feature of malarial affections. Moreover, the splenic enlargement which is so typical of malarial diseases is but an occasional and fortuitous symptom in influenza. METEOEOLOGY During the first three weeks of December there was a rising temperature from a mean of 38° Fahr. to one of 43°'4 Eahr. .and at Christmas there w^as a moderate fall of 2°'5, and a further fall of nearly 1° in the succeeding week. Both November and December were months of extraordinary mildness, with a low degree of humidity, and a rainfall below the average. The month of January, which is generally the coldest month of the year, was so exceptionally warm this year, and in other w^ays the whole period was so unusual, that a few of the leading features in connection with the weather may not be without interest. The month opened with a short spell of frost, but after the first few days mild weather set in and continued until the close of the month. The stations used by the Meteorological Office in the com- pilation of the Daily Weather Report scarcely represent suffi- ciently the weather at inland stations, but they will give an approximate idea of the prevailing conditions. These reports show that the warmest weather was experienced in the south-western parts of the kingdom, the stations in the north-east of Scotland being about 5° colder than in the south-west of England. On the east coast the mean temperatures of Wick, Aberdeen, Spurn Head, and Yarmouth were each about 41°*0.^ ^ Tlie excessive drought to which attention has been called by Dr. E. Assman, of Berlin, as having prevailed throughout Europe during the months of November and December 1889, is of interest in connection with the hypothesis of influenza being due to the presence in the air of a specific micro-organism. It is quite conceivable that the effect of lieavy rain would be to wash the atmo- sphere and precipitate the dust and dust -borne spores which, it has been suggested, may serve to propagate influenza, as is the case with pollen in the causation of hay -fever. On the other hand, the resulting humidity of the super- ficial layer of the soil possibly favours the evolution of the organisms, which may be once more diffused abroad when the mud becomes dust again. 424 EPIDEMIC OF 1889-90 The following table gives the mean temperature results for a number of stations in all parts of the British Isles — c to . QO V- 1 • j3 .d 1 £ 3 £ xn > % . 1z o 3 £ n .s B^ .5 S ix «5 station. 1 O CO d S |2 S c 2 ■5;f o ii C4 c 5 J3 "^ t. =* 5 fcjO S is 5 £§ Wick .... 40-5 + 2-8 45-2 + 3-0 35-7 + 2-7 4 8 Nairn 41-6 + 4-3 47 1 + 5-2 36-1 + 3-4 13 4 Aberdeen . 41-1 + 3-2 45 6 + 3-2 36-5 + 3-2 7 4 Leith 42-2 + 3-0 48 2 + 3-6 36-2 + 2-5 15 9 Shields . 42-3 + 3-4 47 8 + 4-7 36-8 + 2-1 14 5 York 41-8 + 3-6 47 9 + 4-7 35-6 + 2-5 15 8 Loughborough 42-2 + 4-0 48 4 + 4-9 36-0 + 3-1 17 (6 Ardrossan . 43-6 + 3-2 47 3 + 2-9 39 '8 + 3-4 6 3 Donaghadee 42-6 + 2-2 47 7 + 3-3 37-5 + 1-2 15 2 Holyhead . 44-7 + 2-2 48 7 + 2-8 40-7 + 1-7 18 Liverpool . 43-2 + 3-4 48 5 + 4-6 37-8 + 2-2 16 4 Parsonstown 42-2 + 1-9 48 8 + 2-8 35-5 + 0-9 16 7 Valencia . 45-6 + 0-4 51 1 + 1-3 40-0 -0-5 21 3 Roche's Point 45-7 + 1-9 50 2 + 2-3 41-2 + 1-5 23 1 Pembroke . 46-0 + 3-1 49 2 + 3-4 42-8 + 2-9 17 Scilly 48-3 + 2-1 51 5 + 2-4 45-0 + 1-7 25 Jersey 46-6 + 4-2 50 5 + 4-5 42-6 + 3-9 24 1 Hurst Castle 45-4 + 4-2 49 8 + 4-5 40-9 + 3-9 23 2 London 43-7 + 4-1 49 5 + 4-7 37-8 + 3-4 20 5 Oxford 42-5 + 3-4 48 1 + 4-3 36-8 + 2-4 15 4 Cambridge 41-9 + 3-6 48 9 + 5-0 34-9 + 2-3 19 10 Yarmouth . 40-8 + 2-6 45-6 + 3-7 36-0 + 1-5 6 7 From this it is seen that the excess of temperature was least at the extreme western stations, the mean at Valencia only exceeding the average for 1 5 years by 0'''4, whilst the night temperature was even below the average. In nearly every case it is seen that the excess of the day temperatures over the average was larger than that of the night tempera- tures. A feature of especial interest in the table is the large number of days on which the temperature reached 50° or above. It is interesting to notice the very great difference between the temperature in January this year, in comparison with that which occurred in January 1881, when the weather was ex- ceptionally cold. At Loughborough, the mean temperature METEOROLOGY 425 this year exceeded that in 1881 by 17°, which is 4° in excess of the difference between the average temperature for January and May ; there were also several stations in nearly all parts of the kingdom with an excess of 12° and 13°. At Greenwich Observatory the mean temperature obtained from the mean of the maximum and minimum readings was 43°'4; and with the exception of 43°'5 in 1884 and 43°"6 in 1846, this has not been exceeded in January during the last half-century. The mean of the highest day temperatures was 48°'5, which is higher than any January during the last fifty years, and the only other instances of 48°, or above, were 48°-l in 1877 and 1851, and 48°-0 in 1846. There were six years with the mean maximum between 47° and 48°, but only eighteen in all above 45°, whilst in January 1879 the mean of the maxima was only 35°"1, or 13°'4 colder than this year, and in 1881 it was only 36°*2. There have been three Januarys during the last half- century with a higher mean night temperature, but in no year was the excess more than 1°. In January this year the mean minimum was 38°'2, and in 1884 it was 39°'2. The Greenwich observations also show that there were in January seventeen days with a temperature of 50° or above, whereas in the correspond- ing period during the last fifty years there has been no similarly high number of days with this temperature. It was reached fourteen times in 1877, 1853, and 1846 ; thirteen times in 1873 and 1849; twelve times in 1884; eleven times in 1874, 1869, 1852, and 1851; and in twenty- eight Januarys, 50° or above was only attained five times or less. The warm weather was very intimately connected with the heavy wind storms which occurred throughout the month, the storm systems which so frequently arrived on our coasts from off the Atlantic being the natural carriers of warm moist air. Scarcely a day passed during the month without the arrival of some fresh disturbance from the westward, but, with one or two exceptions, the central areas of the storm system skirted the western and northern coasts, and did not pass directly over our islands. In London, curiously enough, a dead calm prevailed during the earlier part of the month of January, the weather being decidedly " muggy." Several well-marked fogs 426 EPIDEMIC OF 1889-90 testified to the unwonted and phenomenal stillness of the atmo- spliere, and it was only towards the latter half of the month that the advent of westerly gales brushed away the accumula- tions of aerial filth due to atmospheric stagnation. The month was also marked by the prevalence of influenza, and, in addition to this, a general unhealthiness pervaded all classes of the community. The death-rate from all causes in London, for the four weeks ending January 25th, corresponded to an annual rate of 2 9 '7 per 1000 of the total population, which is excessively high. The rates for the corresponding period in the last four years were 21"7 in 1889, 23"2 in 1888, 22-7 in 1887, and 22-6 in 1886. In an interesting contribution to the St. James's Gazette of January 21st, an anonymous writer directs attention to the fact that the spread of epidemic influenza was preceded and accompanied by unusual stillness of the atmosphere, and that its decline was coincident with, and very probably due to, the replacement of the pre-existing stagnation by aerial movement. The writer suggests that this may serve to explain the vagaries of the geographical distribution of the epidemic, seeing that the distribution might naturally be expected to coincide more or less with the zones of atmospheric stagnation. We cannot do more at present than chronicle these sugges- tions and the meteorological data upon which they are based, hoping that further and more extended observations may at some time in the future show more clearly what relationship, if any, exists between atmospheric conditions and the spread of this and other diseases. The meteorological relations of influenza are very complex, and the individual factors which make up " the weather " vary to such an extraordinary degree, every year, without causing influenza, that the establishment of any causal relationship between the two must be a matter of difficulty, though not necessarily an impossibility. Such a relationship is perfectly consistent with what we know in respect of other zymotic diseases. That atmospheric con- ditions should have some effect in favouring or retarding the spread of influenza is only what our knowledge would lead us to anticipate, though what these states are, has not yet been determined. It is at least remarkable that epidemics of influenza have frequently been preceded and accompanied by COURSE OF THE EPIDEMIC 427 severe and prolonged fogs and marked changes in the weather. Here, however, as elsewhere, we are confronted by the danger of confounding cause and effect. COURSE OF THE EPIDEMIC Early in October 1889 there were rumours of another outbreak of influenza in Russia, and within a few days the rapid spread of the disease left little doubt as to the identity of the malady with that which has periodically ravaged eastern Europe as far back as history enables one to go. It seems to have been first recognised in Siberia, undoubted cases occurring at Tomsk on October 15th. Almost at the same time its appearance was announced in the Caucasus, St. Petersburg, Poland, Moscow, Sevastopol, and Merv. In the middle of November it was raging at Berlin, and by the beginning of December it had invaded the German provinces, and was present in every important town from Hamburg in the north to Munich in the south. It broke out in Dresden on December 23d, and had got as far as Prague on December 27th. The disease seems to have reached Vienna early in December, although it was officially denied on the 11th, and it was undoubtedly rampant iu Belgrade, Bucharest, and Sophia between the 15 th and the 25 th of that month. Meanwhile the epidemic had also extended westward, reach- ing Brussels about December 12th, and Antwerp on the 16th, having broken out in Amsterdam somewhat earlier. The progress of the epidemic did not follow any regular line of march ; for while it was extending metliodically in Central Europe, it made a rapid stride to Paris, where cases were observed as early as November 17th, and where, by the 25th, it had already assumed formidable proportions. It then rapidly overran the French provinces, but does not appear to have attained anywhere the same degree of intensity as at Paris. The epidemic was first heard of south of the Pyrenees on December 12 th at Malaga, and two days later at Madrid, soon afterwards making itself felt throughout Spain and Portugal. It appeared in Italy at about the same date as at Spain, but though extremely prevalent in many of the large towns, the 428 EPIDEMIC OF 1889-90 inhabitants of Eome seem to have suffered less than those of the other capitals of Europe. For a time, although every one was on the look-out, no cases of influenza were observed, or at any rate identified, in this country, and even at the end of December doubts were entertained as to its presence. Careful inquiry has elicited the fact that on October 15th a family living in Kensington were attacked by symptoms which, in the light of subsequent experience, point strongly to the disease being influenza, and curiously enough the onset is said to have followed closely on the arrival of a parcel from Eussia. Dr. Gilbart-Smith saw a young lady on October 2 2d, who had just arrived from Berlin, presenting the characteristic symptoms, although so far as is known the disease was not then epidemic in that city. Numerous observers claim to have noticed cases of undoubted influenza in West London during the month of December, but it was not until the end of December that the presence of the disease in an epidemic form was formally recognised. In endeavouring to establish the date of the earliest cases, it must be remembered that comparatively few medical men now in active practice can have had any experience of the disease, so that it is highly probable they escaped notice, the symptoms being variously interpreted according to circumstances. More- over, as we shall subsequently have occasion to point out, the earliest cases were for the most part of a very mild and benignant character, and were thus all the more likely to evade recognition. Its appearance in the provinces soon followed the announce- ment of the outbreak in the metropolis ; indeed, it may be said to have declared itself simultaneously in many of the large towns, such as Manchester, Liverpool, etc. According to details kindly supplied by Dr. James Greig Soutar, the disease, as it presented itself at the Barnwood House Asylum at Gloucester, occurred exclusively among the attendants. The interest of the observation lies in there having been but few cases, and in the evidence which is afforded of the possibility of preventing the spread of the disease by rigorous isolation. In every instance the patient was isolated, all intercourse with the other inmates being intercepted, except COURSE OF THE EPIDEMIC 429 what was absolutely necessary for purposes of attendance. The isolation was maintained for at least a week after the tempera- ture had fallen to normal. Only eight cases occurred in all. Seven of these developed the first symptoms within two days after the matrons had been off duty and in Gloucester, where at that time the epidemic was at its height. Dr. Soutar has tabulated the cases as follows : — 1st Case. Off duty afternoon and evening, Feb. 10. First symptoms showed themselves, Feb. 12. 2d Case. Off duty afternoon and evening, Feb. 13. First symptoms showed themselves, Feb. 15. 3d Case. Off duty afternoon and evening, Feb. 17. First symptoms showed themselves, Feb. 19. 4th Case. Off duty afternoon and evening, Feb. 21. First symptoms showed themselves, Feb. 22. Three other cases showed the same record — " off duty two days before onset of attack." The eighth case, the last of the series, was that of an attendant who had been told off to nurse three of the patients affected. She had not been off duty for a week, but she had been in daily attendance on those who were ill. There was nothing remarkable in the symptoms — the usual frontal headache, pain in back, high temperature for a few days, extreme (mental) depression and great muscular prostration. Dr. Soutar, while allowing that so small a number of cases does not justify any categorical inferences, ventures to con- clude : — 1. That the Asylum was not an influenza centre. 2. That the disease was imported from the city. 3. That its spread among the inmates was prevented by the rigorous measures of isolation which were enforced from the very commencement. He points out that whether or not the disease be contagious, the fact remains that the only inmate not exposed to outside in- fluences who contracted the malady was the nurse in attendance on the influenza patients, and it is unlikely that she alone would have been affected had the disease come in any other way than by direct communication. It reached Dublin about the middle of January, but only invaded the Irish provinces during the following month. There, 430 EPIDEMIC OF 1S89-90 however, it appears to have proved fully as virulent, so far as the proportion of persons attacked, as in the cities, though accurate statistical data are naturally very difficult to obtain. Wherever it passed " everybody was down with it," which, allowing for exaggeration, may be taken as evidence that a very large proportion of the population suffered. According to Dr. J. W. Moore, the Eegistrar-General for Ireland' — (1) the epidemic of influenza was more pernicious to the population of Dublin than the extreme cold of January 1881 ; (2) it slew its victims chiefly by complica- tions and sequelae affecting the breathing organs and the heart ; (3) it was less fatal to children of tender years than to the adult and elderly ; (4) its effect upon the death- rate was sudden and pronounced, and lasted throughout the month of January and the first half of February. Dr. Moore argued that it was an acute specific infective disease of the miasmatic rather than the miasmatic-contagious class. Its virus acted primarily on the nervous system. It was pandemic rather than epidemic, and its prevalence was independent of season and weather, a fact which distinguished it from epidemic bronchial catarrh. There was often an interval of one or more days between the reception of the poison and the development of the symptoms ; but this pseudo-incubation period might be explained on the supposition that in certain individuals an intact condition of the mucous membranes might present an obstacle to the entrance of the virus into the blood. He had observed several cases of apparent communication of the disease from person to person, but without being able to calculate the duration of a supposed period of incubation. The symptoms and complications were then described; among the latter. Dr. Moore had observed epistaxis (one case), facial neuralgia (several cases), profuse sweatings (several cases), skin rashes (four cases — three were examples of papular sweat rashes, with sudamina ; one was an erythema fugax), herpetic eruptions (several cases) ; cystitis, followed by mild orchitis (one case). Dr. Moore believed that, in contrast to dengue fever, influenza was a non-eruptive fever. Eashes were accidental, and resulted from hyperpyrexia, or profuse sweating, or from the ingestion of such drugs as quinine antipyrin, or salicylate of sodium. He observes that in the COUESE OF THE EPIDEMIC 431 epidemic of 1847 the death-rate was estimated at 2 per cent of the cases observed in London, and he says it was certainly not higher in the last one. He adds that he knows of no specific for influenza, but the most useful drugs were (1) quinine, (2) antipyrin, except in young children and the weakly, (3) salicylate of sodium, especially in effervescence, (4) phenacetin, and (5) effervescing citrate of caffein. The disease thus seems to have attained its maximum during the first fortnight in January, but continued to be severely felt until the end of the month, when fresh cases became rarer. It is an interesting fact that the Pope granted a dispensa- tion in the matter of abstinence to persons who had suffered from influenza during Lent 1890. As late as the beginning of March, the disease was raging in the south-west of England and elsewhere, and a slight recrudescence of the epidemic seems to have taken place in London (and possibly in the provinces) at the end of March and during the month of April, most of the later victims being those who had escaped the malady when it was general. It has not been possible to obtain reliable data as to the extent of the prevalence at those dates, but the disease seems to have been decidedly " patchy " in its redistribution. It appears from the Orkney Journal for February 26th, 1890, that in the Hebrides " most people in the islands have lately suffered, or are now suffering, from a mild influenza, scarcely more severe than what the Scotch call a * hoast.' No very serious cases have been reported, although the epidemic has been, present amongst us for three weeks." The Shetlands have often escaped in previous " pandemics, but we find in the diary of the Eev. J. Mill, minister of Dun- rossness, Shetland, for 1782 the following entry: "There is a strange distemper called influenza raging through Brittain as it did in Eussia and Denmark, etc., though as yet not proved so mortal. People are variously affected with swelled faces, sore throats, breasts, and stomachs, dizzy heads, coughs, violent pains, and feverishness." Writing at a time when newspapers were practically unknown, we may assume that Mr. Mill de- rived his information from personal experience, and that " Brittain " included Orkney and the Shetland Islands. 432 EPIDEMIC OF 1889-90 In the Eoyal Edinburgh Asylum the percentage of cases was 25 per cent of the inmates and staff. Dr. Clouston has classified the 170 cases into four leading groups: — 1. The feverish type, with bad headache, and pains in limbs, and sometimes giddiness. 2. The rheumatic, where symptoms of subacute rheumatism are present. 3. The respiratory, with affection of the respiratory mucous membrane, from the nose to the minutest bronchials. 4. The gastric, where gastric and intestinal symptoms predominate. Five deaths were reported at the Asylum from influenza of the respiratory type. According to Dr. William Tibbies, medical officer of health, Nottingham {British Medical Journal, April 12th, 1890), the disease seemed to spread from various centres to the neigh- bouring villages. {a) It made its appearance in Melton Mowbray, according to this observer, on December 18 th. From this place it spread rapidly to many of the villages of his district, namely, Sysonby, Asfordby, Burton, Kirby, Frisby, Freeby, Great Dalby, etc. (&) In the south of the district a centre seems to have been formed at Twyford, where it appeared on December 20th (J. Jackson). (c) In the north-west of the district it appeared at Upper Broughton on December 18 th (E. F. Trevor), spreading to Nether Broughton by the 23d (Trevor), to Old Dalby by January 1st (Trevor), arriving also at Long Clawson on January 1st (J. M. Swain), and later at Stathern on the 20th (Swain), and by February 1st at Hose, Harby, and Wycombe (Swain). {d) In the eastern side of the district it appeared at Eaton on December 30th (Swain), spreading rapidly to Eastwell and Branstone. It does not seem to have shown any great tendency to cross the marlstone ridge, as on one side of it the villages were attacked thus early, but on the western side of the ridge it did not appear until three weeks later at Stathern, and four weeks later at Hose, Harby, Scalford, and Holwell. Whether these villages have been thus favoured on account of their being more elevated or because the subsoil is a rocky one (ironstone) he declined to say, but he suggests that probably both factors enter into the problem. (e) At Wymondham it appeared on December 30th (H. COURSE OF THE EPIDEMIC 433 Hamilton), and spread to Saxby, Garthorpe, Coston, Buck- minster, Stonesby, Waltham, etc. The first appearance of the disease was, in every quarter of the district, in villages which lie low, and have a clay sub- soil (middle lias) ; from these it radiated in every direction, attacking villages on the ironstone last of all. By about the middle of January the epidemic was getting pretty general, and " the cases were very numerous and widespread." This observer believes the incubation to be about two days. He observed a rash in a few cases, not always, however, of the same kind; thus — (1) several cases had a papular erup- tion on the head, face, neck, back, chest, and arms, the itching of which was excessive, the eruption lasted about three or four days, and terminated by desquamation around the papules. In two instances the desquamation was rather more general, extending to the hands and feet. (2) A rose-coloured rash and spots have been observed. (3) Herpetic eruptions about the face were common. He observes that haemorrhages were met with in a certain proportion of the cases, the discharge of blood being usually the forerunner of a severe attack, often accompanied by some complication. Among the uncommon cases, four set in with haemoptysis, one with epistaxis, two with hematuria, and several with bloody stools. In cases with haemoptysis and epistaxis, premonitory symptoms preceded the illness by a few hours ; but in the cases of haematuria the patients observed that, after a rigor, the next urine passed was bloody. In one instance a clot of blood was formed round the utensil of the thickness of a shilling. Bloody stools, along with diarrhoea, were also not uncommon. Among other complications, he thinks pneumonia was the most frequent ; but chest symptoms of a catarrhal or bronchitic kind were common, as well as meningitis, severe neuralgias, otalgia, etc. Dr. Jackson, of Somerby, informed him that horses in his neighbourhood had been affected with cough, profuse discharge from the nostrils, swollen sub-maxillary glands, and inability to work, lasting about ten days. The same thing has been observed in other parts of the district. Bronchial attacks in horses had also been common. 2f 434 EPIDEMIC OF 1889-90 The deaths from influenza were few in number. After a very able summary of the principal symptoms and features of the epidemic in his district, the author concludes — 1. That it is a disease ]3er se. 2. That it is of miasmatic origin, the specific germ being an unknown bacillus. 3. That it is severely infectious, and but mildly contagious. 4. That it spreads by atmospheric influence, and by de- velopment in external media. 5. That its development outside the body is the cause of its being so rapidly and widely epidemic. 6. That one attack is not protective against future attacks ;j though it has not been under observation long enough to decide I this, we may judge from analogy with other diseases of this : class that such is the case. 7. The cause of the origin of this world-wide epidemic isj unknown, and that, in a given district, the epidemic probably' fails from want of numbers or some change in the atmospheric conditions. The disease was extremely prevalent among the members i of the London Stock Exchange from about the middle ofi December 1889. Dr. Whitehead, of Ventnor, was called in on Christmas Day to see a stockbroker just arrived at Ventnor from London. He had felt chills on the journey down. He] was found to be feverish, his temperature being 102° Fahr., with] a hacking cough, moist skin, and strongly -smelling, musty,] sour perspiration. On listening over the patient's back Dr. Whitehead felt that he had inhaled very noxious emanations.! Four days later he was himself seized with the same symptoms, and in four days more his four children were " down " with the epidemic, which then became prevalent. Dr. Whitehead! believes that the stockbroker's case was the first in Ventnor. Dr. Charles Pridhaur has kindly furnished the following] account of an epidemic of influenza at Bideford, North Devon, inj the autumn of 1853. A vessel arrived at that port from RigaJ laden with tallow and hemp. A man suffering from Asiatioj cholera was brought on shore and placed in a lodging-house] at the upper part of the town. This disease spread at once over the town, following the course of the natural watershed.' Concurrently with the existence of cholera a severe epidemic of STATISTICS 435 influenza prevailed, though no one at the time thought of asso- ciating it with the Eussian vessel. The disease commenced with catarrh of the air passages, severe pain in the brow and back, extreme exhaustion, and apprehension of death. It was the invariable rule that, in persons who had previously exhibited delicacy of any particular organ, that organ was the part to suffer most, and the disease proved fatal in a large number of the cases. There was very little fever present, but exposure to the external air before the disease had entirely subsided was almost invariably followed by relapse and recurrence of the disease in an aggravated form. The disease usually ran its course in from a week to ten days, but convalescence was frequently protracted, extending in some instances to a month or more. The treatment which gave the best results consisted in the administration of saline diaphoretics and purgatives. STATISTICS Since one of the most salient features of the epidemic (as indeed of all epidemics) is the fact of a large number of per- sons being affected within a very short space of time, it is easier to trace its course in offices and administrations where a large number of persons are employed. It was first noticed among the employees at the General Post Office between the 21st and the 24th December. The average number of per- sons on the sick list, out of a total number of 12,000, is 250. On December 24th the number was 216, but on the 26th it had risen to 343, and then rapidly increased day by day, until on January 4th the number was 1160; on the 5th, 1300; and on the 6th, 1800; after which the numbers as gradually decreased — 1740, 1300, 1200, and so on, until on February 1st the normal figure was almost reached, there being only 280 absentees from illness. The outbreak among the troops quartered in the Home District, numbering 8131 men, commenced on December 30th, and down to January 17th, at which date the epidemic was rapidly abating, 860 cases were admitted into hospital, this being equal to a rate of 10 '5 7 per cent. 436 EPIDEMIC OF 1889-90 According to a report issued by Mr. Talbot, the medical ofl&cer of health for Bow and Bromley, the workmen at the various factories, etc., were very differently affected. The pro- portions were as follows : — in bagging works, 2 in 9 ; in breweries, 1 in 5 ; in ammonia works, 1 in 6 ; water-proofers and lamp-black makers, 1 in 7 ; nitric acid works, 1 in 9 ; jam makers, 1 in 9 ; gasworks, 1 in ll'S ; colour works, 1 in 1 3 ; paper-hanging makers, 1 in 14; sawmills and printers, 1 in 1 5 ; engineers, 1 in 17; sulphuric acid works, 1 in 18; flour mills, 1 in 20. The tramway companies were obliged to reduce the number of cars running, and the Metropolitan Police Force suffered very severely, the first cases occurring on January 3d. During the week ending January 11th, some 1660 were disabled out of a total of 14,000. The troops also suffered severely, and in the Home District especially, the number of cases severely taxed the resources of the military hospitals. Numerous cases occurred at the Wellington and Kensington Barracks and at Hounslow, and for two or three weeks the Herbert Hospital at Woolwich was full to repletion. At the Plymouth Post Office, from January 5th to the 20th, there were 29 cases of influenza out of a total of 290 employees. Mr. Horace Hart, Controller of the University Press at Oxford, has published the following report of the incidence of] the disease among the employees : — " The number of persons employed here at the beginning of January was 562, and out of these about four are usually absent daily through sickness. But from January 6 th on wards' a very different account has to be given. On that day the! absences rose to 29 ; on the following Saturday they were 67 ; on Monday the 13 th there was a slight decrease (owing toi some of the persons affected coming back too soon) ; and on Saturday the 18th the epidemic reached its highest point — 70 persons being away ill. On Monday the 20th we started! with 54 absentees, but from that time the number has steadily] decreased until we are now almost back again to the normal! number. This state of affairs is shown by the followino table : — STATISTICS 43< Nuniber of Persons absent because of Illness from Monday, January Qth, to Saturday, February \st, 1890, both inclusive. Date. Men. Boys. Women and Girls. Total. First Week. January 6 . . . . 12 16 1 29 January 7 . . . . 18 22 1 41 January 8 . . . . 20 27 3 50 January 9 . . . . 25 25 4 54 January 10 27 30 4 61 January 11 ... . 31 32 4 67 Second Week. January 13 ... . 28 28 2 58 January 14 30 21 3 54 January 15 34 27 5 66 January 16 ... . 36 22 8 66 January 17 ... . 33 26 8 67 January 18 ... . 38 24 8 70 Third Week. January 20 ... . 31 22 1 54 January 21 26 21 3 50 January 22 ... . 24 16 5 45 January 23 ... . 28 17 4 49 January 24 ... . 27 15 5 47 January 25 ... . 26 15 4 45 Fourth Week. January 27 ... . 15 8 5 28 Januarj' 28 ... . 16 11 3 30 January 29 ... . 14 7 1 22 January 30 ... , 14 8 1 23 January 31 ... . 14 6 2 22 February 1 . . . . 13 2 2 17 " The total number of persons affected during the four weeks was as below: — Men, 108 ; boys, 103 ; women and girls, 25 ; total, 236." Outbreak of Influenza on Board the Industrial Training Ship "Mount Edgcumbe." {British Medical Journal, 1st March.) "The first case occurred on January 31st, and the subse- quent progress of the epidemic was as follows : — " February 2, 6 fresh cases. „ 4, »> ^> ,. 6, 8 16 16 16 I 438 EPIDEMIC OF 1889-90 "February 7, 10 fresh cases. )) 8, 4 9 t-> j> "^1 ' J) J) )) 10, ,, 11, 1 ,, — 85 in all, out of 196 boys, or 43 per cent. The ages of the boys ranged from 12 to 16, and the average duration of the attack was three days. Four of the officers out of twelve were also attacked, and Dr. Preston, the medical officer in charge, remarks on the greater severity of the pain in the adults as compared with the boys. " Dr. Preston tabulates the symptoms thus : — " Frontal headache , 49 Pain in head, back, and limbs 20 Pain in head and chest 7 Pain in head and epigastrium 3 Papular rash 3 Herpes labialis .... 4 Sickness at onset 3 Sore throat .... 5 Cough 10 Eyes suffused .... 14 Running from nose 7 Relapses .... 3 Complications (catarrhal pneumonia 11 days after commencement of attack ) 1 i Dr. Gilbart-Smith has prepared the following return of the number of those who applied for relief in the out- patient department of the London Hospital on account of influenza : — Male. Female January 1, 37 50 2, 45 38 3, 62 49 4, 76 58 5 (Sunday), 27 46 6, 161 194 7, 160 256 8, 148 138 9, 51 62 10, 47 55 11, 62 34 12 (Sunday), 22 21 STATISTICS Male. Female January 13, 73 81 , 14, 44 80 , 15, 76 74 , 16, 53 68 , 17, 54 57 , 18, 41 40 19 (Sunday), 20 13 , 20, 48 65 , 21, 27 9 , 22, 15 21 , 23, 23 26 , 24, 16 15 25, 11 14 26 (Sunday), 6 4 , 27, 14 33 , 28, 13 20 , 29, 1 24 30, 12 18 , 31, 14 18 439 He remarks that some uncertainty prevailed as to when patients first presented themselves at the London Hospital with symptoms of influenza, owing to the fact that the earlier cases probably passed unrecognised. Taking, however, such symptoms as pyrexia, cold, pain in back, weakness, etc., as indicative of the complaint being influenza, the date of the earliest cases, according to Mr. Eobertson, the receiving-room officer, may be taken to be between the 20th and 2 2d December, the number of cases at that time being about a dozen daily. This continued until the 30th December, when the number suddenly increased to 86 (46 males and 40 females). The following table gives the deaths from zymotic and respiratory diseases, phthisis, circulatory diseases, and in- fluenza, as given in the Eegistrar-General's Eeport : — Weeks ending 7, December 14, 21, 28, 4, January 11, IS, 25,': February 1, 8, Zymotic . 181 155 170 170 203 199 193 160 134 148 Respiratory 432 552 518 467 843 1069 1010 736 550 485 Phthisis . 161 182 161 180 247 267 312 239 220 209 Circulatory 165 163 189 158 222 275 209 193 116 154 Influenza 4 67 127 105 75 38 From an interesting analysis of cases with dates, contributed to the British Medical Journal (March loth, 1890) by Mr. E. 440 EPIDEMIC OF 1889-90 C. Barnes, of Hammersmith, we gather that the first case oc- curred December 28th, 1889, aud tlie last February 21st, 1890 — a period of 8 weeks. No fewer than 140 of the cases were in the 8 days from January 3d to 10th. One hundred and eleven cases (53 males and 58 females) were private patients, 52 were policemen at Hammersmith and Shepherd's Bush, 3 6 were Post Office employees (letter carriers and telegraph messengers), 91 were resident in the Convent of the Good Shepherd. This gives 141 males and 149 female patients. The 111 private patients include 14 children under 1 2 years old, one being a small twin infant of 9 months. The rest of the private patients were between the ages of 12 years and 75 years. In the table he places the police in two columns, because there is nearly one mile and a half distance between Hammer- smith and Shepherd's Bush Stations. He also places the convent inmates in three columns, because the Sisters, Magdalens, and Penitents occupy different parts of the house, and have but little to do with one another, except for nursing in sickness. The Convent inmates are 260 "\ „ Hammersmitli police ,, 124 ( 179 were attacked. „ Sliepherd's Bush „ „ 77 | 27-3 per cent. „ Post Office employees ,, 193 J All recovered, if we except the only patient who has died since, under the following circumstances — for it is doubtful if her death in any way resulted from influenza — A girl at the convent, aged 23, unhealthy, strumous, and ansemic, who had one eyeball removed a year ago at West London Hospital, had influenza on January 3d, wdth eight of her companions. All apparently recovered equally well, and she was not under treatment more than ten days. She had resumed her work, and manifested her usual activity and good spirits until 1 A.M. on February 3d, when she complained of pain and dyspncea, and died before 8 a.m., when he was sent for. Post-mortem examination revealed right pleuritic effusion, pericardial effusion, and congestion of right kidney. STATISTICS 441 Table 0/290 Cases of Influenza. Pate. Cases. Police (52). Convent (91). It PL, Ed 1^ ■< 00 > H 5 § ■«! PM is xpq i CQ 1 1889. Dec. 8 1 1 „ 11 2 2 „ 20 1 1 „ 28 . 2 1 1 „ 30 . 5 5 „ 31 8 3 3 2 1890. Jan. 1 . 4 1 3 2 5 2 3 03 r ,. 3 . 28 3 1 2 3 9 3 7 4 10 5 2 2 1 00 „ 5 . 1 1 _c „ 6 . 21 2 3 "7 9 CO ., 7 . 14 2 1 11 to „ 8 . 28 5 4 "8 2 9 O „ 9 . 14 4 4 6 o „ 10 . 24 1 "4 16 2 1 >-H „ 11 . „ 12 . 9 6 2 4 2 5 2 „ 13 . 10 "2 3 "3 2 „ 14 . 13 1 2 4 6 „ 15 . 8 1 4 3 „ 16 . 12 2 1 3 '5 1 „ 17 . 6 2 3 „ 18 . 3 "1 2 „ 19 . „ 20 . 1 2 i 2 „ 21 . 9 i 1 1 6 „ 22 . 4 i 3 „ 23 . 1 1 „ 24 . 4 3 1 „ 27 . 4 4 „ 28 . 2 2 „ 29 . 1 ... 1 Feb. 1 . 1 1 „ 2 . 1 1 ., 4 1 1 „ 7 . 4 '4 „ 8 . 4 2 '2 „ 9 1 i „ 10 . 6 5 i „ 12 . 5 "2 2 1 „ 15 . 1 1 „ 18 . 3 "3 „ 21 1 i 290 31 21 15 7 69 36 111 Private patients include 1 child of 9 months, 13 children under 12 years ; tin rest are from 12 to 75 years. 442 EPIDEMIC OF 1889-90 The sudden pressure of so many cases fell hardly upon him, for he was himself ill with influenza on December 28th, and before he was convalescent he was pressed by as many as 28 new cases in one day, January 3d, the first day of the eight above alluded to. With reference to the period of incubation and contagion, he observed that the Hammersmith police fell in quick suc- cession day by day; the Shepherd's Bush police and the Convent patients at intervals of from 3 to 7 days. The Posi Office cases were scattered in residence at long distances apart, but one telegraph messenger fell on January 6th, and his brother on the 13th. In private practice he found — In 4 families, 2 cases in each, both ill same clay. 3 ,, 1 case „ and another after 1 clear day. 1 family 2 cases „ ,, two others „ 1 „ „ 1 ,, 2 „ „ ,, another „ 2 clear days. I ,, 1 case ,, „ „ „ 6 „ „ II 4 3 families 1 „ „ „ „ „ 6 „ „ . „ /" 4 cases in 1 family, Jan. 7th, 9th, 12th, 15th. orthrr J " " " " 6th (2 cases), 9th, 11th. davs' interval ) " " " ^*^ ^^ ^'^"'')' " " aays interval ^ ^^ ^^ j^^^_ 20th, Jan. 7th, 10th, 28th. 8 cases in 1 family, Dec. 30th (2), Jan. 1st, 3d (2), 12th, 18th, 28th. 2 „ „ " Jan. 3d, 24th. 2 „ „ „ 7th, 29th. 3 „ „ „ 10th (2), 21st. . The same tendency to haemorrhages (nose and lungs) was noted, and two patients developed orchitis. A rash was not unfrequent, being like that of scarlet fever but generally paler and brighter in colour, more like an erythema, the forehead and face often being oedematous. It was in several instances followed by desquamation. Dr. Hubert C. Bristowe {British Medical Journal, February 2 2d, 1890) gives some notes on the outbreak as it presented itself at King Edward's School for Girls, and his observations are interesting as showing the behaviour of children to the malady. The institution contains in all 240 girls, varying from the age of eleven to sixteen ; of these 175 were affected, making about 73 per cent of the total number. Two mis- tresses are also included in this number. Before January l7th STATISTICS 443 there had been one or two cases, of which, however, no special notes were taken. On the morning of January l7th there were 4 cases, by the 20th there were 76, and by the 24th, 162 ; after which only a few cases appeared daily till the 29th, since which date there have been no fresh ones. These girls spend a great deal of time in the open air, but only in the grounds connected with the schools, and have practically no communication with the outside world, except through the mistresses and medical officers, who might, of course, have carried the infection. In almost all cases the disease was mild, and there were no deaths amongst them. After epitomising the symptoms. Dr. Bristowe goes on to speak as to the rash. Besides what appeared to him to be the true rash, in seventeen cases there was labial herpes. In thirty-six cases, or over 2 per cent, there was a distinct rash ; it was papular in character, the papules being slightly larger than the darker elements in the rash of scarlet fever, and of much the same colour. The papules often contained serum, which occasionally became purulent. The skin round the papules was of a bright scarlet colour. In most cases the rash was confined to the face and neck, though it often appeared on the arms and hands as well, and in two cases on the shoulders and chest ; it itched a good deal, and generally after two or three days the bright colour faded and it became scaly. In one case the rash ex- tended all over the neck, chest, legs, shoulders, and arms, and was at the time thought to be that of scarlet fever ; but the temperature never rose above 100°'4, and the other symptoms of influenza, including pains in all the limbs, were present. There was no sore throat, and the tongue was only slightly furred. In two days the rash had almost completely gone. A simple erythematous blush on the face was present in nine cases. In the cases in which the rash was best marked no drugs had been given, the rash appearing as one of the earliest symptoms. In the other cases salicylate of soda, in 2-| grain doses, had been given three times a day, and only in cases in which the temperature had been high was antipyrin given, and then only in small doses of 2 grains. In all cases the symptoms rapidly subsided, the worst symptoms — that is, pain and high temperature — being over in 444 EPIDEMIC OF 1889- two days, the watering of the eyes generally lasting two days longer, and convalescence was completed in a week, except in the nine cases of bronchitis and the three of pneumonia. Weakness and giddiness were greatly complained of during the first day or two of convalescence. The author tabulates the result of bis observations as follows : — Total. Per cent. Headache 175 98-305 Backache ....... 25 14 124 Sideache ....... 27 15 254 Chest pain 6 3 338 Stomach pain 13 7 344 Leg-ache 29 16 384 Arras-ache ....... 2 1 130 General pain ....... 176 99 435 Watery eyes 170 96 000 Sick 61 34 463 Bowels normal 127 71 751 ,, confined ...... 19 10 734 .,, diarrhoea 21 11 864 Tongue normal 19 10 734 ,, furred 73 41 243 ,, red and dry 7 3 954 ,, pale and flabby ..... 78 44 067 Rash, herpes labialis 17 9 600 ,, erythema 9 5 085 ,, papular 36 20 339 Lungs, cough 72 40 676 ,, bronchitis ...... 9 5 085 ,, pneumonia ..... 3 1 700 Sore throat 5 2 825 Epistaxis 4 2 260 Drowsiness 9 5 085 Face pale 34 19 709 ,, flushed 143 80 800 Shivering Total Total in schools .... Per cent affected .... 4 2-260 177 240 73-75 Dr. Alder Smith, medical officer to Christ's Hospital, reports that altogether upwards of 200 boys were aiffected, equal to 33 per cent. There were no cases of pneumonia as a com- plication, but in several instances the lads were too debilitated to return to school. STATISTICS 445 At Messrs. Spottiswoode's establishment we learn that the number of men absent on account of influenza was as follows: — Statistics at Messrs. Spottiswoode's No. of Cases. December 28, 1889 ..... 8 January 4, 1890 125 „ U, „ 150 » 27, „ 12 A fortnight later the disease had practically disappeared. It is observed that the distribution was very erratic, the malady not affecting men working side by side, but attacking them indiscriminately. The out-door messengers suffered, if anything, rather less severely than those employed in-doors. In his report for the first quarter of 1890, Dr. Cameron, the medical officer for the borough of Leeds, gives figures showing the extent to which influenza prevailed in Leeds. He says : " While the mortality from the seven zymotic diseases has been below the average mortality of the twenty- eight large towns, the mortality from diseases of the air passages has shown a marked increase on that of the corresponding quarter of 1889. The deaths from consumption in the first thirteen weeks of 1889 were 155, and in the corresponding part of the present year they were 189, an increase of nearly 22 per cent. From other diseases of the air passages the deaths in the first quarter of 1889 were 432 ; during the quarter ending 29th March, including those from influenza, they were 800, corre- sponding to death-rates respectively of 4"85 and 8'83 per 1000 of the estimated population, or an increase at the rate of 82 per cent on the rate of mortality from this group of diseases. He observes that the prevalence of influenza in the borough during the quarter accounts largely for the excessive mortality from this group. Commencing with a few sporadic cases in the last week of December, the disease did not attain any great hold upon the town till the close of January. The number of new cases of influenza which came under medical treatment during the seven weeks ended 15th March, as re- turned by thirty-eight medical gentlemen out of 144 in practice in the borough, was 1773. Dr. Cameron thinks it would be tolerably safe to conclude that somewhere about 7000 cases of 446 EPIDEMIC OF 1889-90 influenza came under medical treatment between the 26tli January and tlie 15 th March ; and as these were by no means the dates of either the commencement or the conclusion of the epidemic, and as the cases treated by medical men would form but a small part of the whole of the cases, he does not think it would be an over-estimate to suppose that some 50,000 cases of influenza occurred in Leeds. COLCHESTEE MILITAEY HOSPITAL Supplied hy Surgeon R. Caldwell Admissions for Influenza - 1890. OflBcers. Men. Women. Children. 1890. Officers. Men. Women. Children. Jan. 1 3 Brought "1 forward / 6 331 10 18 , 2 8 Jan. 14 9 2 4 , 3 43 „ 15 1 11 4 , 4 1 29 2 4 „ 16 7 1 , 5 1 41 2 5 „ 17 1 2 2 , 6 1 41 1 3 „ 18 5 , 7 1 49 2 3 „ 19 2 , 8 41 3 1 „ 20 1 , 9 18 1 „ 21 i 3 1 , 10 26 1 ,, 22 2 1 , 11 2 14 „ 24 1 "i , 12 8 Feb. 4 i' , 13 10 „ 7 1 Carry \ forward / 6 331 10 18 Total . 13 365 20 31 Average ") strength V per cent j 86 15 2512 14 217 9 403 7 In the Glasgow City Police Force (numbering about 1000 men), Dr. M'Gill reported that during the five or six weeks of the epidemic the sick -rate rose from 3 per cent (the average) to 8 per cent at the maximum (January 21st), the average duration of absence being 9 days (5 to 15 days). In the barracks at Maryhill, with an average strength of 24 officers, 800 non-commissioned officers and men, 81 women, THE COST OF THE EPIDEMIC 447 and 159 children, only thirteen cases were reported between the 14th and the 21st January. At the prison in Duke Street, Dr. Sutherland reported 15 cases of influenza in the 31 days preceding January 20th, 1890, besides 22 of coryza which may or may not have par- taken of the epidemic influence. The total population among which these cases occurred numbered 1280. Five of the 15 cases occurred among the temporary inmates (1140), and 10 among the attendants and their families (140). At the Boys' Eeformatory at West Thorn, Dr. Scott, of Toll- cross, gives the following figures of the number of cases under treatment, bearing on a population of 200 inmates, from December 2 0th- 2 7th, 1889 : — ber 20 2 December 24 . 52 „ 21 . . 20 „ 25 . . 22 „ 22 . . 76 „ 26 . 9 „ 23 . . 96 „ 27 . 4 According to this observation the outbreak in Scotland considerably antedated its appearance elsewhere. At the Eoyal Asylum for the insane at Gartnavel, Dr Yellowlees recognised 30 cases of varying severity, only 3 of which occurred anions; the insane, who are, as a rule, little susceptible to epidemic influences. At the Eoyal Asylum, Morningside, Edinburgh, Dr. Clous- ton reports that out of a total population of 990, 11 per cent had the disease, or, including officials, servants, etc. (170), 25 per cent have suffered. There were five deaths due to broncho-pneumonia, occurring in weak and elderly patients. At Galashiels, where the proportion of cases is reported to have been unusually large (60 to 70 per cent), it was remarked that the workers in the dye-works were comparatively exempt, only 7 per cent having been affected. THE COST OF THE EPIDEMIC According to Mr. Smee, the chief medical adviser of the Gresham Life Assurance Society, we may assume that the insurance companies and friendly societies will have paid for 448 EPIDEMIC OF 1889-90 increased mortality and increase of sickness not far short of £1,000,000. He claims to have made this statement from facts wliich have come under his own immediate notice. The editor of Unity, the organ of the friendly societies, states that the two great Orders have been paying £5000 per day, and the London District of Foresters alone has paid £300 per week for death claims, and the Hearts of Oak in one week in January had 8715 claims. In addition to this, he is of opinion that the loss of earning power by loss of wages, dis- organisation of business and factories, cannot be much less than another £1,000,000, and the total cost is not unlikely to have reached £3,000,000 before the epidemic finally left these shores. From facts which are in his possession, he believes that he is understating the case when he assumes that over 8 per cent of the total population of England has been attacked. The outbreak of influenza among the labourers of Kent during the weeks of epidemic cost the Labourers' Union in sick pay at the rate of £600 a week; while, as showing the incidence of the epidemic among medical men, the returns of the Medical Sickness, Annuity, and Life Assurance Society, for the quarter ending March 25th, 1890, indicate a marked increase in the number of claims. Dr. J. Beresford Eyley, consulting physician to the Hearts of Oak Benefit Society, which numbers 130,000 adherents, has been good enough to ascertain that the amount dis- bursed as sick pay for the quarter ending March 27th was .£61,000, as compared with £35,000 for the corresponding period in 1889. The maximum was reached on January 23d, when there were 9074 members on the fund, as against 3964 on the same date in January of the preceding year. The cost of the epidemic to this society is thus represented by an excess of disbursements amounting to £26,000. While these figures are remarkable evidence of the cost of the outbreak to the community, the experience of the Health Assurance Corporation, a sickness and accident in- surance society, is still more striking. The claims in January 1890 were five times, and in February four times, as numerous as in the corresponding periods of the year preceding. INFLUENZA IN SCHOOLS 449 INFLUENZA IN SCHOOLS The discussion which was initiated by the author at the April meeting of the Medical Officers of Schools Association possesses a special and pecuKar importance as showing the extent to which the epidemic affected the inmates of schools. It has therefore been thought desirable to give the abstract report as it stands, representing as it does the experience of responsible medical men, having imder their immediate observa- tion a very large number of children of both sexes, and belong- ing to aU classes of society. After reviewing the origin, course, or principal features of the epidemic, the author asked for information as to the pro- portion of children affected, as to the symptoms and duration compared with adults, and lastly as to the transmissibility of the disease by contagion or otherwise, and the possibility of preventing its spread in schools. Mr. Adams Clarke, of Bushey (Herts), said that at his school, out of 600 children, he had 157 cases of influenza marked enough to find their way into the infirmary. There were probably many other cases that escaped attention. The first case was noticed at the end of December, the outbreak attaining its maximum during the month of January, and it was stiU. going on (April 1890). As late as the preceding Saturday the head nurse had contracted the disease. The later cases had been the more severe. Of these 157 cases two had proved fatal, one from pneumonia, and one from meningitis. He remarked on the much more rapid course of the disease in children as compared with adults. He had been unable to make up his mind as to the question of contagiousness. It first appeared amongst the boys, then among the girls, and then among the infants. It was not confined in the beginning to special dormitories, nor did it spread at once to those in most im- mediate contact with the sick. He could not speak positively as to the period of incubation, but he thought it was probably from three to five days. One attack certainly did not confer an immunity. He had seen many relapses, and in most cases the second attack was the more severe. He had seen several cases of severe and even alarming dyspnoea, but in every in- 2g 450 EPIDEMIC OF 1889-90 stance it liad yielded to ordinary treatment. He regarded rest in bed as the most necessary part of the treatment. Most of the cases recovered within three days, whereas in adults the dura- tion of the attack was much longer. The absence of subsequent prostration in children was itself a rather remarkable feature. Dr. Statham, of the Foundling Hospital, explained that the boys were located in one wing and the girls in another, while there was a mixed school for the two sexes. The epidemic commenced on January 2d and ended on or about February 3d. It commenced in the boys' wing, and for a time was limited exclusively to that side of the building. Most of the cases were from the infant school where the sexes were mixed. Then it broke out among the girls, and the number soon equalled that on the boys' side. Altogether they had 95 cases — 47 boys and 48 girls — out of 317 inmates. The officers and servants numbered 32, of which number 10 were affected, being about the same proportion as among the children. As a rule the children recovered in three days. In two of the cases he gave no medicine at all, and these seemed to do better than those in which he had administered antifebrin. With reference to the action of antifebrin, he observed that in two cases it had given rise to remarkable depression of the pulse rate, reducing it in one instance from 120 to 76 pulsations per minute. One of the girls took ten grains of antifebrin three times a day and continued the medicine longer than he had intended, and she developed cyanosis, headache, and an inter- mittent pulse. These symptoms, however, passed off under ammonia and bark. This epidemic was followed by one of measles, which attacked 107 of the children ; 3 5 of those who contracted measles had previously had influenza. One girl who had had influenza eight weeks before, developed chorea, and on the fourth day the rash of measles appeared and the chorea ceased. He remarked that eight young women were employed in the laundry, and none of these took the influenza. They liad two cases of very severe dyspna3a with cyanosis, but this symptom, alarming as it was, disappeared by the following day. Dr. Armstrong, of Wellington College, said that at Easter of last year (1889) he had seen a local epidemic of undoubted influenza in a neighbouring private school. There were 42 boys INFLUENZA IN SCHOOLS 451 with 17 cases, and of that number 7 developed pneumonia, but all recovered. With reference to the question of contagion, he had come to the conclusion that it was distinctly contagious, if indeed this was not the only method of transmission. He had seen several cases which distinctly proved contagion. The disease was introduced into the neighbourhood by one of the masters' wives, who came down from town on Friday, 28th December, and had been seized with shivering and headache in the train. In spite of this she fulfilled an engagement to dinner that evening, and both the gentlemen who sat on either side of her were the next to develop the malady. He himself was the next to succumb, and he felt sure he had contracted it from one of these gentlemen with whom he had sat for two hours. A boarder at the college got it on Friday, and on the succeeding Monday the wife and child- ren of the head master were down with it. Nearly all the boys in the sanatorium got it, and in most cases one could trace an interval of four or five days between exposure to condensed poison and their taking the disease. All the j)ersons engaged in the sanatorium got it — seven in number — and it was nothing like so severe among the staff employed in the other parts of the building. Altogether 130 boys were down with it, and lie saw in addition 130 cases outside, but of them all only one developed serious lung symptoms. The question of the rash had a particular interest to him, since it was a difficulty which might prove serious to them as medical officers of schools. He saw a good many cases of rash, most of them of the herpetic form. In one instance, however, it was papular, and was followed by very marked peeling — more so indeed than he had ever seen after scarlet fever. He consulted with the Medical Officer of Health, and they agreed to suspend their diagnosis, keeping the patient isolated in the meanwhile. Peeling was complete on the 23d day, which he said was never the case with scarlet fever. In another case a boy had a high temperature, 104°, and the next day developed a measly rash. The lad was isolated, and the rash ran its course. With it there was profound prostration, sordes, rheumatism in all the joints, etc. The next day, however, he was comparatively well. He thought it would be very useful to collect the mortality rates for schools. 452 EPIDEMIC OF 1889-90 Dr. Eichards, of the Hanwell Lunatic Asylum, explained that although he was not attached to a school he had a large number of grown-up children under his care. The total number of patients in the Asylum was 1894, of which 1142 were on the female side, over which he had control. They were subjected to a very severe epidemic of influenza, which came on during the second week of January, the nurses and the staff being affected in the first instance. There was a definite period of time between the staff being attacked and the outbreak among the patients. Out of 144 attendants on the female side 63 were attacked, or 43 per cent. He only in- cluded well-marked cases in this number, excluding the doubtful cases, of which there were a good many. On the male side, out of 73 attendants 30 were attacked, or 43 per cent. Of the 1142 patients under his care 178 suffered, or 16 per cent; while on the male side only 40 out of 753, or 5 per cent, contracted it. He thought this fact was of some little interest, because it had been supposed that persons who were much in the open air were more liable than others to contract the disease. His observations seemed to prove the contrary, for while the male patients were engaged mostly in outdoor work, the females had been obliged to stay at home in consequence of the large number of attendants who had been disabled. He fancied from the distinct interval between the occurrence of cases of the disease among the nurses and the outbreak among the patients, that the latter must have caught it from the former, and that the nurses had brought it from outside. At the end of the epidemic it seemed to him as if a pandemic wave had gone over the place, smiting down a certain proportion of the inhabitants, subsequently spreading to the others. They had the ordinary types of the disease, the most marked being the nervous symptoms. The general view as to the influence of depressing emotions was not exactly borne out among his patients, for most of them were dements and had no emotions at all. He had noticed a rash in a large number of the cases very like that of scarlet fever, but none of the children in the Asylum had caught the disease. Dr. Squire said he had noticed several rashes, and in one case the skin split and came off. At the same time there INFLUENZA IN SCHOOLS 453 were some herpetic spots. The rash was distinguished from scarlet fever by the fact that it was not very marked at first, and disappeared earlier than would have been the case had it been scarlet fever. The measly rash was a little more difficult to deal with, except that it came out at an earlier period of the disease. He did not think that there was any relation- ship between the influenza and any subsequent epidemic of other diseases. He observed that antifebrin was a very dangerous drug, and was far more depressing than antipyrin. He had seen three instances of relapse in persons who were most carefully nursed. In two cases the disease had ap- parently been contracted in passing through London, the symptoms developing two days later. In several instances the persons first attacked were the only ones in the family who suffered. He thought that the appearances pointed to malaria. Dr. Alfred Brett, of the London Orphan Asylum, said that they had 500 iamates, of whom 70 boys and 30 girls did not go home for the holidays. None of these contracted the complaint. The absentees returned on January 13 th, and the very next day one of the boys developed influenza, then after an interval of a few days some of the others were down with it, followed still later by a general outbreak. Altogether they had 115 cases out of the 500, equal to 25 per cent. Only four among the staff, which numbered 80, took the disease. At the beginning of the year the Local Government Board sent down a series of questions to be answered, and they made a weekly report of the progress of the epidemic in their neighbourhood. He had gone very carefully into the matter with Dr. Parsons, and they came to the conclusion that contagion could be traced. There were several cases of children suffering from hip-joint disease, etc., in the infirmary, and curiously enough none of them took it. So far as his experience went, the period of incubation was rather less than five days, nearer two. With respect to treat- ment, the patients were kept in bed four days on a light diet. Antipyrin was given if the temperature exceeded 102° F. He had only two cases of pneumonia and seven relapses. He had seen a few rashes, but nothing of a very definite character. The proportion of cases in the school was greater than obtained in the town, where it did not exceed from 10 to 15 per cent. Many of the cases appeared to date from a visit to London. 454 EPIDEMIC OF 1889-90 The onset was sometimes very sudden, attacking persons half way on a journey and obliging them to return. He had two deaths from pneumonia in private practice. Dr. Lever suggested that they should ask themselves what were the lessons that had to be learned from the history of the epidemic. He had noticed a case of sudden loss of memory which was not traceable to any other cause. He did not think that the course of the epidemic pointed to contagion, and speaking as a medical officer of schools, he thought it was at most only slightly contagious. He knew of cases in which the husband had it, and the wife who nursed him escaped. On the other hand, he had seen it spread through a family from one first case. The great question was as to whether it was necessary to adopt any quarantine measures in regard to the spread of the disease in schools. Dr. C. E. Shelley, of Hertford, pointed out that so far as statistics went, not more than 2 per cent of the boys who went home from Christ's Hospital had suffered from the disease, but when they reassembled there was an outbreak which assumed considerable proportions, 60 x^er cent of the boys having been down with it. One might indeed regard the school as filled with explosive material with some slow matches in it. Dr. MacAlister had told him there were 70 cases at St. John's College at Cambridge. At first the infection went by sets of rooms, but after a time the men went down irregularly. There was only one death, and that occurred in a young gentleman who was suffering from Addison's disease. The disease depended a good deal on the resistance of the individual, both in regard to escaping the disease and in modifying its character. He had seen persons who took large doses of nux vomica as a prophy- lactic. Some of them had a severe attack, but recovered com- pletely within eight hours. A rash of some kind was common on the cheeks and neck, in some instances markedly papular. He had noted the occurrence of epistaxis on several occasions during convalescence. Moreover, they had had more rheu- matism in the neighbourhood of Hertford than had been seen for years, also an unusual number of cases of jaundice. He had seen 25 cases of jaundice in ten days in private practice, and he had heard that schools had had to be closed on account of this epidemic of jaundice. Another point that had attracted INFLUENZA IN SCHOOLS 455 his attention was the prevalence during the last few months of alopecia areata, but whether this was due to mere debility or indirectly to the influenza he could not say. The contagious- ness of the disease had been admirably shown, as for instance in the case of some ladies living in an isolated country house, with no case of the disease within four miles. One of them had been to see her dentist in town, who was himself struggling in the throes of an attack, and the very next morning she was utterly prostrated with the complaint. His impression, after observing 400 cases, was that severe cases were capable of infecting others, but that the zone of infection was a narrow one. Moreover, the period of contagiousness was soon over, A paper read by Dr. Thresh, medical ofiicer of health for the Chelmsford and Maldon E. S. Districts, on the epidemic as it affected public elementary schools in the Chelmsford and Maldon E. and W. S. Districts, casts a further light on this interesting and important branch of inquiry. The total area of these Districts is about 300 square miles, and the population about 57,000. Early in March a circular letter asking for certain information was sent to the head master or mistress of every Parish School, and after receipt of the replies many districts were visited in order to verify state- ments or obtain further particulars. In this manner particulars have been obtained from 74 schools, varying in average attend- ance from 30 to 200, and embracing altogether about 6000 scholars at ages ranging from 4 to 1 3 years. The district is a purely agricultural one, is almost entirely on the London clay, very flat towards the east and south, more undulating near centre and in north and west. About the time of the invasion by the influenza, whooping- cough was very prevalent in many parishes, measles had broken out in one parish, and there was a considerable amount of sickness amongst children generally. In mid-December one school was closed for lack of scholars. Nearly all were ill, and a medical man who was consulted said the sickness was of an indefinable character, the symptoms being slight feverish- ness and malaise, sometimes associated with nausea or cough and catarrh. Many other districts suffered in a similar manner and caused the teachers to assert that the infhienza was 456 EPIDEMIC OF 1889-90 prevalent early in December or even in November. In one group of parishes at extreme N.W. of his districts, the master of each school gave mid-November as the date of invasion, and the report from one village was so definite that he was inclined to fully investigate the matter. The schoolmistress of Pleshey stated that the epidemic commenced on 18th November 1889, and reached its acme in the last week of that month, that the school children suffered severely, but especially the infants. About half the children were attacked. That recently the epidemic had returned, but was attacking adults only. The medical practitioner who attended many of the early cases believed that two-thirds of the children in the village were attacked. The children were taken ill in rapid succession, the symptoms being fever, headache, cough, and bronchitis, little or no limb pains, and rarely any catarrh of eyes or nose. Several deaths occurred from bronchitis and broncho - pneumonia. Similar cases occurred in all the surrounding villages. The true influenza invaded the village in February and attacked a large proportion of adults but very few children. Dates when schools were first affected. — The date of the week-end during which the influenza first made its presence felt amongst the school children in each school having been ascertained, he found there was only evidence of three parishes being attacked prior to week ending 3d January 1890. The dates for the parishes are given in the following table : — ate of week-end. No. of parishes attacked. Total number in which influenza appeared. January 3 •.. 3 „ 10 9 12 » 17 25 37 „ 24 6 43 „ 31 3 46 February 7 4 50 „ 14 2 52 In four parishes very few cases have occurred and no date can be given, and in one parish no case has been recorded. During January it was a common occurrence for children to be suddenly attacked in school with nausea or vomiting, headache, fainting, etc. The rapidity with which the epidemic reached its acme INFLUENZA IN SCHOOLS 457 varied in an extraordinary degree. In some cases the schools had to be closed for lack of scholars within a week from the onset, in others no acme was discoverable, a few cases only- occurring at a time. In one large village only about a dozen children had the influenza, whilst the adult population suffered severely. As at Pleshey, the invasion of the adults did not take place until February. In a few other villages the epidemic seems to have shown a marked preference for those above school age. In those cases where the school attendance was consider- ably affected, the period which elapsed between the onset and the reduction of the attendance to a minimum is given in the following table : — between onset and acme. No. of parishes. 1 week 13 2 weeks 13 3 weeks 7 4 weeks and over 6 In the majority of the cases in which the acme was reached within a fortnight the onset was during the week ending l7th January. Where the acme was later the outbreak was usually reported to have occurred earlier. This would seem to indi- cate that the type of the disease in those districts in which it first appeared was not so virulent as in the districts invaded a week later. The proportion of children attacked is given in the sub- joined table : — No. of parishes. Proportion of children attacked. 7 Less than 5 per cent 4 „ 5-25 „ • 18 „ 25-50 „ 28 Over 50 „ The length of time which the children were away from school varied from 2 days to 2 or 3 weeks. About 3 or 4 days seems to have been the average. The Boys', Girls', and Infants' Departments seem on the whole to have been pretty equally affected, though the reports from different districts varied considerably. In some places 458 EPIDEMIC OF 1889-90 the boys had suffered most, iii others the girls, and in still others the infants. In nearly all cases the teachers observed afterwards in the children a " general weariness and lack of interest," which made teaching for some weeks a most disheartening task. Dr. Thresh estimates that not less than one half of the population in these districts under 15 years of age (estimated at 16,000) were victims of the epidemic, yet only 3 deaths below this age have been certified as due directly to the disease. This would give a mortality of 4 per 10,000 cases. He estimates the excessive mortality during the 3 months ending 31st March of children under 15 as being such that, if all of it be attributed to the direct or indirect influence of the epidemic, the mortality would be 4*5 per 1000. Mr. H. r. Elliot gives the following details of the epidemic of influenza which occurred at the Infant Orphan Asylum at Wanstead, which commenced on 15th January 1890, and terminated on or about 12th February 1890 : The total number of children in the institution was 553, and the total number attacked was 164, including 22 pupil teachers and servants. The school is divided into seniors, infants, and nursery children. All children under 5 are styled "nursery children," while those over 5 but under 8 are described as " infants," those above 8 and under 1 5 are " seniors." Number of cases in each division — Nurserj' ..... 4 out of 28 Infant Children . . . 12 out of 162 Senior Boys . . . . 110 out of 227 Senior Girls . . . . 16 out of 136 Staff 22 out of 86 Comiilicaiions — Out of the total number 3 suffered from acute rheumatism. 1 „ from broncho pneumonia. 1 „ from hypnotism. Average temperature 101° to 102°. Average period of incubation seemed to be from 12 to 24 hours. INFLUENZA IN SCHOOLS 459 With the above exceptions, in no single case did the temperature exceed normal on the following morning. In all cases the tongue presented a foul appearance, breath most offensive, severe frontal headache, pain in thighs and calves of legs. A very few complained of pain in the lumbar region. There was no diarrhoea, but occasional vomiting. The average absence from school was four days. The rheumatic fever cases supervened some few days after they had convalesced from the influenza, and were accom- panied by a great many typhoid symptoms — tongue parched and presented a glazed appearance, teeth coated with sordes, excessive sickness and delirium, tenderness over abdomen and diarrhoea. One boy had nearly every point at one time or another affected. He also suffered from pericarditis ; in his case the delirium was very great, and he presented a most cadaverous appearance, but ultimately recovered. Another lad was also most dangerously ill, and suffered much from the hips and knees, but had no cardiac complica- tion, although the heart's action was for a considerable period much accelerated. Some three wrecks after he was attacked with rheumatism. Very considerable swelling of the left thigh set in, the difference between the right and left exceeding five inches, particularly tense, and accompanied by very great pain, appeared to be due to an attack of thrombosis, and the prog- nosis seemed most unfavourable. Numerous leeches were applied ; fomentations were kept on day and night well sprinkled with laudanum. About a fortnight afterwards, fluctuation being distinctly marked, he aspirated and removed about ten ounces of most offensive pus, but as it rapidly refilled, he determined to make a free incision, and placed a fair-sized drainage tube, which gave great relief to the symptoms, and the boy ultunately did well. The broncho-pneumonia case presented no unusual symp- toms. A boy who suffered from somnolence, aged ten years, was sent over to the infirmary suffering from the prevailing epidemic, but in his case the temperature registered 104°, tongue parched, teeth coated with sordes, no delirium, but most profound sleep, was with difficulty roused to take liquid or relieve bladder, did not after the first day complain of pain anywhere ; anticipating brain mischief, he had liis hair cut 460 EPIDEMIC OF 1889-90 close, applied ice compresses, and had the bowel well cleaned out. On the fourth day the temperature suddenly came down to normal ; the boy awoke, said he felt perfectly well when asked how he felt, and had no further disturbance whatever. The shortest case of incubation occurred in regard to the secretary of the institution. He had occasion to go over to the infirmary in the morning at 10 a.m., and whilst talking to the nurse, who was suffering from the epidemic, was much affected at the state of her health, but thought no more of it at the time, went to his ofiBce feeling perfectly well, trans- acted business till four o'clock, then, affected with severe frontal headache, came home to Marlsbrook, and at seven o'clock same night was very ill, temperature 103°, and all the usual symptoms. Next morning temperature normal, but felt utterly weak and good for nothing. This case was followed by a sharp attack of articular rheumatism. OBSERVATIONS ON THE SPREAD OF INFLUENZA In an interesting contribution to the Practitioner (April 1890) Dr. Sheridan Delepine, of St. George's Hospital, dis- cusses the question as to whether influenza is to be considered a contagious or a miasmatic disease. He admits that the records of previous epidemics had led him to regard the malady as of a miasmatic nature, and he mentions, as bearing on this point, that during the first three weeks of January almost all the specimens of urine which he had to examine became rapidly turbid, owing to the growth of bacteria of all sorts, a pheno- menon which, he observes, is very seldom the case, especially at that time of the year. Between the 8th and the 18th of January, only one out of 14 specimens remained tolerably clear, and this fact acquires additional interest from the fact that Sir Andrew Clark, whose attention was called to the fact, remem- bers a similar state of things during the cholera epidemic of 1866. It is worth noticing too, if only a titre de renseigne- ment, that this period of unusual tendency to decomposition on the part of the specimens of urine coincided with the period during which the number of deaths attributed to influenza reached its maximum. OBSERVATIONS ON THE SPREAD OF INFLUENZA 461 He gives very detailed notes of two cases of influenza between the 18 th and the 26 th January, in both of which the patients were in a state of high fever within twenty-four hours of coming into contact with persons who had previously suffered from the disease. His belief in the miasmatic nature of influenza was shaken by the facts which came under his observation, according to which the length of the period of infectiousness cannot be much under from seven to ten days. It then occurred to him to investigate the matter further, and he turned his attention to the disease as it presented itself among the workmen employed at Messrs. Broadwood and Sons' pianoforte manufactory, which, for several reasons, offered peculiarly favourable opportunities for observation. The employees are picked men, working under very satisfac- tory sanitary conditions, and their number was sufficiently large (460) to allow of averages being taken. He points out that, owing to the fact that all the workshops open on a limited number of staircases, and that either on the staircases or at the gate all the men are liable to meet several times in the day, he could not hope to trace exactly how the disease had spread through the factory. It was evident, how- ever, that if the disease was of miasmatic origin, the cases of illness would be pretty equally distributed through the factory, and that irregularities of distribution, if found, would correspond to local circumstances, such as the height of the workshops above the ground, their exposure to certain winds, etc., or to certain predisposing influences of the occupations carried on in them. On the other hand, if the disorder were contagious, certain groups of workshops would be found to be much more afiected than others, and that more or less independently of the local circumstances above mentioned. At first only a few men left their work. During the first days of January a few of those who had left from iUness came back to work. By Saturday, January 4th, about six convalescents had resumed work : this was fol- lowed on the following Monday by a considerable increase in the number of absences attributed to influenza. During that second week tlie number of men absenting themselves 462 EPIDEMIC OF 1889-90 was mucli greater than during the preceding week, and all the while a few convalescents were returning daily. The third week showed a still greater number of men leaving, this increase corresponding to a similar increase in the number of men coming back to the place. It may therefore be said that so long as the epidemic loas on the increase in the factory, the numhcr of men falling ill was proportional to the numher of convalescents coming hack to work. It may be also noticed that the numher of men leaving was greater than that of men coming hack. During the fourth week the epidemic abated almost com- pletely, and it can be noticed that the tabulated results sliow an inverse proposition, hetween the numher of men coming hack and that of men leaving, to what had taken place heforc. It was noticed that at the onset the cases were of greater duration than those that followed. The average duration of the cases beginning during the first week was from 7 to 10 days, while the average duration of the cases beginning during the second and third weeks was from 3 to 5 days, and during the next week the average fell to 21 days. He showed by diagrams that when one of the workshops belonging to a set of four or of two was much affected, one, two, or three of the others were much affected also. On the con- trary, some groups of workshops were but little affected. The fact that the men were constantly meeting on the staircases and elsewhere rendered it impracticable to follow the con- tagion further — if contagion there be. No connection could be shown to exist between the number of men employed in each place and the amount of illness, nor did there appear to be any relation between the kind of work and the amount of illness, except that while the clerks were the first to be attacked, the metal workers and the men employed in the mill were comparatively little affected, and the engineers, stokers, carpenters, carmen, etc., escaped altogether. Under normal circumstances, the number of men absent from the factory through illness is seldom above six during the week at this time of the year. During the month of January, however, this number rose gradually to 5, 6, 10, 13, 14, 15, 22, 25, 29, 34, 38, till it reached 40 in one day. Besides these men, a few suffered as usual from OBSERVATIONS ON THE SPREAD OF INFLUENZA 463 bronchitis, asthma, consumption, renal disease, rheumatism, erysipelas, etc. During the same month, as is well known, influenza was spreading through London ; it is therefore natural to connect the excess of illness in the factory with the epidemic prevailing at the time. Comparing the results of his observations at Messrs. Broadwood's with those recorded at Edinburgh and Oxford, he points out that the epidemic followed nearly the same course, but did not begin in the three places at the same time, the Morningside Asylum at Edinburgh being affected several days before the Broadwood factory, and the London factory had already been affected for at least four days when the Oxford University Press began to suffer. In all these places the disease began very gradually, a few persons at first being ill, the number increasing for some time in direct proportion to the number of individuals previously affected. Then suddenly this proportion was reversed, and the number of new cases fell rapidly, this "defervescence" following rapidly the " fastigium " of the epidemic. In attempting to analyse this phenomenon by means of the data obtained in the Broadwood factory, he found very distinct evidence of a relation between the number of con- valescents returning to work and the number of men obhged to leave the factory through illness. Putting aside the Monday cases, which for reasons explained correspond to the accumulated illness of at least three days (namely, Saturday, Sunday, and Monday), a comparison of the other days of the week made this relation very clear. On the day on which the amount of illness attained its maximum in the place, the number of men leaving the factory- was ten, whilst that of men resuming work was seven. On the following day the disease began to abate, and the i^ropor- {6 men leaving 6 commg back ^ . , r , , • T (2 men leaving On 2d day after acme the proportion became ■{ ., o • if '^ ^ ^ I lo coming back ^ j 2 men leaving " '"^ " " " " I 5 coming back ( men leaving 4th I 3 coming back 464 EPIDEMIC OF 1889-90 On 5tli day after acme the proportion became < { men leaving coming back p,i J ^ ^^^^^ leaving 9 coming back If for the sake of comparison one expresses the proportion of men leaving to that of men coming back by similar frac- tions, the following proportions are obtained : G leaving 7 returning 20 leaving 15 returning leaving 1 returning 7 leaving 1 returning 2 leaving 3 returning {5 leaving 1 returning ( 4 leaving ( 4 returning ( 5 leaving ( 2 returning I 12 leaving I 5 returning 1 day befor e the acme 2 days 3 „ 4 „ 5 „ 6 „ 7 „ 9 » » » )> » Dr. Delepine observes that if the disease were of a mias- matic nature it would be very difficult to account for this relation between the number of men falling ill and those resuming work during convalescence. It might be said that after settling in a place the virus increased in virulence for a certain number of days and then gradually died out, and that, the few people first affected coming back to the factory just as a new set of persons became overpowered by the more virulent poison, there was only an apparent relation between the number of old and new cases. He admits that it is diffi- cult to answer such an argument, but he urges that it is evident, on looking at the figures, that during the last days of OBSERVATIONS ON THE SPREAD OF INFLUENZA 465 the first week the first distinct batch of convalescents returned to work, and on the following Monday the first great exodus is observed. During the second week, on the days following those on which a large number of convalescents had come back, there was a marked increase in the number of men leaving. The turning-point occurring during the third week, the relations are slightly altered, yet the figures still pointed in the same direction. He feels therefore strongly inclined to consider the course of the epidemic in the Broadwood factory as supporting rather than invalidating the view that influenza is con- tagious. The theory of contagion is still further supported by the length of time which elapsed between the beginning of the outbreak in the Broadwood factory and in the Oxford Press. The remarkable similarity of course in two communities, composed of about the same number of persons of very much the same classes, seems also to indicate that there is a relation between the spread of the virus and the size of the com- munity attacked — a relation which would perhaps be not so clear if the disease were the result of atmospheric con- ditions or the development of some miasma. There still remains to be accounted for, the extreme rapidity with which the epidemic attacks not only a considerable number of indi- viduals in any locality, but also places very distant from each other. He concludes that if the facts which he has brought for- ward are correct there can be no difl&culty in explaining this by the contagion theory, for in two carefully-observed cases the illness seemed to follow within twenty-four hours of the first exposure of the patient to contamination. The sequence on these two cases is so remarkably clear that it would be necessary to admit a most extraordinary coincidence in order to deny the existence of contagion. What renders tliis denial still more difficult is that (1) the two patients had passed through the worst period of the epidemic unaffected, and a few days later, when coming for the first time in contact with persons who had had the disease, they contracted it ; (2) the two patients were not taken ill at the same time, but each one fell ill after coming independ- 2 II 466 EPIDEMIC OF 1889-90 ently in contact with affected persons ; (3) the time elapsing between the beginning of the attack in the first and second case was longer than the whole length of the illness in the first case. This therefore points not only to a very short period of incubation, but also to a long period of infectiousness (con- sidering the length of the illness) ; for in one case the contagion was transmitted about ten days after the onset of the illness, i.e. about six or seven days after apparent recovery. The factory returns also point to a very short incubation process, for there was a remarkable correspondence between the number of convalescents resuming work and of men obliged to leave work on each day. With these two factors — shortness of incubation and length of the period of infectiousness — the rapid and complete diffu- sion of the disease from one person, one town, or one country to another can easily be explained. It follows from what precedes that, whether cases of influenza are studied singly or collectively, one is driven to the conclusion that the disease is a contagious fever, which, when typical, has a very short latent period (twelve to twenty- four hours), an equally short initial stage leading to a fastigium lasting at most a few hours, followed by a sudden deferves- cence, taking the form of a crisis. Then a comparatively tedious convalescence begins, during which the patient con- tinues to diffuse the contagium for about one week or perhaps a longer time. This of course refers only to uncom- plicated cases. The author adds that he has been careful to avoid intro- ducing into this discussion any of the facts which were not recorded in his paper, otherwise he might have added many more supporting the view that influenza is a contagious disease. The greatest difference has prevailed, and still prevails, upon the apparently simple question of the contagiousness of in- fluenza. A careful review of the evidence and opinions of competent observers, however, authorises the belief that the disease is contagious, but it does not of course follow — nor does the author believe — that contagion is the only, or even SUMMARY 467 the most frequent, method of communication. The assertion that the malady had been imported into this country by direct contagion from parcels, letters, etc., emanating from infected districts, is not borne out by facts ; at any rate the history of the outbreak as it affected the Post Office and Foreign Office employees affords the idea no kind of support. The fact that the disease does not spread more rapidly now than of yore, in spite of the present rapid methods of transit, and the fact, too, that it does not necessarily spread along the main lines of travel, suffice to demonstrate the fallacy of the assumption of the disease being spread principally by contagion. Con- tagion, such as it is, seems to act more promptly on persons engaged in the open air, but there are so many apparent exceptions to this rule that it would be imprudent to insist upon it. EPIDEMICS OF 1510-1837 SUMMARY The previous annals bring under our review about twenty visitations of epidemic catarrh. The distinctive features of each important visitation may here be briefly recapitulated. Course. — North-westerly from Malta to Sicily ° Spain, Italy, France, Britain, raging over all Europe, and scarcely missing an individual. Meteorological Conditions. — It was preceded by a long con- tinuance of moisture, and followed by remarkable storms. Symptoms. — In addition to ordinary symptoms, violent pain over the eye, delirium, gastrodynia. Sometimes from the seventh to the eleventh day, syncope, and snatching of the tendons. Diarrhoea or sweating on the decline. Treatment. — Five blisters : two to the arms, two to the legs, one to the back of the head. Bleeding and purging said to have been injurious. Coincident Phenomena. — Signacula on linen and food. Blood rain; great swarms of locusts in Seville, in 1507, 1508, and 1510. Great devastation by caterpillars in Germany. ]\Iur- 468 EPIDEMICS OF 1510-1837 rain among cattle at Meissen. A damp season. Eruption of Hecla. Earthquakes. In the following year a comet. ^erH Course. — This epidemic took a westerly course from Asia, by Constantinople to Europe, and after- wards visited America. SymiJtoms. — The attendant fever is said to have been a double tertian. There was severe pain of side, relieved by bleeding, if adopted early. Meteorological Conditions. — It was preceded by ill-smelling fogs, and followed by great inundations. There was great dearth in England, in consequence of the wet season which preceded harvest. The disease commenced in October, after a month of unusually cold winds. A comet. The previous year an eruption of Etna. In 1561, the plague. Course. — From east and south, to west and north, raging chiefly in autumn. Symptoms. — Epistaxis. Vigilance or somnolency, giddiness resembling intoxication, parotid swellings, bilious vomitings. Mctcorologiecd Conditions. — It commenced in October, after a cold dry wind, preceded by two or three years of a moist, rainy, southerly constitution. Earthquakes in Yorkshire and Kent. Eemarkable meteors in November. Phenoinena among Animals. — Plague of insects, birds migrating prematurely, and cattle deserting their pastures, plague of mice, flight of owls, and murrain among beasts in Kent. Measles and smallpox speedily followed. In 1583, dys- entery. In 1584, plague. In April, in the midst of a winterly spring. Peculiar Symptoms. — Epistaxis, much cephalic affection, haemoptysis, often dysenteric affections. In the summer, a new fever affecting the " brain and nervous stock." ^^ In Autumn, after pungent fogs, and cold moist weather following a hot summer. An eruption of Etna. SUMMARY 469 Symptoms and Treatment. — Those of " pleuritic fever/' rather than pleurisy ; bilious derangement. Smallpox shortly followed, and in 1677 dysentery. t^ J _ In the Spring. — During a moist southerly con- stitution, preceded by a long -continued, intense frost. Symptoms. — Severe cough, quick pulse, headache. Plague broke out the year following. j^ After a rainy November, with high tides. Symptoms. — Loss of appetite ; rheumatic pains. .. H. q 9 q q Course. — lu England, during a damp chilly ' spring. Southerly. At Edinburgh, in November ; in Cornwall, not till the following February. Symptoms. — Sanguineous discharges frequent from the nose, lungs, and bowels ; bilious derangement ; occasionally swellings of the parotid and salivary glands and testes. Meteorological and other Phenomena. — Dry southerly, wet northern winds. Volcanic eruptions. Vivid aurora borealis. A comet. Prevalence of the arctia phseorrhoea. At the de- cline of the disease, remarkable meteor exploding in the air, and a fetid fog. Measles previously epidemic ; subsequently cholera and diarrhoea, much nervous disorder; pain in the head ; and delirium without fever. Coincident cough, and other diseases among horses. ^ij.-^yy Q Q Commenced in November. Peculiar Symptoms. — Much sickness ; bilious de- rangement ; affection of salivary glands ; rheumatic pains, toothache, and hemicrania. Meteorological Conditions, etc. — An eruption of Vesuvius. Earthquakes and a comet. Eemarkable meteors. Coincident and subsequent Phenomena. — ]\Iuch disease among horses. Lumbago, After the decline of the epidemic, nervous fevers, apoplexy, and palsy prevalent. p^ Occurred in the spring. Symptoms. — Lassitude; shivering; pain of head, limbs, and back ; loss of taste and appetite ; inflamed eyes ; 470 EPIDEMICS OF 1510-1837 epistaxis ; at the decline, often diarrhcea, sometimes pustules on the skin ; subsequently dysentery, and worms prevalent ; also apoplexy. In 1741 and 1742, smallpox, measles, and hooping-cough. Meteorological Fhenomena. — Aurora borealis frequent. Sol- diers fighting in the air. Great atmospheric vicissitudes. In 1743, very severe easterly winds for months before the visita- tion. Earthquakes and a comet, and a stinking fog. The previous year remarkable abundance of fruit. Mange, glanders, and cough among horses. -.Yjf-r, Commenced in September, during easterly winds. Universal in Scotland ; irregular in course. Symptoms. — The most characteristic was a sensation of tracheal excoriation ; profuse epistaxis was also frequent. Meteorological Phenomena. — An unusual prevalence of easterly winds, but sky clear. In 1759, earthquakes. The Bostrichos typographicus singularly destructive. Previously much dysentery, and a bad kind of smallpox. -.Hnc) Commenced in September, after severe and vari- able weather. Symptoms. — Affection of head ; harassing cough, and pain under sternum ; bilious derangement ; crisis by perspiration. Natality extremely different in different places. Phenomena. — Uncommon vicissitudes of heat and cold. Bostrichos typographicus prevalent, as in 1757-58. The Chareeas graminis very destructive. A comet. In 1763, an eruption of Etna. Subsequently dysentery prevailed, and bilious fevers. -,)-,r.yj Raged in June and July, after cold weather. Symptoms. — Characterised by lassitude, loss of appetite ; fever. ^ H w - Prevailed during a wet autumn. Symptoms. — Some, a sudden giddiness and pain of head ; some, nausea and intestinal disturbance ; pain in the loins and sides ; cramps ; prurigo ; erysipelas ; pustules. This epidemic was followed by diarrhoea. Coincident Phenomena. — Sudden changes of temperature. SUMMARY 471 Thick noisome fogs. These phenomena, and the occurrence of the epidemic respectively later in Britain than on the Continent. Earthquakes and volcanic eruptions. Much disease among dogs and horses. -.Hnn Perhaps the most widely diffused of all recorded visitations. Course. — Commenced at sea between Malacca and Canton, travelled westward through Russia, Denmark, and Holland, to England, where it appeared in May. Symptoms. — Languor; loss of smell and taste; sensation of contusion of limbs, and of soreness of cheek bones ; pain in chest and sides, and sometimes delirium, occasionally diarrhoea. Meteorological and other conditions. — In 1781, summer very dry, autumn very rainy, winter changeable. Spring of 1782 late, then gloomy, cold, and humid, with occasional dry fogs and peculiar storms. An eruption of Hecla, The brown-tail moth, and the Bostrichos tj'pographicus very destructive. ISO'? CoiW'se. — During the spring in England, from south to north, preceded by epidemic diarrhoea. Symptoms. — Much bilious derangement and affection of the head. Epistaxis ; often interchanging with scarlatina or super- seding it. Low fever frequently prevalent. Meteorological coincidences. — North-east winds, fetid acrid fogs, aurora borealis, sudden atmospheric changes. Shocks of earthquake. Excessive mortality among insects, and disease of cattle and domestic animals. ^r^o-i ^^ June, after great vicissitudes of weather, having been a year in its passage from China. Symptoms. — Much affection of head, loss of taste, and soreness behind the sternum. Coincident Phenomena. — Dysentery concurrently and sub- sequently ; a gradual transition to cholera. Much disease among the lower animals. ^ - „ „ In April, after damp weather succeeding to cold ; characterised by much nervous disturbance, and slow convalescence. Extensive concurrent disease among horses. 472 EPIDEMICS OF 1510-1837 „j^ Commenced at Sydney, October 1836, reached London, January 1837, after great humidity and considerable atmospheric vicissitudes. Those most exposed to the weather most severely attacked. Symptoms. — Much weight and pain of forehead, sometimes of vertex and occiput ; soreness of sternum ; discharge of tears, and acrid distillation from the nostrils ; severe pain of the back ; tendency to diarrhcea. Coincident Phenomena. — Disease of cattle and sheep. Much nervous fever. Transition in some instances to diarrhoea and cholera. 1 Q/L^y zt« Prevailed from October to January. Symptoms. — Catarrhal form characteristic. Pneu- monia, erysipelas, and rheumatism common as complications. Enteric symptoms frequent. Capillary bronchitis very fatal. Phenomena. — Aurora eight times, magnetic disturbance. FoGTs and darkness. Prevailed December to March. Extended from ■ Siberia to Eussia, Europe, America, and later, India and Australia. Symptoms. — Coryza generally absent. Prostration and nervous complications varied and severe. Broncho-pneumonia common and fatal. Ptashes of various kinds, followed by desquamation, of frequent occurrence. Phenomena. — Unusually warm moist weather for some months previously, with fogs during active phase of epidemic ; lessened prevalence in London after strong gales. Disease (pink-eye) among horses well marked and severe. Chronological Survey of Kecorded Epidemics. (Adapted from "Hirsch.") Yeak. Month. Akea of Prevalence. 1173 December England. 1510 August )) 1557 October )5 1580 Autumn >> 1658 April London. 1675 October 5) 1688 May )) jj July Dublin. 1693 Oct. & Nov. General diffusion in Great Britain. 1710 Spring London. 1729 November London, Plymouth. >} December York. 1732 December Edinburgh. 1733 January London, York. >» February Plymouth, Cornwall. 1737 November Plymouth. 1743 April etc. 1758 September Universal in Scotland. i) October St. Andrews, Aberdeen, York. 1762 September Dublin. 1767 June London. 1775 Oct. -Deer. Devonshire. 1782 April Newcastle. 1788 July London, Kent, Bath, Manchester. )J August Cornwall, Montrose. 1803 January London. >j February Widely spread in Britain. » April » » 1807 November Edinburgh. 1808 December London, Nottingham. » January Newcastle. 1831 June Glasgow, Douglas. 1833 July London. 1837 January London, Birmingham, Liverpool, Ireland. 1842 March London, York. 1843 March London. 1847 January Richmond. >» November London, York, Edinburgh. it December North of Scotland. 1853 December Bideford. 1866 May London. 1889 December London. 1890 January Diffused over England. INDEX OF PLACES VISITED BY THE EPIDEMIC, OR ON OTHER ACCOUNTS REFERRED TO Aberdeen, 100, 158 Abergavenny, severe storms preceding the disease at, 315 Africa, shower of red dust observed to the west of, 348 west coast of, 388 Alcmaria, 7 Alfort, horses suffered from anorexia at, 278 Alsace, 63 America, 39, 84, 89, 107, 187 Amsterdam, 427 Anglesea, 385, 386 Antwerp, 427 Armagh, horses seized vnth cough at, 201 Ashbourne, 191 Ashburton, 85 Ashton, 386 Asia, 89 Asia Minor, 397 Aston, 386 Augsburg, 85 Baltic Sea, 3, 321 Barbadoes, 39, 90 Barcelona, 340, 342 Barnstaple, 107 Basford, 386 Bath, 33, 185, 293, 354, 380 Belgrade, 427 Bengal, 145 Berlin, 271, 427, 428 Bew Regis, 316 Bideford, 434 Birkenhead, 410 Birmingham, 91, 386, 411 Blackburn, 410 Blandford, 100 Bolton, 290, 386, 411 Boston, 187 Bradford, Yorks, 353, 380, 411 Brescia, 388 Breslau, 63 Bridge water, 191 Brighton, 278, 354, 385, 411 Bristol, 354, 386, 411 Britain, 3, 4 Broughton, 432 Brussels, 427 Bucharest, 427 Burnham, 290, 293 Burslem, 386 Bury, 321, 386 Bushey School, 449 Caithness, 54 Cambridge, 385 Canton, 145 Cape Town, 321 Cardiff, 410 Carlisle, 386 Carnarvonshire, 179 Caucasus, the, 427 Chelmsford, 455 Cheshire, 77, 179, 353 Chester, 96, 99, 143, 180, 186, 386 Chichester, 293 China, 106, 268, 269, 415 Chorlton, 386 Clifton, 386 Constantinople, 4, 354, 387, 388 Copenhagen, 69, 106 Corfu, island of, 344 Cork, 191, 199, 201 Cornwall, 29> 85, 89, 143 Coventry, 386 Croydon, 316 Delft, visited by plague, 8 Denmark, 106 Derby, 386, 411 Derbyshire, 353 Devonshire, 89 Doncaster, 190 Dorchester, 82 Dover, 108 476 INDEX OF PLACES Dresden, 427 Droitwich, 202 Dublin, 23, 27, 67, 108, 159, 202, 217, 322, 429 East Anglia, 404 Eastbourne, 219 East Indies, 106 East Eetford, 190 Eaton, 432 Edinburgh, 33, 35-40, 50, 143, 353, 386, 420, 432 England, 6, 27, 33, 107, 180, 388 afflicted by dearth, 8 earthquakes in, 8 extremely severe weather in, 25 great mortality in, 4 sweating-sickness in, 2 Essex, plague of mice, 10 Etna, eruption of, 6, 23 Europe, 2, 3, 9, 10, 11, 84, 89, 157, 397 Evesham, 315 Exeter, 85, 385 Falmouth, influenza prevailed in vessels of war at, 340 Flanders, 24, 39 Framlingham, 293 France, 3, 23, 24, 26, 34, 78, 81, 107, 387 brown-tail moth in, 40 Franconia, swarms of the Bostrichos typographicus in, 186 Fulneck, 198 Galgou, cattle affected by the disease at, 348 Geneva, 348, 354 Germany, 3, 33, 64, 81, 90, 388 north, caterpillars in, 2 Gibraltar, influenza in vessels of war at, 340 Glasgow, 143, 419, 446 Glasnevin, 322 Godshill, 385 Gosport, many cows died at, 201 scarlatina and ophthalmia prevailed at, 206 schools escaped at, 193 Gowrie, horses affected with cold, 51 Guildford, 143 Gulick, extraordinary storm at, 3 Had LEIGH, 143 Hague, the, visited by plague, 7 Halifax, 386, 411 Hamburg, 63, 427 Hanover, 39 Hebrides, the, 431 Hereford, 193, 293, 315, 386 Holland, 24, 34, 81, 190, 388 Hong-Kong, 388 Hounslow, 436 Huddersfield, 386, 411 Hull, 190, 411 Hungary, 3 Hunslet, 386 Hutton Bushell, 206 Iceland, earthquakes and volcanic erup- tions in, 4 Inverness, 54 Ipswich, 155 Ireland, 39, 106, 180 Isle of Man, 180 Isle of Wight, 316, 385 Italy, 3, 4, 64, 78, 107, 132, 387, 388, 427 South, 33 Upper, 388 Jamaica, 39, 90 earthquake and hurricane at sea, 25 Jena, 25 Jersey, 166 Juliers, extraordinary storm at, 3 Kendal, 385 Kenninghall, relapses frequent at, 293 Kent, 166 plague of mice in, 10 Kilkenny, globe of fire in the air at, 43 Kingston, 143 L' AiGLE, in Normandy, shower of meteoric stones at, 200 Lancashire, 353 Lancaster, 101 Languedoc, corn laid waste by grass- hoppers, 24 Lausanne, 348 Leeds, 386, 411 relapses frequent at, 199 Leghorn, 39, 180 Leicester, 293, 386, 411 Lima, earthquake overthrew city of, 24 Lincoln, 386 Lisbon, influenza prevailed in vessels of war at, 340, 341 Liveri:.ool, 143, 386, 411, 428 Llandausaint, Anglesea, 385 Lombardy, 4, 388 London, 24, 33, 39, 48, 64, 65, 69, 72, 74, 105, 107, 136, 142, 145, 152, 185, 190, 349, 384, 387, 410, 428 increased mortality concurrent with the disease in, 346 progress of disease in, 321 swarms of ants in, 278 Low Countries, 26, 78 Luton, 152, 153 Lyons, 348 Macclesfield, 386 INDEX OF PLACES 477 Madrid, 39, 354, 387, 427 Maidstone, 385 Malaga, 427 Maldon, 455 Malta, influenza prevailed in vessels of war at, 340 Manchester, 64, 191, 386, 411, 428 Manilla, 269 Mantua Carpentaria, 6 Marseilles, 387 Medoc, horses afifected at, 348 Melite, island of, 3 Melton Mowbray, 432 Merv, 427 Mexico, 39, 90 Monmouth, 315 Morges, 348 Moscow, 106, 271, 427 Naples, 33, 39, 90 Navan, cessation of fever at, during influ- enza, 204 Negapatam, 145 Netherlands, 388 Newark, 190 Newcastle-upon-Tyne, 50 142, 155, 293, 314, 386, 411 New England, 33, 90 Newfoundland, 388 New York, 189 New Zealand, 388 Northampton, 354, 385 Norwich, 64, 143, 385, 411 Nottingham, 386, 411, 432 Nova Scotia, 187 Numigen, 8 Okehampton, 85 Oldham, 386, 411 Oxford, 24, 33, 143 Paris, 33, 39, 185, 190, 271, 348, 354, 387, 427 escaped the epidemic of influenza of 1762, 63 mortality not increased by influenza, 271 Pechlin, 3 Pennsylvania, 189 Penzance, 354, 386 Peru, 39, 90 earthquake in, 10 Plymouth, 29, 65, 85, 143, 146, 187, 268, 354, 386, 411 influenza prevailed in the vessels of war at, 340, 342 Poland, 427 Pontefract, pottery escaped the disease near, 193 Pontyi^ol, 386 portsea, 190, 385 Portsmouth, 143, 411 influenza prevailed in the vessels of war at, 340, 342 Portugal, 3, 107, 388, 427 Prague, 427 Prescot, 386 Presteign, dense fogs at, 315 relapses frequent at, 293 Preston, 386, 411 Prussia, domestic animals suffered from catarrhal affections, 346 Redruth, 386 Rennes, 355, 387 Rochester, 191 Rome, 9, 10, 428 Russia, 132, 388, 427 Ryegate, workhouse escaped at, 193 Salem, U.S.A., 189 Salford, 386, 411 Salisbury, easterly winds at, 316 Saxony, 33, 39 Scotland, 38, 49, 106, 180, 321 progress of epidemic in, 50, 51 Sevastopol, 427 Seville, locusts in, 2 Sheerness, influenza prevailed in the ves- sels of war at, 340 Shefiield, 386, 411 Shetlands, the, 431 Shrewsbury, 191, 386 cats seized with houst at, 201 Siberia, 427 Sicily, 3 red rain and snow fall in, 264 Smyrna, 340, 397 Sophia, 427 Soutlianipton, relapses frequent at, 293 Spain, 3, 89, 90, 107, 132, 387, 388, 427 influenza prevailed in the vessels of war on the coasts of, 340, 345 sweating-sickness in, 4 St. Albans, 152, 163, 385 Stamfordhani, 155 St. Edmund's Bury, 143 St. lago, peculiar dust fell in, 279 St. Kilda, 135 St. Neot's, 206 St. Petersburg!!, 106, 271, 427 Stockport, 386 Strasburg, 63 Stratford - upon - Avon, relapses frequent at, 293 Stroud, 293, 386 Sunderland, 321, 386, 411 relapses frequent at, 293 Sutherland, 54 Swabia, swarms of the Bostrichos typo- graphicus in, 186 Swansea, sore throat at, 205 478 INDEX OF PLACES Switzerland, 93, 388 Sydney, 321 Syria, 388 Tenbuey, 314 Tobolski, 106 Tolmezzo, mountain in Frioul, red snow on, 264 Tomsk, 427 Topsham, 386 Toulon, 387 Trieste, 340 Truro, 85 Tunis, influenza prevailed in the vessels of war at, 343 Twyford, 432 Tynemouth, 386 United States, 187 Utrecht, 159 Valebiola, 3 Valparaiso, 388 Wales, 96, 99, 179, 315 Walsall, 386 Wanstead, 350 Waterford, 214 West Derby, 386 West Indies, 84 Wigan, 386 Wolverhampton, 386, 411 Woolwich, 436 Worcester, 100, 315 Wrexham, 386 Wymondham, 432 Yarmouth, 154, 385 York, 93, 143, 386 earthquake near, 10 Yorkshire, disorder amongst horses, 82 INDEX OF AUTHOEITIES QUOTED Addison, Mr. Malvern, 317 Alderson, Dr., Hull, 209 Alves, Dr., 54 Alvey, Dr., 206 Anderson, Dr., Alnwick, 105, 108, 110, 112, 116, 118, 123 Appleton, Mr., Evesham, 285, 296, 298, 307, 308 Arbuthnot, Dr., 32 Armstrong, Dr., Wellington College, 450 Ash, Dr., 91 Ash win, Mr., Abergavenny, 298, 310, 312, 315 Assey, Mr., Beccles, 110 Baddeley, Mr., Newport, Salop, 218 Baglivi, 60 Baird, Dr., 282, 285, 292, 293, 294, 308, 311, 312, 313 Baker, 8 Baker, Sir G., 56, 79, 233 Bardsley, Dr., 191, 198, 216, 218, 222, 223, 320 Barlow, Dr., Bath, 285, 302, 310, 312 Barnes, Dr., 403 Barnes, Mr. E. C, Hammersmith, 440 Barton, Dr. Kingston, 412 Becket, Mr., Bristol, 162 Bennett, Mr., 268 Bertram, Dr., Hull, 205, 224 Binney, Mr., Newbury, 166 Binns, Dr., 108 Bird, Mr., Hereford, 294, 308, 315 Bird, Mr. Gwynne, Swansea, 285, 298, 309, 315 Bishop, Mr., 198 Bisset, Dr., 106, 108, 115, 123 Black, Dr., Bolton, 290, 314, 317 Blakiston, Dr., Peyton, 329 Blagden, Dr., 107, 177 Blount, Dr., 193 Bloxam, Mr., Newport, 298, 308, 316 Bollinger, 420 Bond, Mr., Glastonbury, 211, 225 Boys, Mr., Sandwich, 115, 129 Bree, Mr., 285, 290, 296, 300, 309, 311 Brett, Dr., 453 Bristowe, Dr. Hubert C. , 442 Broderip, Dr., 244, 258 Broughtou, Mr., Bristol, 162, 170 Brown, Dr., Sunderland, 286, 287, 290, 292, 294, 295, 305, 306, 308, 309 Brown, Mr. G. T., Board of Agriculture, xi Brtson, Dr., 340-348 BuRNE, Dr., 265 Burnett, Captain, 348 Burnett, Sir Wm., 388 Bun-, Mr. W., 419 Burroughs, Mr., Clifton, 210 Bush, Mr., Frome, 224 Caldwell, Surgeon R., 446 Callamen, Dr., Cork, 191 Cam, Mr., 246 Cameron, Dr., Leeds, 445 Campbell, Dr., Lancaster, 101, 109, 111, 119, 121, 123, 130 Carey, Mr., Wanstead, 350 Carrick, Dr., Bristol, 235 Ceeley, Mr., Aylesbury, 287, 294, 298, 300, 302, 307, 313, 314 Celsus, 140, 393 Chomel, 272 Clark, 6 Clark, Dr., Newcastle, 133 Clarke, Mr. Adams, Bushey, 449 Clark, Sir Andrew, 460 Cleghorn, Dr., Dublin, 116, 120, 121, 122, 248 Clendinning, Dr., 287, 294, 296, 298, 316, 335 Clouston, Dr., Edinburgh, 432 ' Those from whom special communications are introduced are printed in capitals. 480 INDEX OF AUTHORITIES QUOTED Constance, Mr., Kidderminster, 221 Cooke, M. C, xii Crookshank, xii Cullen, Dr., 105, 135, 388 Cuming, Dr. William, 82 Currie, Dr., Chester, 204 Dain, Dr., 391 Daniel, Dr., Crewkerne, 112, 114, 123, 124 Darwin, 279, 348 Davis, Dr. J. F., 246 Davis, Dr., Presteign, 284, 285, 293, 294, 298, 303, 310, 315 Davis, Mr., Tenbury, 285, 294, 309, 311, 314 D'Azyr, M. Vicq, 109, 117, 121 De Bary, xii Del^pine, Dr. Sheridan, 460 Dent, Mr., Kenninghall, 302 Dixon, Dr. Joslma, 199, 202, 224 Dobson, Dr., 179 Dodonens, 8 Doyle, Dr. Koss, Ireland, 206 Dugard, Mr., Shrewsbury, 210, 213, 215 Duncan, Dr., Edinburgh, 213 Dunning, Mr., 203 Fade, Sir Peter, 404 Edgeworth, Mr., Edgeworth Town, 217 Ehrenberg, 2, 264, 272 Elliot, Dr. Fettes, 458 Erasmus, 4 Evershed, Dr., 403 Falconer, Dr., 112, 157, 170, 240 Farbstein, Dr., Hull, 403 Fauvel, M., Paris, 369 Fieldhouse, Mr., Stafford, 214, 218 Fife, Dr., Newcastle-on-Tyne, 287, 293, 298, 301, 304, 307, 310, 314 Fletcher, Mr., Croydon, 285, 316 Fleury, Dr. C. J., 102 Flint, Dr., St. Andrews, 119, 120, 121, 123, 222 Forest, 10 FoTHERGiLL, Dr., 74, 95, 161, 169, 171, 174 Fowler, Dr., Sarum, 212 Fox, Mr., Cerne, 295, 307, 317 Fracastorius, 390 Frank, xii Frazer, Dr., Southampton, 117, 127 Frazer, Dr., Wisbeach, 194, 204 Friend, Mr., Newbury, 166 Gairdner, Professor W. T., 420 Gallini, Dr. , Venice, 126 Gamble, xii Garthshore, Dr., 109, 120 Geach, Mr., Plymouth, 162 Gilchrist, Dr., 105, 112 Girdlestone, Dr., 226 Glass, Dr. Thomas, 85 Godfrey, Mr., Bath, 285, 307, 308, 309 Grant, Dr., 88, 106, 152 Graves, Dr., 322, 323, 417 Gray, Dr. Edward, 104 Green, Dr. George, 325, 327 Greenhow, Dr., North Shields, 322 Groguier, 272 Grove, Dr., Salisbury, 285, 298, 316 Hall, Mr., Bridgenorth, 210 Hamilton, Mr. H., Wymondham, 433 Hamilton, Dr. R., London, 108, 111, 151, 176, 261 Hancock, Dr., 378 Hargraves, Mr., Wotton, 316 Harness, Mr., Tavistock, 211 Harper, Mr., 193 Hart, Mr. Horace, Oxford, 436 Hartig, R., xii Harvey, Mr. Augustus, 414 Hastings, Dr., 282, 286, 288, 293, 294, 297, 306, 307 Hawkins, Dr. H. P. , 401 Hay, 167 Haygarth, Dr. John, 96, 179, 241, 247 Heberden, Dr., 72, 78, 184, 321 Hecker, 390 Henry, Mr. , Manchester, 120, 124, 128, 134 Hesse, xii Hickman, Mr., Burslem, 201 Hingeston, Mr., 270, 273 Hippocrates, 12, 90, 390 Hobbes, Dr., Swansea, 211 Hodson, Mr., Lewes, 196 Hoffman, 389 Holer, 8 Holland, Dr., 355 Hooper, Dr., 378 Houlston, Dr., Liverpool, 108, 119, 120, 130 Hugo, Mr., Crediton, 215 Hull, Dr. T., Retford, 225 Hunter, Mr., Dumbarton, 204, 226 HuxHAM, 27, 41, 45, 64, 157 Jackson, Dr., Somerby, 433 Jackson. Mr. I., Twyford, 432 Jacob, Mr., 108 Jeafferson, Mr., 193 Johnston, Mr. Keith, 416 Jolles, Dr., Vienna, 412 Judson, Mr., Ware, Herts, 207 Kerr, Dr. Norman, 407, 422 Kinglake, Dr., Taunton, 217, 223 Kirby and Silence, 186 Kirkland, Dr., Ashby, 105, 108, 109, 113, 114, 115, 123, 127 Klebs, Professor, Zurich, 413 INDEX OF AUTHORITIES QUOTED 481 Klein, xii Knipe, Mr. William, 202 Lassere, M., 377 Latreille, ' Hist. Nat.,' 56, 186 Laval, Dr., 387 La\\Tence, Mr., Cirencester, 211 Lawson, Mr., 268 Leith, Dr., 106, 111, 114, 115, 122 Lever, Dr., 453 Limaricis, Dr., 397 Livingstone, Dr., Aberdeen, 108, 109, 110, 111, 116, 117, 118, 122, 129 Longfield, Dr., Cork, 214, 224 Luscombe, Mr., Eastbourne, 221 MacAlister, Dr., Cambridge, 454 Macaulay, 23 Macqueen, Dr., Great Yarmouth, 109, 110, 113, 117, 119, 120, 121, 124, 131, 134, 163, 170 Macrorie, Dr., 282, 286, 293, 314 M'Cabe, Dr., Cheltenham, 292, 312 M'Can, Dr., Armagh, 199, 201, 204, 208, 219, 222 M'Gill, Dr., 446 M 'William, Dr., 342 Magennis, Dr., PljTnouth, 213 Martial, 28 Maul, Mr., Southampton, 284, 285, 296, 298 May, Mr. , Reading, 285, 287, 298 May, Mr. Vaughan, Plymouth, 187, 205 Mease, Dr., 109, 111, 113, 115, 120, 129 Melhurst, Mr. J. C, Tiverton, 224 Mercatus, 88, 89 Mezeray, Comte de, 2 Mill, Rev. J., 431 Millar, Dr., 55 Molyneux, Dr., 23, 24, 27 Moore, Dr. W. J., Registrar - General for Ireland, 430 Morrison, Dr., Wolverhampton, 117 Mortimer, Mr., Surgeon, North Devon Militia, 107, 132 Mossrnan, Dr., Bradford, 209 Murray, Dr., Norwich, 105, 109, 112, 117, 118, 122 Myles, Mr., Warrington, 286, 294, 312 Newell, Mr., Colchester, 115, 119, 120, 121 Nordlinger, xii Nott, Mr., Bew Regis, 287 Oakley, Dr., London, 193 Offley, W., 64 Olivier, 272 Ozanam, 388 Parsons, Dr., 453 Paterson, Dr., 108, 111, 119 Peacock, Dr., vi, 349-379 Pearson, Dr. R., 220, 228 Percival, Dr., 202 Petrequin, 348 Petrie, Dr., Lincoln, 116, 119, 121, 123, 124 Petrie, Robert, 61 Pettigrew, 187 Peu, 23 Phillips, W., xii Piedagnel, 348 Platerus, 8 Plowright, C. B., xii Preston, Dr., 438 Pridham, Dr. C, Bideford, 434 Priest, Mr., Burnham, 316 Pringle, Dr., 49, 55 Pringle, Sir John, 77, 339 Prichard, Mr., Leamington, 285, 311 Pulteney, Dr. R., 100 Rainet, Dr. Daniel, 103 Ramsay, Dr., 282, 293, 307, 308 Rayment, Mr., 194, 198 Reaumur, 40 Reilly, Dr., Monmouth, 122 Reimarus, Dr., Hamburgh, 118, 119, 126 Reimer, J. H., 63 Renault, Dr., 387 Renny, Dr., Newport Pagnell, 122 Rever, 8 Reynolds, Dr. Henry Revell, 81 Reynolds, Dr. J. Russell, 416 Ribbert, Dr., 413 Rice, Mr., Stratford-on-Avon, 283, 292, 296, 309, 313 Richards, Dr., Hanwell, 451 Riverius, Lugd., 10 Robertson, Mr., 439 Robinson, Dr., Newcastle, Stafford, 222 Robinson, Mr., 207 Rosa, Chevalier, Modena, 125 Rose, C, 63 Roux, Dr., 413 Rowe, Mr., Portsea, 225 Russell, Dr., 420 Russell, Hon. Rollo, 415 Rustou, Dr., 108, 109, 110, 113, 114, 118, 123, 129, 132 Rutty, Dr., 67, 258 Ryan, Dr., Kilkenny, 209,216 Ryley, Dr. J. Beresford, 448 Salius, 11 Sampson, Mr., Salisbury, 285, 308, 316 Sauvage, M., 257 Schinckius, 8 Schdnlein, Professor, 414 Scott, Dr. J. Nelson, Isle of Man, 108, 111, 116, 118, 122, 123, 258 2i 482 INDEX OF AUTHORITIES QUOTED Scott, Dr., Stamfordham, 107, 116, 166 Scott, Dr., Tollcross, 447 Scott, Sir Robert, 111 Seifert, Otto, 413 Senuertus, 10 Shaim, Mr., 207 Sliapter, Dr., Exeter, 285, 287, 291, 293 Shelley, Dr. C. E., Hertford, 454 Short, Dr. , 3, 25, 27 Simmons, Dr., 109, 124 Skene, G., 100 Smart, Mr., Cranbourne, 298, 309, 316 Smart, Mr., Hutton Bushell, 213 Smee, Mr., 447 Smith, Dr. Alder, 444 Smith, Dr. Gilbart-, 428, 438 Smith, Mr. , Bideford, 206 Smith, Mr. C, Worthingtou, xii Smith, Mr., Stroud, 294, 295, 296, 315 Smyly, 335 Smyth, Dr. Carmicha.el, 136 Soraner, xii SouTAR, Dr. J. Greig, 428, 429 Spangeuberg, Cyriacus, 1 Spence, Dr., Guildford, 117, 130 Sprengel, 388 Squire, Dr., 452 Stark, Dr., Edinburgh, 353, 386, 387 Statham, Dr., Foundling Hospital, 450 Stone, Mr. , Christ's Hospital, 349 Stow, 1, 8, 9 Streeten, Dr., 279 Surius, 4 Sutherland, Dr., 447 Swain, Mr. J. M., 432' Swift, Mr., 331 Sydenham, vii, 17, 43, 86, 138, 272, 389 Symes, Mr., Bridgewater, 191 Talbot, Mr. , 436 Thomson, Dr. William, 100 Thorne, Dr. Bezley, 417 Thornton, Dr. Regius, 422 ' Thorp, Dr., Ludlow, 217, 218, 222 Thrksh, Dr., 455 TiBBLES, Dr. William, Nottingham, 432- 434 Toulmouche, M,, 355, 387 Tozzetti, Targioni, 388 Trevor, E. F., 432 Turton, Dr., Swansea, 200, 205 Vaillard, M., Val-de-Grace, 413 Vaughan, Dr., Rochester, 205, 222, 225 Vignier, 8 Villalba, Don Joachin de, 4 Voltaire, 277 Wall, Dr., Oxford, 223, 224 Walter, Mr. , 206 Ward, Marshall, xii Ward, Mr., Woodchester, 225 Warren, Dr., Boston, 187 Watson, Dr., 64 Webster, Mr., Denham, 201 Webster, Noah, 1, 4, 7, 23, 25, 45, 48 Weichselbaum, Professor, Vienna, 412 Welchman, Mr., Kineton, 297 Whateley, Mr., Burton-on-Trent, 194, 207 White, Dr., 207 White, Dr. W., 93 White, C, 64 Whitehead, Dr., Ventnor, 434 Whytt, Dr., 49 Wiervs, Amstel., 10 Wilkinson, Mr., 206 Williams, Mr., Holywell, 295 Willis, Dr., 11, 89 Willkomm, xii Wiimer, Mr., Coventry, 110, 112, 118, 122, 123 Wilson, Dr., 416 Woodforde, Dr., 191, 209, 224 Woolcombe, Dr., Plymouth, 209 Yellowlees, Dr., 447 Yeo, Mr., Clifton, 210 Youatt, Mr., 278 GENEEAL INDEX Abdominal cojiplicatio^ts, 308, 369 Abortion, a common result of influenza, 23 ^Etiology of influenza, 414-423 Age, influence of, 3, 12, 30, 34, 38, 45, 53, 55, 58, 69, 73, 79, 89, 91, 109, 137, 143, 158, 160, 189, 197, 198, 204, 206, 263, 276, 280, 339, 355, 382, 389, 391, 406, 411, 430, 449 Air-bubbles absent from sputa, 329 Air, change of, useful for protracted cough, 330 Alcohol, sometimes useful, 408 Alfort, horses at, affected, 278 Alopecia areata, prevalence of, 454 Amendment, signs of, 248, 362 Ammonia, when useful, 375 acetate of, recommended, 224, 232 useful, 276 Ammoniacum, useful, 54 with oxymel scill., useful, 38, 47 often objectionable, 250 Anodynes, often injurious, 19 niles for use of, 95, 374 Antifebrin, results of administering, 450, 453 Antimony, peculiarly valuable, 44, 238, 250, 376 Antipyrin, useful, 408, 431, 443, 453 overdoses of, fatal, 408 Ants, swarms of, 278 Apoplexy, concurrent with influenza, 45, 307, 388 Appearances, post-mortem, 325, 326, 339, 340 Appetite restored by purgatives, 277 Arctia phccorrhcea prevalent, 40 Asthma, concurrent with influenza, 353 fatal during epidemic, 390 Asylums for the insane, outbreaks in, 447, 452 Atmosphere, conditions of, during the epidemic, 314, 320, 351, 390, 414 generally humid before visitation of 1837, 314-317 Atmosphere in eastern district, 316 in midland, 314 in northern, 314 in south-eastern, 316 in western, 315 eflect of, 102, 126, 128, 158, 162, 178 exposure to, favouring influenza at Clifton, 237 its influence questionable, 344, 345 relation of, to influenza, 49, 55, 57, 77, 78, 82, 125, 204, 392, 434 state of, 269 autumnal constitution of, arising irregularly, not the cause of in- fluenza, 90 Aurora Borealis, 42, 351, 381 Authorities quoted, 477 Bacteriology of epidemic, x, 412 Bark, indications for its use, 73, 140, 141 injurious, 93, 225, 233 useful, 80, 122, 225, 260, 375 Bed, confinement to, remedial, 261, 407, 449, 453 Birds migrating prematurely and chang- ing their roost, 11, 35 Blanket manufactory, immunity of, 193 Bleeding, remarks on, 118, 223, 234. 374 conditions for employment of, 61, 118, 119, 150, 167, 310, 311 fatal to 2000 persons at Mantua Carpentaria, 6 fatal at Rome, 9 fatal near Birmingham, 93 rules for its use, 46, 275, 333 when appropriate, 54, 150, 170, 172, 249, 261 when injurious, 3, 43, 65, 87, 95, 310 when useful, 6, 7, 9, 10, 20, 31, 37, 61, 69, 73, 100, 197, 238, 248, 255 Blisters, recommended, 20, 31, 34, 40, 54, 83, 88, 225, 251 484 GENERAL INDEX Blisters, in severe cases, singularly useless, 335 usefulness of, 40, 65, 88, 92, 95, 121, 140, 149, 251, 375, 377 Bfood, appearance of, 31, 34, 42, 59, 65, 69, 81, 83, 88, 91, 99, 114, 118, 140, 167, 169, 198, 275, 331 differing in different places, 93 condition of, after death, 326 sizy, not a conclusive proof of phlo- gistic diathesis, 156, 169, 171 buffy coat sometimes present in phthisis and pregnancy, 167 Blood-rain, ix, 2, 6 Bostrichos typographicus, prevalent, 56, 186 Bowels, confined, common, 242, 308 Breath, saccharine odour of, 196 Bronchitis, capillary, how to be treated, 376 complications of, 359, 433 common, 406 Brutes, disease among, x Burton-on-Trent, escaping, 194 Caffein, citrate of, useful, 431 Calomel, recommended, 222, 231, 232, 233, 239, 261, 312, 375 free use of, with antimony and opium, 313 good or bad, according to mode of use, 276 ' Canopus,' severe epidemic in the crew of the, 342 Cardiac weakness a special feature of the epidemic 1889-90, 406 Cases illustrative of the disease, 266 Catarrhal complications, prevalence of, 349, 433 Catarrh, bronchial, how relieved, 408 Caterpillars, destructive, in Germany, 2 plague of, 72, 200 Cats affected during influenza, 201, 421 Cattle, murrain amongst, at Meissen, 2 black, affected, 202, 346 Cerebral complications, 331, 353 Chareas Graminis superabundant, 200 Chickens diseased during epidemic, 272 Childbii-th, increase of deaths in, 353 Cholera, in relation to influenza, 36, 205, 272, 346, 434 epidemic of, 380 Chorea, supervening, 406, 450 Christ's Hospital, outbreak among pupils at, 349, 444 Circulatory diseases, deaths from, during epidemic, 439 Clysters, useful, 92, 250 Colchicum, recommended, 312 Colic, occasionally present, 157 Conditions, hygienic, influence of, in the influenza epidemics, 393 Comets, appearance of, noticed, 1, 4, 6 8, 25, 45, 48 Complaints, pectoral, aggravated by in- fluenza, 296, 297 benefited, 297 Complications of the disease, 337, 405 abdominal, 308, 369 catarrhal, 405 gouty, 406 nervous, 303, 404 neuralgic, 303, 406 rheumatic, 303, 406 Consumption, following influenza, 9, 10, 32 whether induced by influenza, 123, 263 Contagiousness of the disease, conclusions regarding, 434, 450, 453, 465, 467 destroyed by acid fumes, 218 different iu different visitations, 149 facts supporting, 132, 133, 134, 135, 144, 161, 163, 164, 181-184, 210- 217, 236, 247, 259, 343, 430, 434, 451, 452, 454, 465, 466 facts opposing, 53, 55, 218-220, 237, 295, 454 more obvious iu 1782 than in 1762, 149 rapid influence of, 261 the question discussed, 128-132, 295, 296, 391, 449, 460 Convalescence, often tedious, viii, 59, 363, 435, 466 sooner established in some visitations than in others, 74 Convulsions, sometimes present, 307 Cordials, when iiseful, 122, 150 Corn, scarcity of, in 1557, 6 Cough, character of, 329, 356, 359, 361 Course, irregularity of, 132, 143, 190, 191, 463 rapidity of, 389 Cows affected during epidemic, 201, 348 Creatan, a Gaelic name for influenza, 1 Crisis by diarrhcEa, 3, 9, 260 sweating, 3, 9 urine, 9 Croup in relation to influenza, 358, 366 Cupping, advantage of, 62, 375, 376 Dangek, indications of, 275 Death, appearances in patients after, 245, 246, 326, 339, 404, 440 causes of, iu fatal cases, 292, 327, 362, 381, 405 period of, 353 Debility, a characteristic symptom, 34, 116, 177, 358, 370, 401 often continuing long, 123 accompanying influenza, an argument for its contagiousness, 164 in later times a more frequent con- GENERAL INDEX 485 dition in iljnsequence of altered habits, 172 Deer affected during influenza, 48 Delirium, an occasional symptom, 41, 98, 100, 113, 138, 157, 197, 241, 268, 331, 361, 362, 370, 372, 388, 400 induced by ammoniated wine, whey, and paregoric, 87 Diagnosis, differential, 116, 397 Diaphoretics recommended, 239, 249, 374, 435 Diarrhoea attending the epidemic in some localities, not others, 54, 94 in relation to influenza, 24, 36, 51, 55, 70, 81, 149, 353, 370, 371, 373, 433 epidemic of, 380 Diet, regulation of, 233, 313, 374, 408, 453 sparing, recommended by Erasmus, 5 Digitalis, 226 Dogs aff"ected during influenza, 77, 83, 90, 100, 202, 203, 272, 421 Dover's powders useful, 408 Dredgers not affected, 323 Drought, disease preceded by, 32, 35 when so produced benefited by bleed- ing, 9 Duration of disease in patients, 16, 24, 292, 357, 370, 388, 401, 435, 444, 449, 450 the epidemic, 143, 350, 382, 389, 445 in different districts, 281-284, 450 Dust, can it be a means of conveying con- tagion, 415-417 Dysentery ^^receding influenza, 349 accompanying, 25, 48, 71 succeeding, 66, 71, 272 less fatal during influenza, 353 Dyspnoea, cases of, 449, 450 disproportioned to structural change, 323, 324, 360 sometimes of asthmatic character, 401 intermittent, 324 Ear sometimes aff"ected, 307, 373, 433 Ears, abscesses in, 111, 307 Earthquakes noticed, 4, 8, 10, 24, 45, 48 Emetics at onset good, 188, 311 mode of action, 188 useful, 31, 65, 69, 93, 120, 139, 149, 173, 188, 221, 231, 249, 271, 374 not always indicated, 103 England, marshy state of, in sixteenth century, 5 Epidemics of influenza, chronological sur- vey of, 473 accounts of (1847-48), 349-395; (1889-90), 395-467 cost of (1889-90), 447, 448 general course of, 390 nature and causes of, 377-379 Epistaxis attending influenza, 51, 264, 356, 372, 373, 430, 433, 454 Erasmus's letter to Cardinal Wolsey, 4 Erysipelas, 40, 206 concurrent with influenza, 341, 353, 358 Erythema sometimes present, 400, 430, 443 Ether, inhalation of, less useful in in- fluenza than in common catarrh, 231 ExemiDtion, some supposed causes of, 298 Expectorants less eftectual in influenza than in ordinary pulmonary affec- tions, 334 useful, 121, 374 Expectoration from influenza compared with that from bronchitis, 329 from influenza not containing air- bubbles, 329 sanguineous, 260 in acute capillary bronchitis, 359- 361 Factories, outbreaks in, statistics of, 436, 445, 461 Famines noticed, 8, 415 Fatal termination, causes predisposing to, 291, 390, 435 Fever and cough not essentially related, 97 attending influenza sometimes inter- mittent, at the commencement often resembling ty25hus, 198, 259; particularly when bleeding em- ployed, 87 ; or when lasting be- yond fifth day, 229 catarrhal, characteristics of, 172, 355 sometimes intermittent, 61, 76, 93 simple, 355 ; treatment of, 373 with pulmonary comijlications, 359- 369 ; treatment of, 374 ; mortality from, 367 complicated with pneumonia, 363- 366 with abdominal complications, 369- 373 with disorder of the gastro-enteric membrane, 369 with rheumatic complications, 372 with tendency to relapse, 370 character of attendant, 94 ; when increasing for three days takes the character of the season, 88 declining in four days, 87 distinguishing influenza from catarrh, 124, 329, 330 low, an occasional termination of influenza, 54 never intermittent at Aberdeen, 101 sometimes remittent, 94 Floods, 8 486 GENERAL INDEX Fog, pungent, accompanying the epidemic in France, 23 dense in London, 381 ; in Edinburgh, 387 stinking, preceding the disease, 33, 48 Forehead, sense of constriction of, 148 France, brief description of the visitation there in 1803, 251-258 Friendly Societies' losses by epidemic, 448 Frost, effect of, on the epidemie, 95, 316 Frosts, extreme, preceding the disease, 11, 24, 25 Fuacht, an old Irish name for influenza, 1 Oeesb, remarkable flight of, 26 Germs, vegetable, as a cause of epide- mics, xi Olands, salivary, affected, 9, 41, 86 Goats aflected witli rheumatism during the epidemic of 1837, 346 Grasshoppers, plague of, 24 'Gri^jpe, la,' a name for influenza, 387 HEMATURIA induced by influenza, 433 Haemoptysis induced by influenza, 264, 433 Hajmorrhages, occasional occurrence of, 406, 433, 442 Headache, varieties of, 137, 356, 359, 372, 399 Health, public, deterioration of, 172 state of (Oct. -Dec. 1847), 379 Hereford Lunatic Asylum escaping, 193 Herpes labialis, 400, 430, 433, 443, 451 Hooping - cough, concurrent with influ- enza, 353 increased mortality from, during epidemic, 384 Horse-exercise, useful, 141, 260 Horses, aflected during influenza, 23, 25, 39, 45, 48, 51, 77, 82, 90, 99, 100, 201-203, 272, 278, 348, 419, 433 their liability influenced by size of stable, 278 Hospital, Loudon, number of cases among out-patients at, 438 Hydrothorax, concurrent with influenza, 353 Hyperjjyrexia, an occasional symptom, 400, 430 Immunity of Paris in the epidemic of 1762, 63 instances of, 110, 180, 193 as produced by typhus, ceasing with convalescence, 323 Incidence of the disease, 411 Incubation, period of, 261, 344, 429, 433, 442, 449, 451, 453, 459, 460, 466 Infants, rarely affected, 160 severely afl"ected, 456 Influenza, analogies i'^^hveen it and other disorders, viii contrasted with oi ler diseases, vii epidemicity of, dejiendent on condi- tions of environment, 418 independent in a great degree of hygienic precautions, viii jn-obably always exists, 389 remarkable power of, to increase mortality from other diseases, viii, 390, 411, 430, 445 value of recorded observations in investigating the aetiology of, ix Inhalation, use of, 250 Insurance companies' losses by epidemic, 448 Intermittents, in relation to the disease, 271 Ipecacuanha, recommended, 232, 374 use of, in checking diarrhoea, 82, 149 Intestines, disturbed condition of, 308 Isolation of patients, importance of, 428 ' Jasseur,' the crew of the, apparently contracting the disease from H.M.S. ' Childers,' 343 Jaundice complications in pneumonia cases during epidemic, 366 epidemic of, 454 Johnson, Dr. Samuel, quoted, 273 Kali, acetated, recommended, 233 Kidneys, congestion of, 406 Lambs, epidemic among, 422 Languor, more protracted in 1782 than in 1762, 148 Laryngeal complications, 366, 400, 406 Laryngitis, deaths from, more numerous during ej^idemic, 366 Laxatives, the most efficient remedies, 62 Lemons, juice of, useful, 35, 43 Lips, eruiDtious on, indicating a favourable crisis, 86 Liver, state of, 275, 401, 404 Locality as influeuciug the disease, 115, 322 Locusts, 2>lague of, 2 London, filtliy condition of, in the six- teenth century, 4, 5 ; in the seventeenth century, 23 Lozenges, Sydenham's, for catarrhal cough, 22 Malaria, non-resemblance of influenza to, 398 Malarial theory of origin of influenza, discussed, 422, 453 Maniacal diseases, concurrent with influ- enza, 29, 34 among dogs, 35 Mania sometimes induced, 124, 362 GENERAL INDEX 487 Measles, concurrent with influenza, 11, 29, 34, 205, 206, 207, 353, 412, 455 following influenza, 71, 208, 450 Megrim, 196 Meningitis, sometimes present, 306, 400, 406, 433, 449 Mercury, its value in treatment, 44, 313 variously combined with advantage, 313 Meteorology (1889-90), 423-427 Meteorological tables, 424 Meteors, remarkable, 43, 48 Mice, plague of, 10 Mind, depression of, predisposing to attack, 59, 160 Miscarriage, induced by influenza, 60, 123, 137, 264 Modifying influence of locality, 271 Moon, supposed influence of, 199 Morphia, how administered by Dr. Graves, 334 Mortality, dependent on complications, 336 from the disease, 32, 34, 38, 48, 67, 69, 76, 104, 151, 166, 246, 256, 263, 270, 289, 322, 346, 352, 353, 367, 439 not always increased by the epidemic, 104, 166, 382, 386, 387, 394, 409 induced by influenza in Dublin, 322; in London, 322, 380, 382, 384, 411 ; in the British fleet, 270 variable in difl'erent places, 64, 384 tables of (1839-47), 380 in Loudon districts, 385 during various epidemics, 394 comparative, 395 Moth, brown-tail, prevalent, 186 ; a mere coincidence, 163 Mumps, co-existent with influenza, 205 Muriatic acid, fumes of, not prophy- lactic, 323 Nasalis, an occasional complication, 400 Nausea, an occasional symptom, 91, 93, 356 Navy, health of, 271 Nerve vagus, the, involved in the disease, 325, 328 Nervous diseases, accompanying influenza, 34, 418 system, influenced, 404, 452 Neuralgic complications, 309, 430, 433 Nitre, 333 Nomenclature of disease, 396 Nostrils, api^lication of leeches to, 311 Numbers simultaneously attacked at Exeter, 85 Oats, blighted during epidemic, 200, Occupations, influence of, 323 Ophthalmia, 206 Opiates of doubtful utility, 312 useful, 121, 173, 224, 231, 251 Opium, conditions for its use, 275 injurious, 224, 408 ; necessary, 251, 374, 375 large doses to be avoided, 231 ; large doses preferable to small, 262 rules for its use, 262, 334 Oranges recommended, 225 Orchitis, complications of, 442 Otitis, complications of, 373 Owls, flight of, 10 Ozone, excess of, a sujiposed cause of epidemic disease, 414 Pain, fallacious seat of, 246 Paralytic symptoms, rare, 401 Parasites of plants, xi Pastures spoilt by virus, 11 Pediluvium, usefulness of, 174 Peripneumonia, a more frequent complica- tion in country than town, 60 prevalent, 389 Perspiration, 197 crisis by, 173, 197 ; on the third day critical, 70 Pestilence, that mentioned by Homer pro- bably influenza, 90 Phenacetin, useful, 431 Phthisis, accelerated by influenza, 45, 208, 297, 407 deaths from, 439 Pink-eye, outbreak of, among horses, 419 Places referred to, 473 Plague, superseding the catarrhal consti- tution, 11 Pleurisy, coincident with influenza, 18, 114, 388, 389, 406 a more frequent result in 1762 than in 1775, 148 recent adhesions from, not often pre- sent from influenza, 326 Pneumonia combined with influenza, 258, 363, 400, 406, 433, 449, 450, 453 jOToportion of cases so complicated, 235, 241, 259, 363, 369 Police, City, jiroportion attacked, 354 average period of invaliding, 358 outbreak among, statistics of, 436, 440, 441, 446 Poor, contrast with the rich, in patience, 276 Population, proportion of, attacked, 3, 8, 13, 18, 29, 30, 32, 85,96, 98, 103, 109, 143, 159, 247, 263, 288-291, 336, 348, 354, 387, 391 numl)er of, attacked simultaneously, 90, 387 Pose, an old name for influenza, 388 Post Office employees, statistics of out- break among, 435-436, 440-441 488 GENERAL INDEX Pottery iu Pontefract escaping, 193 Prescrii^tions, complicated, to be avoided, 173 Prisons, outbreak in, 447 Prognosis, grounds of, 15, 248 Progress of disease iu England, 33 ; British Isles, 192 ; iu Scotland, 38, 51 ; over the globe, 39 Prophylactics, 217, 218 Protection, whether given by previous attack, 297-298 Provisions, salted, deprecated by Erasmus, 5 Ptyalism, spontaneous, 309 Puerperal state, as affecting liability, 199 Pulse, intermittent, 308, 361 state of, 243 not hard or tense, 91 peculiarities of, 94, 102, 137, 308, 399 preternaturally slow, 195-196 variable conditions of, 94, 102, 113, 195-196, 243, 302, 357, 359, 360, 361, 365, 369 Purgatives, usefulness of, 32, 44, 92, 149, 231, 277, 435 Questions issued by Provincial Medical Association, 279 Quinine,' when useful, 312, 374, 408, 431 Quinsy, iu relation to iuiluenza, 36, 41, 204 deaths from, more numerous during epidemic, 366 Rain, excessive, 6, 8, 350 red, 264, 272, 279, 348 Rank of life influencing liability, 98 Rash, cases of, 402, 403, 430, 433, 442, 443, 451, 452 Recurrence of attacks, 405, 434 Registrar-General's Report (1847), extracts from, 350-355 (1889-90), 439 Relapses, 199, 358, 371, 405, 436, 453 compared with first attacks,53, 115,449 liability to, influenced by treatment, 199 relative frequency of, at difierent places, 199, 293 Respiratory diseases, deaths from, 439, 445 Rheumatic complications, 28, 309, 358, 372, 432, 459 Rheumatism, alternation of influenza with, 260 associated with influenza, 68, 353, 451 Rhubarb, dysentery relieved by, 8 Rubefacients, utility of, 311 Salicylates, useful, 408, 431, 443 Saltpetre, 226, 334 Sanitation, neglect of, in London, a pre- disposing cause of epidemics, 393 Scarlatina, in relation with influenza, 206, 207 Scarlatina, occasional resemblance of in- fluenza to, 68, 79, 157, 400, 442, 452 prevalent, 381 Scarlet fever, concurrent with influenza' 353, 412 Schneiderian membrane, leeching, reliev- ing headache remarkably, 311 Schools, Association of Medical Officers of, discussion at, 449-455 statistics of outbreaks in, 442, 444, 449-460 public elementary, and the epidemic, 455-460 Scurvy, prevalent, 380 Seamen, suffering much from the disease, 159 Season, during the same epidemic in different countries, varying, 6 Seasons accompanying influenza, 6 as modifying the form of disease, 187, 277 Seat of the disease, 275 Sensorium, concomitant disturbance of, 307 Servant-men suffering severely, 58 Sex, influence of, 109, 198, 199, 206, 286, 287, 382, 389, 403, 406, 411 Sheep, diseased during influenza, 202 Ships, rapidity of attack in, 117, 342 size of, not always connected with severity of disease, 345 the disease culminating and declining quickly, 347 training-ship, outbreak on board of, 437 Sickness, an occasional symptom, 78, 80 Signacula, or blood-spots, their nature ex- plained, 2 Signs, physical, 327, 363 Sinapisms to the feet, useful, 92 Skin, desquamation of, occurring in 1743, not in 1762, 65 occurring in 1889-90, 401, 433, 442 efflorescence on, critical, 69, 70 icteric discoloration of, 196 seldom dry, 91, 357, 360, 365, 369 sometimes dry, 400 temperature of, in influenza, 331, 359 Slaodan, an old Irish name for influenza, 1 Smallpox, in relation to influenza, 11, 29, 40, 71, 208, 353 Snow, melting, effect of, 316, 321 red, 264 Soldiers, disbanded, supposed to bring the disease from Dunkirk, 26 outbreak among, statistics of, 435, 436, 446 Specifics, so-called, powerless, 408, 431 Spermaceti linctuses, useful, 54 Spider, a peculiar, abundant during influenza, 203 GENERAL INDEX 489 Spirit of nitric ether, 232, 250 Spleen, state of, 401, 404 Spring, visitations in, 14, 277 Squadron, British, catarrhal fever afifect- ing, in 1837, 341 Squills, conditions for use of, 232 useful, 276, 375 Stages, disease divisible into two, 292 Statistics (1889-90), 435-447 Stimulants, sometimes requisite, 95, 122, 150, 174, 376 often pernicious, 240 Stones, meteoric showers of, recorded, 4, 200' Storms, 1, 3, 24 preceding influenza, 99, 176, 276, 425 Summary of chief epidemics, 467-472 Susceptibility to influenza not destroyed by other diseases, 85 to other diseases awakened by in- fluenza, 55 Sweating-sickness ravaging England in 1506, 2, 4 ravaging Spain, 4 Swine diseased during influenza, 202 Symptoms, 9, 12, 14, 18, 24, 30, 34, 40, 45, 51, 55, 59, 69, 73, 112, 146, 147, 265, 266, 274, 336, 399 as appearing in the squadron, 345 as classified by Dr Streeten — febrile, catarrhal, mixed, 299-304 as observed in the United States, 187 catarrhal, 300 connected with diff"erent organs or systems, 302 described by Dr Fothergill, 75 febrile, 299 remarkable, alternations of, 97 varying in diflerent places, 195 summary of, 97, 229, 345 violence of, not proportioned to danger, 137 in complicated cases, 337, 359-361, 365, 369 in simple cases, 336 in special cases, 301-303 Syncope, occasional symptoms, 197, 308 Synochus catarrhalis, an appropriate name for inflammation, 230 Tables, meteorological (1889-90), 424 Tables, mortality (1839-47), 380 for London, 385, 394, 395, 410 Tartar, cream of, when administered with advantage, 232 emetic, 334 Taste impaired, 196 loss of, 91 Tea, a debilitating drink, 172 Tears, fiery, ix Temperament as modifying liability, 286 Temperature chart (1834-36), 318 Temperature, cool, useful, 223, 233 effect of changes in producing disease, 316, 317, 320, 322 regulated, importance of, 314 of patients, high, 400, 401, 403, 443, 451 Thaw inducing influenza, 320, 389, 390 renewing epidemic, 101 Tobacco, its eflBcacy, 226 Tonics, the period appropriate for their use, 334, 374 Tongue, appearance of, 91, 113, 242, 302 305, 356, 359, 360, 361, 399, 459 ; during relapses, 230 covered with white cream-like mucus, 59, 195, 369 in bad cases sometimes little atfected, 242 Tonsillitis, an occasional symptom, 400 Tonsils, suppuration of, 112, 198, 205 ulceration of, 86 Toothache, 41 Trachea, leeches to region of, useful, 333 Treatment, 16, 19, 29, 83, 87, 139, 310, 407 contrasted effects of dejDletory and sustaining, 346 medical, often imnecessary, 16, 47, 54, 61, 79, 99, 103, 117, 149 review of, 373-377 to be modified according to constitu- tion of the air, 22 Turni}^, insects assailing, 279 Typhoid preceding influenza epidemic, 349 Typhus, relation of, to influenza, 204, 206, 380, 384 Urine, conditions of, 30, 34, 197, 303, 305, 357, 399, 406, 460 containing purjiuric acid, 331 diagnosis derived from, 94 guide to treatment, 95 promoting, tends to remove the fever, 232 jjrognosis derived from, 242 speedy decomposition of, 460 Urticaria, sometimes present, 400, 402 Vabieties of the complaint, 274, 407 disease in 1833, 273 Vegetables, blighted during influenza, 202 whether atfected concurrently with influenza, xi Ventilation, importance of, 233, 262 Vertigo, an occasional symptom, 241, 248 Villages compared with towns as respects liability to tlie complaint, 64, 69, 96, 107, 144, 179-181, 185, 191, 322, 348 Vinegar administered by Dr Whytt, 54 Virus continuing after subsidence of the disease, 282 490 GENERAL INDEX Volcanic eruptions, 6, 23, 25, 45 noticed in Iceland, 4 Washington, President, attacked with the disease, 189 Water, very hot, external application of, very useful, 335 also in croup, 335 Weather, changeable during epidemic of 1775, 77 exposure to, as influencing at- tack, 80, 158, 200, 276, 348 aggravating the symptoms, 60, 159, 294 lessening liability, 294 consistent with speedy recovery, 86 peculiar, not a cause of the disease, 57 preceding the disease, 13, 24, 25, 26, 29, 32, 55, 57, 176, 350, 381 very hot, following the epidemic, 17 unusually cold in 1767, unusually hot in 1762, 74 ; cold in 1782, 152 ; in 1831, 269 ; warm in 1847, 351 ; warm in 1890, 425 Weather, epidemic uninfluenced by, 404 Wliey, white-T/ine, so largely used as to exhaust the supply of milk, 31 Whooping-cough, preceding influenza, 455 Wind, change of, i^roducing amelioration, 344 Winds influencing course of disease, 3 north, effect of, 7, 12 prevalent, during influenza, 204 Women, puerperal, very liable to the disease, 199 Worcester Gaol, immunity of, 193 Worms passed by patients during in- fluenza, 36, 65 Wounds, prone to mortify, 33 YouATT on close stables as producing catarrh, 278 Zymotic diseases, deaths from, 439, 445 THE END Printea by R. & R. Clark, Edinburgh. Iii:^lu^nza 6^ epidemic ft(!:i56 caterhal fever T37 1890