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calculus were pus and crystals in acid urine, frequency ofmicturition, sweating before and after the act, rarelyvomiting, and cramps in the legs. Although for a yearthe existence of a renal calculus was suspected, itwas not until Nov. 26th, 1890, when there was a well-marked attack of renal colic and swelling of the leftkidney, due to blockage of the ureter, that theexistence of a calculus in the left kidney was madecertain. Nor was there any evidence that the rightkidney was useless until after left nephrotomy. The quan. Itity of urine passed from the bladder gradually diminished,and gradually ceased on Dec. 26th. After this the rightloin was freely palpated, with a view to prove the absence ofthe right kidney, and then (possibly from this manipulation)the suppuration in the right kidney rapidly increased,necessitating the nephrotomy, which was performed twodays before death. It is a question when the destruction ofthe right kidney occurred, and when its pelvis and ureterbecame blocked. Possibly the symptoms were masked bythose due to the hip disease. During the sixteen months’stayin hospital there was never any blood in the urine, nor, Ialthough there were so many small stones in the kidneys,was one passed.

Medical Societies.EPIDEMIOLOGICAL SOCIETY.

A MEETING of this Society was held on May 20th, Dr.EwART, President, in the chair.

illeasles, an Epidemiological Study.—A. CAMPBELLMUNRO, M.B., D.Se., medical officer of health to the countyof Renfrew, read a paper on the above subject. Measles,he said, was, with the doubtful exception of diphtheria,the only infectious disease that had not only provedunamenable to sanitary measures, but had actuallyincreased within the last fifteen years, the mean death-rate from this disease throughout England and Waleshaving risen from 277 per million of the populationfor the decennium 1871-8 to 422 in that of 1881-90.At Yarrow, with a marked decline in the general and thezymotic mortality, the deaths from measles had risen from274 per million in the former period to 927 in the latter.The most careful inquiry had convinced him of the evidentconnexion between the spread of measles and school attend-ance, and of the absence of any other special cause. Theschool attendance, which in 1871 was only 52 per 1000 ofthe population, rose from 68 in 1874 to 162 in 1882, or froma mean of 95 in the decennium 1871-80 to 164 in 1881-90. Dr.Ransome’s theory of the production of epidemics was theproximity of susceptible persons, and Dr. Munro found inthe infant department of a Board school-i.e., among thoseof the age most liable to measles—sixty-nine children writingon slates in a space of fifteen feet by nine, or on less thantwo square feet per head. No such crowding was possiblein the streets or at home, while the conditions of mentalfatigue and foul atmosphere were infinitely more conduciveto infection than those of play and exercise in the open air.Chemical and microscopical examination by Prof. Carnellyin Edinburgh of the air of schools, of single room dwellingsat night, and of bedrooms in a better class, gave the

mean respective proportions of cubic centimetres of CO2in a litre of 18’6, 11’2, and 7’7, and the number ofbacteria 151, 58, and 8’5. In one school the numberof bacteria was not less than 600 per litre ! In townswith a less exclusively working-class population therewas a proportionately less aggregation of children inpublic elementary schools and a less marked tendency toepidemicity of measles. This was well seen in the adjacentborough of South Shields, where the school attendance per1000 of population rose only from 96 in 1874 to 122 in 1882,an increase of 26 per 1000, against 94 in Jarrow. In Jarrow,as in many other towns, there was a striking biennialrecurrence of epidemics ; the vast majority of the caces werechildren attending the infants’ school, and their mean agewas 4’2 years. In 1887, with no data beyond those affordedby the deaths and a very imperfect voluntary notification,Dr. Munro’s attempts to check the progress of the epidemicby closure of infant schools were far from successful, but in1889 the compulsory notification had come into force, andthe results of his action, which were exhibited in a diagram,

were most satisfactory. Taking the day of the eruption asthe date of the " occurrence," and noting only the first casein each family, on the assumption that subsequent caseswere infected by this one at home, it appeared that whilein no previous week had there been more than two cases, inthat ending April 5th there were thirty-six, or 1 per 1000 ofthe entire population. Of these thirty-six children, twenty-nine were attending school, and twenty-eight the infantdepartment of the Grange Board School. These belonged todifferent grades of society, and lived in different quarters,so that their mixing much in the streets was unlikely; but itwas ascertained that just a fortnight previously an infant hadbeen sent to school with the rash fully out. She was at oncesent home, but had already attended for three or four days,during which she had been capable of infecting others. Theschool was promptly closed Dr. Munro found that in the thirdweek from this-i. e., at the end of the incubation period-butone new case was notified among children usually attendingthis school; this particular outbreak was stamped out,only a few sporadic cases occurring at irregular inter-vals during the rest of the epidemic period. In theCatholic school it did not appear till the week end-ing May 24th, when there were twenty-two cases, andfifteen in that following. It was closed, and only a fewisolated cases occurred afterwards, though the childrenbelonged to very poorest class. Outbreaks appearing ineach of the other public elementary schools, the autho-rities closed them all on June 7th for five weeks, anticipatingthe usual holidays, so that when they were reopened onJuly 26th there were no measles in the town. At SouthShields, where measles was not notified and the schools werenot closed, no such speedy extinction of the disease wasobserved. The cases not being known, the deaths furnishedthe only data for comparison. These were for the twelvemonths of the year 1889 in Jarrow : 0, 0, 0, 4, 3, 15, 2, 1, 0,1, 1, 1, and in South Shields 0, 1, 1, 0, 2, 2, 15, 6, 9, 9, 2, 1.Measles broke out again in the Dann-street school inSeptember and October, and in Grange-street school inNovember. There being little or no measles elsewhere,Dr. Munro, instead of closing the schools, kept it from

assuming the proportions of an epidemic by close personalsupervision, excluding all children from the infectedhouses so long as any danger existed, and instructingthe teachers to watch for the earliest febrile or catar-rhal symptoms, sending home and reporting to himany that seemed in the least degree suspicious. The suc-cess attending this procedure convinced him that could suchmedical supervision be exercised over all schools actualclosure would rarely if ever be necessary. The diagramsshowing the prevalence of measles in each of the sevenschools, and in the rest of the population, proved that theoutbreaks in the former were not parts of a general epi-demic, but independent of, and not synchronous with, oneanother-each arising from a single focus, as was seen mostclearly in the Grange school. The tendency to a bien-nial recurrence of epidemics of measles was probably neverso unequivocally manifested as at Yarrow, where it had pre-vailed in every alternate year from 1881 to 1889 inclusive,the deaths per mille having been, from 1883 to 1890, 2.9, 0.1,2-4, 0-03, 1-4, 0-0, 0-9, and 0-0. In Sweden, on the otherband, the tendency for the past hundred years had been, asDr. Ransome pointed out, to a septennial recurrence, theexplanation being doubtless that in a sparse population alonger period was necessary for the accumulation of materialin accordance with Dr. Ransome’s law of epidemic periodicity." That these disorders can only become epidemic when theproximity between susceptible persons becomes sufficientlyclose for the infection to pass freely from one to the other."Depending on sociological, not on meteorological conditions,these biennial exacerbations were to a great extent deve.loped in each centre of population independently, in differenbdegrees, and not necessarily in the same years. Generallythe odd numbers in the north of England and the evennumbers in the south were those of the epidemic years,though there were exceptions in each case, and in some fewtowns the periodicity was erratic. These local differencestended to obscure the biennial curve for the entirekingdom, which nevertheless was distinctly recognisablein the mortality returns. There was also a seasonalcurve, a higher wave in the spring and a lower in theautumn, although some as yet ill understood factorsaccelerated, retarded, or prolouged the one or the other,whence it followed that whereas the biennial cycle wasmost clearly seen in each several locality, the seasonal

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curve was best defined in the death-rate of the wholecountry. Dr. Munro, from a consideration of these factsand the results of hia efforts in 1889, was convinced thatthose medical officers of health who believed that all attemptsto stay the progress of an epidemic of measles were futile,and that no good could follow from its notification,were in error. Compulsory notification was an essentialcondition of action. If this were given promptly, and allchildren from infected houses excluded from the schools,further steps might not be necessary. If, however, from sixto ten new and independent cases had occurred within oneweek in an average-sized school, the infant departmentshould be at once closed ; in the senior departments, wherethe children had passed the age of greatest susceptibilityand a large proportion had probably already had the disease,close personal supervision and exclusion of any giving theleast ground for suspicion would in most cases suffice.At the same time the infected houses should be indicatedto the managers of all Sunday schools, who should beinduced, as at Jarrow, to carry out the like exclusion of allsuspected children.-Dr. WILLOUGHBY having for twentyyears been connected with public elementary education,considered Dr. Monro’s paper one of the highest scientificand practical importance. In the recent discussion of theguestion at the Society of Medical Officers of Health hehad stood almost alone in urging the notification of measlesfrom a school standpoint, and he had in the columns of theSchoolmaster indicated the samemodeof dealing with childrenfrom infected houses, with the further recommendation thatthe Education Department should be induced to extend tocases of individual compulsory absence the same allowanceforenforced non-attendance made in the event of closure of anentire school. He suggested that the biennial recurrence ofepidemics might have some connexion with the two years’average stay of children in the infant school, after whichthose who had escaped were in the upper schools " diluted"by being mixed with insusceptible or less susceptible chil-dren, and their places in the infants’ school entirely filledby other and highly susceptible individuals.

After some remarks by other members. Dr. SISLEY read ashort note on the Prevalence and modes of Propagation ofInfluenza as observed in the Epidemic of 1889-90 in thiscountry.

OBSTETRICAL SOCIETY OF LONDON.

On Visceral Hcernorrhages in Stillborn Children ; an Analysisof 130 Necropsies. being a Contribution to the Study ofthe Causation of Stillbirth.A MEETING of this Society was held on Wednesday,

June 3rd, Dr. T. Watt Black, President, in the chair.Dr. HERBERT R. SPENCER read a paper on the above

subject, in which he gave a detailed account of a consecu-tive series of 130 necropsies on fresh, mostly stillborn,foetuses, in so far as congestion of and haemorrhage intothe viscera were concerned, together with tables of themore important organs affected, and a description of thenaked-eye and microscopic appearances of the variousviscera as regards congestion and haemorrhage. The cau-sation of the baemorrhage was discussed, and the followingpractical conclusions were drawn: 1. In children stillborn,or dying shortly after birth, congestion or osdema, andhaemorrhages are usually found in various important viscera.2. These haemorrhages occur in cases delivered naturally orby version or by forceps through normal and abnormalpelves; in primiparae and multiparæ; with large and smallchildren ; in " easy " and difficult, rapid and prolongedlabours. 3. Th" haemorrhages are, however, most frp-quent and most severe in childien subjected to much pressureby the parturient canal or instruments or the hand of theattendant, especially when delivered by the lower extremity.4. Cerebral haemorrhage is more frequently found in still-born children delivered by the forceps than in those bornby the breech, and in these latter more frequently than inthose born naturally by the head. 5. Hæmorrhage intomost of the other viscera is more frequently met with inpelvic than in cephalic presentations. 6. These hæmor-lhages and the accompanying injuries are in many casesthe cause of stillbirth, and, when not immediately fatal,may be followed by the gravest consequences. 7. Theyare most likely to be avoided by preventing prematurerupture of the membranes, by artificial dilatation of theparturient canal (when necessary), by restricting the

employment of version and other artificial manipulationsto urgent cases, and by preferring cephalic to podalicversion in cases suitable for the former. 8. The use of theforceps should be absolutely limited to cases in which thereexists some pressing danger to mother or child, and itshould never be employed merely to shorten the time oflabour. 9. In breech presentations, examination of thegenital organs of the child should be carefully avoidedduring delivery. As soon as the child’s limbs are bornthey should be wrapped in a thick layer of antiseptic wool(which keeps the child warm and prevents the hand fromslipping, and protects the limb from pressure). If tractionbe necessary, it should be made over wool wrapped aroundthe child’s limbs or pelvis; it should never be made by thehand around the child’s waist. 10. In delivering the after-coming head care should be taken that the sterno-mastoidmuscles are not unduly stretched or pressed upon. Whenthe after-coming head is in the pelvis, where there is evenslight difficulty, resort should be had to the forceps.

Dr. HERMAN said io was impossible to controvert Dr.Spencer’s carefully observed and recorded facts, but hecould not agree that the forceps should never be used toshorten labour. In cases in which there was no pelvicdeformity, nor disproportion between the child’s head andthe pelvis, the os uteri was fully dilated and delivery wasslow simply because the pains were too weak. To quicklyovercome the resistance of the pelvic floor he thought theuse of forceps to shorten labour would be good practice.He thought accoucheurs all over the country used theforceps for this condition more frequently than for anyother, and that they did not find harm resulting to thechild. He agreed in recommending the forceps for thedelivery of the after-coming head. That injuries to thebrain were more common in forceps-delivered children thanin those born naturally was due, he thought, to the factthat the forceps was used in the worst cases, and so thecondition which rendered forceps necessary had producedthe iniuries.

Dr. PETER HORROCKS related three cases in which,after podalic version and delivery by traction, the childrenhad made no attempt at respiration, although the heartwas beating. In one of these an attempt was made tocatheterise the trachea, but the catheter passed down theoesophagus and the stomach was filled with air. Sotracheotomy was performed, and the child’s heart was keptbeating for an hour and a half. No effort at respiration,however, was made, and a post-mortem examination showedhæmorrhage into the fourth ventricle of the brain. In theother two cases there was also haemorrhage into the fourthventricle, and in one on the surface of the brain also. Hehad considered the total absence of all efforts at respirationto be due to pressure on, or damage to, the respiratorycentre in the medulla oblongata or bulb.

Dr. DAKIN thought that many children who survivedsuffered from visceral haemorrhages, some of them, as, forinstance, into the muscles and cellular tissue, did not, per-haps, materially affect the child’s welfare. He asked if theseextravasations were, as thought by some, a cause of themilder cases of jaundice, by the absorption of their bloodpigment into the general circulation, and consequentstaining of the tissues. He noticed that out of twelve orthirteen cases which survived over three days only two werejaundiced. He thought the intestinal and uterine hæmor-rhages would explain many of those cases in which bleedingtook place from the rectum in male and from the vagina infemale children.Mr. ALBAN DORAN thought that many children were

born with visceral haemorrhages which did not kill, butwhich set up diseases. Large subcutaneous extravasationsof blood caused by violent blows were sometimes followedby the development of a sarcoma.

Dr. LEWERS suggested that some morbid conditionof the vessels might have caused the haemorrhage insome of the cases. Considering the fact that so manychildren that afterwards throve had been delivered byforceps, it seemed improbable that the forceps skilfully usedwould often cause visceral haemorrhage in healthy fœtuses.Dr. JOHN PHILLIPS alluded to parturition in hoemophilic

women. He had never met with a case. He related twocases of visceral haemorrhage in newly born children; onea breech case, with hæmorrhage into the liver; the othera normal labour, with haemorrhage from the stomach. Heagreed that many so-called "asphyxial deaths" were reallydue to internal hsemorrhage.