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frequent. The child became weaker and died on Dec. 12th,fourteen days after admission.At post-mortem examination Peyer’s patches were

found to be much swollen, particularly at the lower endof the ileum, the peritoneal coat of the intestine over themshowing some inflammatory reaction. There was no

evidence of haemorrhage or perforation. The spleen didnot appear to be enlarged and was fairly firm. The mucousmembrane of the stomach was congested and showedsmall petechial haemorrhages.The main features of the case were that : (1)

diarrhoea was not a prominent feature and was notmore severe than in an ordinary infective enteritis ;(2) the spleen was early felt ; (3) there were no rosespots ; (4) the Widal reaction was positive ; and

(5) the urine and stools were negative on culture.The source of infection was apparently the child’sfather, who had already been admitted to a neigh-bouring hospital and found to have paratyphoid B.

I am indebted to Dr. Alan Moncrieff for permissionto publish this case.

MEDICAL SOCIETIES

ROYAL SOCIETY OF MEDICINE

SECTIONS OF EPIDEMIOLOGY ANDCHILDREN’S DISEASES

AT a combined meeting of these sections held onJan. 26th, Dr. J. D. ROLLESTON being in the chair,the subject of discussion was theAtiology of Acute Rheumatism and Chorea

in relation to social and environmental factors.Dr. J. ALISON GLOvER, in introducing the subject,

took as his basis No. 187 of the Special Report Seriesof the Medical Research Council issued in 1927 onSocial Conditions and Acute Rheumatism. This

investigation included the medical and social historiesof 721 rheumatic families, 200 control families, and2000 children living in poor-law schools ; and thepossible social factors investigated included maternalcare, exposure, sleeping accommodation, clothing,cleanliness, distance from school of the home, birth-place, occupation, and income of the parents ; themedical particulars of course embracing familialincidence and heredity, the familial incidence of sore-throat and throat conditions, and tonsillectomy.Housing sites and accommodation were specially noted.Yet the outcome was declared to be largely negative.A remarkable finding was a low incidence of rheu-matism in the children living in the poor-law resi-dential schools, perhaps because of better generalhygiene in comparison with that of children of thesame class living in poor homes. But the social andenvironmental conditions as well as the bacteriologyand the aetiology of acute rheumatism still formed oneof the enigmas of preventive medicine. Still, poverty,urbanisation, overcrowding, malnutrition, and damp-ness were associated factors of undoubted significance.A possible factor not dealt with in the report was diet.

Gray Hill and Allan seemed to have shown clearlythat no " rheumatic type

" of child was distinguishableby bodily conformation, physical standard, or pig-mentation. The Child Life Committee of the MedicalResearch Council, under whose auspices ReportNo. 187 was issued, stated that if hospital patientswere divided into three classes according to their

degree of poverty, the poorest of them-i.e., thedestitute poor-showed a lower rheumatic incidencethan did the other two. But despite this findingDr. Glover believed that the incidence of acuterheumatism was in direct proportion to the degree ofpoverty.The most hopeful recent advance was that on the

aetiological relationship of Streptococcus pyogenes toacute rheumatism. The work of Coburn in the UnitedStates had shown a direct correlation between the

geographical and seasonal distribution of hsemolyticstreptococcal throat infection and acute rheumatism :also that poverty and unhygienic conditions favouredboth throat trouble and acute rheumatism, and

bacteriological investigation demonstrated a closeassociation between these in susceptible persons.Coburn had also shown that those who escapedrespiratory disease remained free of rheumatic mani-festations, and that most of those who, having hadrheumatism, developed a pharyngitis of streptococcalnature had a recurrence of rheumatism soon after thethroat infection.

Dr. Glover also dealt with some epidemics insemi-closed communities of various kinds, in whichthe cases of acute rheumatism were associated withan epidemic of tonsillitis due to one serological strainof haemolytic streptococcus. Paul and Salinger hadmade a study of 15 rheumatic families, and theyfound that" non-specific" respiratory infectionsoccurred before the appearance of characteristic acuterheumatism. They also found that the health of theparents was not so good in rheumatic as in controlfamilies. Dr. Glover considered that the results of

investigations in recent years did not justify a feelingof pessimism as to the future.

Dr. REGINALD MILLER said that of the causativefactors of juvenile rheumatism, three sets emerged:(1) the bacterial cause circulating in the blood stream ; I

(2) the predisposing factors; and (3) the excitingfactors. In 1923 he put forward a plea for the

investigation of the causes of the class incidence ofjuvenile rheumatism. The profession possessed a

mass of knowledge of the natural history of thedisease, and that was probably in the main right. Itwas agreed that the disease was essentially one of thepoorer classes, but he questioned whether it could beregarded as a true poverty disease in the sense thatactual poverty and squalor determined its classincidence, and this view was supported by the figureswhich showed that it was in the two better-circum-stanced of the three divisions of hospital class childrenthat the incidence was highest. Dr. Miller did not

regard even damp as the determining factor, thoughdamp and cold were exciting factors. To move

children of the rheumatic stratum from their homesand transfer them to poor-law boarding schoolssufficed to prevent the appearance among them ofrheumatic infection. He did not feel very clear as tothe position on the subject occupied by hsemolyticstreptococcic infection. If it were proved that thecausative agent of juvenile rheumatism is a haemolyticstreptococcus. there would be need for a considerablerearrangement of prevalent ideas ; but more evidencethan was now available would be needed to establishthat view. It was well known that epidemic sore-throats would activate rheumatism. With regard toallergy, he agreed with W. Sheldon that if it wereknown what was happening in the interval betweenthe throat infection and the occurrence of systemicrheumatism, much of importance would be revealedin the pathogenesis of carditis. It was in connexionwith this latent period between the two that Dr. Millerlonged to be able to accept some explanation involving

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allergic reaction, as suggested by Schlesinger, Mac-donald, and others. One proposition was that aninfectious sore-throat might set up juvenile rheu-matism, though one of these was due to a haemolytic,the other to anon-haemolytic, streptococcus. It had

long been known that epidemic sore-throats such aswere usually associated with haemolytic streptococcalinfections could at least unmask or reactivate

rheumatism ; it was not so certain that it could

originate the disease. Could it be held, he asked,that apart from outbreaks of rheumatism secondaryto outbreaks of epidemic sore-throat, the ordinaryseemingly sporadic case of juvenile rheumatism wasset up by latent or accumulating infection by hsemo-lytic streptococei ? If this were proved it would bea consideration of great importance. The BritishMedical Association report seemed to have been rightin saying that juvenile rheumatism was essentially adisease of children of the artisan class who lived indamp houses in industrial towns, attending a publicelementary school under compulsion, and sufferingfrom infected tonsils. But knowledge at present didnot justify the arraignment of any single factor.Dr. W. S. C. COPEMAN thought it most probable

that acute rheumatism was an infection, and if so,the importance of secondary factors was not lessened,as they could modify the clinical course of the disease.Soil, climate, barometric variations, wind, degree ofdamp, temperature, poverty, ventilation. and over-crowding all had their importance. He suggestedthat the physiological manifestation of the rheumaticdiathesis lay in an abnormality of the heat-regulatingmechanism of the skin, and hence the failure ofrheumatic children to adapt themselves climato-

logically to their environment. We were exposed tonatural climate for only a fraction of our lives ; duringthe remainder of the time we lived in a climate of ourown choosing, the surroundings lying between theinside of the clothing and the surface of the skin, orat night, the bedclothes. To eliminate a layer ofmoisture from the skin surface, the clothing must beporous and also heat-retaining. Often in the kind ofcases under discussion the dietetic factor was operative,and this might not merely mean a defective calorieintake, but, as Dr. Warner suggested, it might extendback to the beginnings of the disease. It was difficultto see how overcrowding could be a factor, as it wasinvariable below a certain poverty level. He thoughtthe comparatively minor aetiological factors should bemore studied ; there still remained a great field ofclinical research on the subject.

Dr. E. C. WARNER said that in discussions on this

subject it had usually been assumed that rheumaticdisease in childhood was primarily of infective origin.This was true of rheumatic carditis, but not demon-strable as to all rheumatic manifestations. In thecase of chorea without carditis there was a considerableamount of evidence against the hypothesis of aninfective encephalitis. In these cases, too, thesedimentation-rate did not show any rise from thenormal, but immediately on the supervention ofcarditis-even before its clinical evidence-the sedi-mentation-rate rose. Some of the manifestations ofacute and even subacute rheumatism might be, hethought, non-bacterial in origin. A study of the classand familial incidence of rheumatic disease and of thebiochemical evidence suggested that a metabolicfactor played an important part. In many rheumaticfamilies inquired about the total calories of food wereample-i.e., an average of 3250 per man-value perday ; nor was there evidence of deficiency of protein.But among rheumatic children the consumption ofanimal fat, in the form of fresh milk and butter, was

diminished in comparison with that consumed by thecontrols, chiefly because rheumatic children dislikedthose foods. Rheumatic children, however, showeda fondness for potatoes. It emerged from an inquiryat a public school that on a diet rich in both animalfats and other constituents there was a markeddecrease in rheumatic disease. An inquiry in regardto chorea showed that the calcium content rose inthe cerebro-spinal fluid, while the phosphorus fell.

Many observers had noted a history of a period ofgeneral debility in those developing rheumatism orchorea ; this debility may have had a dietetic cause.

Dr. R. L. J. LLEWELLYN put forward the view thatthe cause of acute rheumatism lay mainly in the skin,only secondarily in the joints and bones. In thecomplex adaptive processes of the body the cutaneousglands, especially the sebaceous glands, participatedto a marked degree ; in infancy and young childhoodthose glands were practically inactive, hence therewas a lack of protective and lubricating sebum, withthe resultant sensitivity to dampness and humidity,and deficient heat retention. The chief chemicalconstituent of sebum was cholesterol, and he believedthe hereditary make-up largely determined whetheror not a child would escape rickets or acuterheumatism.

Dr. C. BRUCE PERRY said that Dr. Warner’sremarks on the normal sedimentation-rate of theblood in cases of uncomplicated chorea were closelyparallel to his own findings, but as Dr. Warner hadsaid, the onset of a clinically recognisable carditis

might be preceded by a rise in the sedimentation-rate. With regard to the investigation into rheumatismoccurring in Bristol and the three surrounding counties,a closer study of the figures for Bristol itself hadshown that in the three years (1927-30) there weregreater differences of incidence in respect of freshcases of rheumatic heart disease between the variousparts of the city than between Bristol as a whole andthe three counties. The city ward with the highestincidence had 3-7 cases of rheumatism per 1000 of thepopulation, whereas the lowest incidence was 0-15 per1000 (in Clifton and Redlands). If a concentrationof h2emolytic streptococci played a very importantpart in this striking distribution, the incidence ofscarlet fever over the same period should show aparallel distribution : this, however, was far frombeing the case. Diphtheria had a spread similar tothat of scarlet fever. The Bristol inquiry seemed toshow that it was not the infection itself which was sovitally important, but the soil, the child’s diathesis,and his environmental conditions which allowed aninfection of the disease to gain a footing.

Prof. J. A. NixoN, commenting on the fact thatthe incidence of acute rheumatism in poor-lawresidential schools was low, said this was so also ininstitutions for mental defectives, and also with regardto respiratory infections generally. Yet there hadbeen a number of outbreaks of scarlet fever in thoseinstitutions.

Dr. LEONARD FINDLAY said probably most medicalmen were agreed that acute rheumatism was aninfectious disease, and if that were conceded it wouldbe astounding if social conditions had no influence onits incidence, either by favouring transmission or 1~,yundermining the general health of the individualpatient and so rendering him more susceptible toattack. But the specific cause of the disease was stillto seek ; he did not think the causal culpability of thehaemolytic streptococcus had been made out, despiteDr. Glover’s arguments. The illustrations supportingthe original work of F. J. Poynton and AlexanderPaine on rheumatism showed many forms of organism

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in profusion, not only in the endocardial but also inthe joint lesions. There was some other factor ; wasit a symbiosis, or was it simply a matter of environ-mental influence ? ‘ That Dr. Warner should havetaken chorea as a manifestation of acute rheumatismwas not very happy, as the speaker regarded it as oneof the least of the rheumatic presenta,tions. One

thing which had been abundantly made out in all theinquiries was the great need among the poor ofdecent and sound houses to live in.Dr. E. W. GOODALL asked as to the association of

tonsillitis with the cases of acute rheumatism referredto by Dr. Glover. In the usual way one would notexpect acute rheumatism to be infectious from onepatient to another.

Dr. GRAY HILL said that among the 3000 inhabi-tants of the hospital where he worked at Carshaltonthere were seldom any manifestations of rheumatismwith the exception of chorea. It was on a chalk soil.The children lived under very good hygienic conditions,and the diet was generous. His view was that acuterheumatism was largely due to bad environmentalconditions.

Dr. GLOVER, in reply, said that practically all thecases of acute rheumatism he had been referring tohad had tonsillitis. He did not agree that anyinfectious disease would activate acute rheumatism ;for the latter to develop he considered there must bean infection with hsemolytic streptococci. A hightonsillectomy rate did not increase the resistance tothe invasion by streptococci ; the influence was theother way. He thought that an inquiry worth

carrying out would be to take a number of rheumaticfamilies and a number of control families and keepa record of the illness of every member, week byweek, in parallel lines, and, in addition, to take aweekly throat swab.

Dr. REGINALD MILLER said he thought it was

important to study communities which were freefrom rheumatism, and that was done by the B.M.A.Committee. He agreed that the inhabitants ofinstitutions for mental defects were notoriously freefrom rheumatism and heart disease, and it formedone of the reasons for thinking that the wear and tearand exposure incidental to compulsory school atten-dance was a factor in the production of rheumatism.It was a serious matter for anvone at this date tocast doubt on the infective origin of acute rheumatism.

SECTION OF UROLOGY

AT a meeting of this section held on Jan. 25th thechair was taken by Mr. A. CLIFFORD MORSON, thepresident, and a discussion on the

Factors Influencing Renal Functionwas opened by Dr. T. IzoD BENNETT. The factors,he said, were numerous and complicated. Theymight be classified as intrinsic or anatomical changes,and extrinsic, including mechanical, circulatory,lymphatic, and nervous groups. Bright’s diseasebelonged to the first group and would be better knownby the term" ischaemic nephritis." Cases of highblood-urea with high blood pressure were familiarto every physician ; blood -pressure estimation shouldform part of every urological investigation, both toavert catastrophe and to add to knowledge of thesubject. There were cases of temporary ischsemiasufficient to produce severe change in renal function.Dramatic disaster occasionally followed passage ofan instrument; such cases were mysterious and rarebut were probably due to a reflex iscbsemia resultingin suppression. Cold sponging might cause suppres-

sion of urine ; cold on the skin might be the originof the nephritis of sailors and others exposed to badweather. Far more numerous were the changes inrenal function due to alterations in the quality of theblood reaching the kidney. Infections headed thelist, followed by the various poisonings, which some-times produced specific lesions. For example, mercuryaffected the convoluted tubules only while the effectsof lead were seen mainly in the glomeruli.

Changes in the relative normal constitution of theblood played an important part. The hormonecontent of the blood profoundly influenced urinaryfunction. Alterations in renal function brought aboutconsiderable change in the blood and, conversely, if therelative concentration were changed a diminution inthe secreting capacity might result. The decidingfactor in all these cases was probably the establish-ment of an oliguria ; if the water-supply were reducednitrogen retention would appear and would then stillfurther interfere with renal function, possibly pushingthe patient into um.mia. A salt-free or high-proteindiet, alkalosis, severe vomiting with depletion of

chloride, or intestinal obstruction might produce thisstate. Post-operative suppression of urine was a

similar condition. The blood-urea always rose afteroperations, and if there was a slight impairment ofthe kidney the resulting nitrogen retention might befatal. Post-operative vomiting might be a vital factor.Prophylactic normal saline intravenously was saidto have the greatest value in preventing suchcatastrophes.No adequate estimate of renal function could be

formed without blood and urine analysis. Beforeany evidence of nitrogen retention was available thekidney might show failure to concentrate urea.

Important information about the urine was : thespecific gravity, urinary flow, result of the water testand of the urea-concentration test (il2acLean), and ofthe urea-clearance test of van Slyke. The urea-clear-ance test was far more valuable than any other singletest, but it only represented the patient’s renal func-tion at one particular moment. It must be repeatedat intervals if a fair picture of the kidney were to beobtained. Nor should it replace full analysis of theblood or the other urinary tests.

Another group was the nephrosis group, character-ised by oedema and albuminuria. In these the vanSlyke test might be normal. A rising blood pressurewas ominous. Experience of the van Slyke test inacute nephritis showed that apparent improvementsmust not be taken too optimistically. Special post-mortem inquiries ought to be held on renal tragedies :careful blood examination before death would showwhether the patient died of nitrogen retention,acidosis, or hypocalcfemia, and this information wouldforewarn the physician on other occasions. Dyeswere of very little value as tests of the total renalfunction. Estimation of the kidney output, coupledwith estimation of the intake, might give valuableinformation. All methods of estimating renal func-tion must give way to careful clinical investigation.

OBSTRUCTIVE LEStOXS

Mr. DUNCAN MoRisoN said that stasis and infectionwere closely related and often superimposed one onthe other. Primary obstructions were most oftenfound at the sites where there was anatomicalnarrowing : an obstruction near the kidney wouldmore rapidly produce more grave renal impairmentthan one further away, but there were exceptions-for example, if the kidney pelvis were extrarenal andso could absorb back pressure by expanding. Allthe lesions produced straining, leading to relaxation

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and stasis. Stasis might also be due to neuromusculardysfunction. Some of the lesions might only be foundin the course of routine observation ; a kidney mightbe completely destroyed without symptoms.Secondary obstructive lesions followed infections

and constituted a large group. A typical examplewas gonococcal infection. Gradual fibrous infiltrationof the bladder floor and outlet led to back pressureon the kidneys. In women a corresponding lesionwas usually attributed to trauma in childbirth. Therewas chronic trigonitis and the ridge was pulled downinto a U-shape. Resultant ureteritis led to dull

suprapubic pain. Influenza, septic foci, and similarupsets might cause urinary infection. The chief sitesof ureteritis were at the pelvo-ureteral junction,where the ureter crossed the iliac artery, at the broadligament, and at the junction with the bladder. The

corresponding sites of pain were : just below the ribsat the side ; just lateral to the umbilicus, in the iliacfossa, and above the pubes. A ureteritis might bea zone of irritability with attacks of spasm or theremight be permanent narrowing with back pressure.Any departure from the normal process of drainagethrew a strain on the kidneys. For a time the inter-ference was so slight that tests were uncertain, butthere were vague symptoms such as headaches,fatigue, and loss of mental clarity. Symptoms dis-appeared when the ureteritis was treated. A lateralas well as an end-view urethroscope should be usedboth for adults and children in order to obtain a clearidea of the lower tract. Whistle-tipped cathetersshould be used for the upper tract. Intravenous

phenolsulphonephthalein tests were useful. Bulb

bougies or catheters were necessary for investigatingureteritis. Pyelography was instructive as collateralevidence but less precise than bougies. It was difficultto define exactly what was recoverable and what waspermanent impairment.

Dr. CUTHBERT DUKES showed slides illustrating theeffects on renal tests of operations, intestinal obstruc-tions, and urinary obstructions. A minor operationon a healthy man might reduce the urea-clearancetest from 75 to 50 per cent. for 24 or 48 hours. Severeabdominal operations effected a tremendous alterationfor 24 hours ; the test might drop from 105 to 15 percent. The defect was over-compensated by a dayor two of over-function afterwards. Intestinalobstruction, in the absence of any kidney disease,might be accompanied by a drop of 10-20 per cent.In a fatal case of paralytic ileus the blood-urea rosesteadily, but so did the urine urea, the kidney makinga valiant effort to deal with the situation. In uraemiathe clearance test fell to about 10 per cent., but inthe ileus cases it kept up until just before death. Whena patient had urinary obstruction the test fell verylow. Different forms of test might be required forthe investigation of different types of disease. Theurea-clearance test had great scientific and medicalinterest.

DISCUSSION

Mr. K. H. WATKINS spoke of the phenolsulphone-phthalein test, which he had found most useful.Specimens were taken each half-hour after the injectionof phenolphthalein. The greater part was excretedin the first half-hour and then the curve fell for twohours. Delay appeared, in c:se.s of obstruction, atthe onset, the peak, and the two-hour eliminationpercentage. An excellent graphic representation ofrecovery after relief of obstruction could be obtained.The test was simple to carry out; a large volume ofwater should be given beforehand.

Mr. E. W. RICHES described work on the urea-clearance test in surgical cases. The clinical condition

of the patient was the most reliable index of renalfunction only in extremes ; in borderline cases

laboratory tests were of value. He had taken 60 percent. van Slyke test as the index between one-stageand two-stage operations and had not since lost acase. A tuberculous kidney could be removed withquite a low clearance test. When one kidney wasabsent or functionless the test might still be 100 percent. It tended to rise after nephrectomy providedthe bladder and remaining kidney were healthy.Infection seemed to be the most potent single factorlowering the urea clearance.

Mr. H. P. WiNSBURY-WHiTE said that there wereoften operative dangers not reflected in renal functioncapacity. The tests must be kept in their place ;equal consideration must be given to clinical facts.They showed some facts that clinical observationcould’ not reveal. Urinary drainage greatly reducedrisks in urinary manipulations and operations. An

extremely debilitated patient could be coaxed backby stages to a condition suitable for prostatectomy.The process was well reflected by function tests. The

specific gravity charted in relation to meals was auseful piece of information. The concentration testwas not nearly so reliable as the water test.

Dr. GEORGE GRAHAM pointed out the importanceof infection in lowering renal function. Alkalosiscould be produced by vomiting ; alkali treatment for

post-operative vomiting was therefore entirely wrong.Intravenous saline, glucose, and insulin or acidadministration would save many of these patients.Other cases bad an acidosis and could be helped byalkalis. The acidosis patient often showed air-

hunger like that of diabetic coma, but the breathingin alkalosis was very quiet. The alkaline reserveshould be ascertained. Whenever acid or alkaliwere given a check on the blood should be kept.If a patient were practically starved he would excrete6-7 g. of nitrogen in a day, but would excrete nomore if he were given that amount in his diet ; equallygood results would be obtained, therefore, by givinga certain amount of food in acute nephritis.

Mr. SWIFT JOLY distinguished between reduction inquantity and in quality of renal function. In theformer type much less urine was excreted thoughqualitatively the urine appeared good. In most

surgical cases there was reduction in quality butmight be increase in quantity. The elimination ofwater was important in prostatectomy; he alwaystried to double it before operation. Where there hadbeen a voluntary reduction of intake of fluid, operationwas singularly dangerous. The percentage of ureacould be ignored, but a, good result could be expectedif the patient excreted a tenth of the dose given everyhour afterwards. The test could thus be done withoutreducing fluid intake.

LIVERPOOL MEDICAL INSTITUTION

AT a meeting of this institution on Jan. llth, withDr. H. R. HURTER, the president, in the chair, a.

communication on the

Differential Diagnosis of Pregnancywas made by Prof. A. LEYLAND ROBINSON andMr. M. M. DATNOw. They pointed out that the

physical signs and symptoms of pregnancy might beobscured or simulated so that in all complicated casesclinical methods alone might not suffice for diagnosis,even in late pregnancy. Radiography gave decisiveresults from the fourth month onwards, but affordedno help before the sixteenth week. In the early weeks