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thing new; I wish only to corroborate and to propagato astriking truth which is, unfortunately, not yet generallyaeknowledged. If one has at once to deal with sixty seriouscases of typhoid fever in otherwise strong young men, theconditions are too evident to allow deception. Of these

sixty cases, I have lost to this time one case from peritonitis,two from intestinal hsemorrhage, and a fourth will probably Ibecome fatal through profuse diarrhosa, though the typhoid

I’fever may be said to have passed. If I consider this case Ias fatal, the mortality is 6’6 per cent. As far as I remem-ber, the mortality in the German clinical hospitals beforethe introduction of the antipyretic treatment varied from12 to 25 per cent., but has been reduced by this method toa similar figure as the one obtained by us. To avoid mis-

understanding, I repeat that the sixty cases in questionbelonged all to the gravei- type, while the others (about 130)were registered as mild typhoid fever. We may from thisexperience, at all events, draw the inference that, under acareful but persistent antipyretic treatment of typhoid fever,few patients, if any, will die of exhaustion in consequenceof the febiile temperature continuing for weeks, and thecauses of death will be restricted to less frequent com-plications.The moderately cold bath and the quinine exercise, be-

sides their immediate effect on the febrile temperature, avery beneficial influence on two other conditions importantin typhoid fever. The frequent baths promote cleanliness,so necessary on account of the diarrhoea, and through thisgreatly diminish the tendency to bedsores, which is furthercounteracted by the application of unguentum cerussse,with camphor (twenty parts of the former to one part ofthe latter), to any patch of skin becoming red. The largedoses of quinine administered in the evening have a calm-ing effect, as well on the action of the °°humours" as onthat of the nervous system ; and through this the nocturnaldelirium, this horror of hospitals crowded with typhoidfever, was almost absent. If the effect of the cold bath onthe 11 heated humours" had already diminished their ten-dency to irritate the brain, fifteen to twenty-three grains ofquinine completed the calming influence; and thus we neverrequired more than two night attendants in each of ourtyphoid wards, containing thirty patients. I ought to men-tion that all the patients received, after the bath, a glass ofsherry or Marsala. This was done with the intention (1) toincreas e the cooling effect of the bath by the internal anti-pyretic remedy (alcohol), though it exercises, given in thisway, only a transitory influence; (2) to revive the action ofthe heart, which is generally rather depressed after thebath ; (3) to counteract the sometimes excessive feeling ofcold, which is principally caused by the contraction of thecutaneous capillaries. In connexion with this subject youwill be glad to hear that two cases of Marsala supplied bythe dep6t of the English National Society at Remilly havebeen especially useful in the treatment of these cases.

January, 1871. _____________

THE CAUSATION OF SCARLATINA.

BY ALFRED CARPENTER, M.D. LOND.(Concluded from p. 112.)

THE spontaneous origin of scarlatina is also occasionallyshown in the colonies. Thus in 1848 it suddenly made itsappearance in Auckland, New Zealand, as reported in THELANCET of June, 1850, by Dr. Thompson, of the 58th Foot.N’6 communication had existed with any other place by seafor four months previous to the outbreak. An emigrantship had arrived the preceding January, but no case ofscarlatina had occurred during the voyage out. The firsttwo cases occurred in different streets on the same day.Simultaneously with its appearance at Auckland it also

appeared in Sydney. It was not shown in the report thatblood was the source, but as in every place where Europeans,and especially Englishmen, live blood is often allowed to ilie on the ground, and animals to be slaughtered withoutreference to any sanitary regulations, it is evident that, ifI have indicated the right cause, it may exist anywhere.

If the disease can arise spontaneously, any measures that

may be taken by the local authority or the imperial govern-ment on the idea that it is produfc’} by contagion willfail. It becomes necessary thercf’)re t.o e.9; rid of tl1:l,j, idea;but at the same time it is not to be assumed that by the term°° spontaneous" it is I11Cltnt that the disf’ac:;e win arise with.out a first cause. It is contemlcd that the molecules con-tained in blood-the germinal matter upon which probablythe vit:11 force of the animal depends-do, under certainconditions of air, moisture, and magnetic action, become sochanged as to be able to set up one or other of the epidemicdiseases of the scarlatina type. If these inolectiles got ad-mission into the blood of a living person, they rapidly pro-duce an action of a zymotic character, and probably set freea product allied to the formic acid series, which, being ex-pelled by the capillaries in minute quantities, sets up thestate of the skin which is so indicative of the disease underconsideration, and allies it with erysipelas, some forms ofpuerpera,l disease, and especially those rashes which aresometimes seen to arise in surgical cases, and which maybe caused by decomposing blood in the body of the patienthimself.Annexed is a table which shows the rise and fall of the

death-rate from scarlatina during the last 22 years in

Croydon. It gives negative evidence, but it points out someimportant facts.

Table showing the occasional rise of Scarlatina since1848 in C1’oydon.

There have been four epidemics, though it has never beenquite absent for long together; every quarter of the yearhas had its quota of cases, but it is seen that the largestnumber generally occurred in the last four months of theyear, although in 1849 and again in 1863 it was in the firsthalf of the year that the greatest mortality occurred. Dr.B. W. Richardson has published a statement showing theaverage mortality in London from scarlatina per 1000 ofliving population, derived from statistics extending overseven years. This is fixed by him at 1’10, whilst we have hadit several times above the London average. The excessivemortality would seem at first sight to be opposed to the ideathat sanitary supervision diminished mortality, but by dis-secting the cases the result is shown to be as represented.The poor have provided 95 per cent. of the fatal cases, whilstthe mortality among the citizen class has been very slight;and it is to be borne in mind that the citizen class form inCroydon a very considerable moiety of the whole population.The analysis of deaths at various ages for the past two

years exhibits some differences when compared with Dr.Richardson’s tables. He makes the ages of those dying atfive and under equal to 67’63 per cent. ; between five andten, 24-27 per cent.; above ten, 8 per cent. In Croydon, atfive and under they equal 76’5 per cent.; between five and

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ten, they are 12’6 per cent.; above ten, 10-9 per cent. Itis, however, in the first two years that the greatest differ-ence exists: thus Dr. Richardson’s table shows a mortalityat two and under as 32’24 per cent.; but in Croydon it hasbeen 63’7 per cent. of the whole.From this result it may fairly be assumed that the chances

of life being extinguished by scarlatina are greatest in thosewho live least in the open air, and that children in arms,from some cause, have the largest mortality, and of these ithas been seen that a large per-centage consist of childrenbrought up by hand. It is also interesting to note that forsome time no part of the year has been free from the evi-dence of the presence of scarlatina, as shown in the follow- Iing table of deaths in every month during the past two ’’

years. lRR9. 1HM

The next point to which the writer has directed specialattention has been the locality in which the deaths haveoccurred. They have taken place in 46 streets or roads outof the 256 existing in the parish. Three districts have hadthe largest numbers of fatal cases, single dots upon themap alone marking other parts of the parish. There isonly one point common to each of these three districts:they are comparatively 6at they have lines of sewers along distance from the outfall, and, as far as the poor areconcerned, the house-connexions with the sewers are imper-fectly ventilated, and, most significantly, they have slaughter-houses in connexion with these lines of sewer. One of thesedistricts is mainly on cha/!k; the second is principally a claysubsoil; whilst the third has clay upon gravel, or gravelupon chalk, as its principal substratum. It follows fromthis that terrestrial or subsoil influence has not been ex-erted as far as gravel, chalk, and clay are concerned. One ofthe districts has in it a number of badly made roads, anduntil recently they were not under the supervision of thelocal authority. These roads became swamps after everyheavy rainfall. This district contained the largest numberof fatal cases. There are two very observable facts with

regard to the houses in which the fatal cases occurred. Themajority of deaths took place in comparatively new houses ;many of them built without foundations upon garden-ground, the aluvial soil not being removed, except such ofit as was used for mortar. This garden-inoiild, with itsdebris of manure (often animal), was simply screened,scarcely more lime being used than was sufficient to makeit sticky. The houses were frequently occupied-before theywere dry; and it is evident that a low state of generalhealth must be induced by living in an atmosphere such aswould exist in such buildings. Of the whole of the fatalcases, about 92 per cent. occurred in cottage property, andabout 80 per cent. in houses which have been built withinthe last five or six years.An analysis of a table of the absolute mortality from

scarlatina shows a decreasing mortality in each of the fourepidemics which have arisen in the last twenty years, if wecompare the deaths with the total population. Thus,in 1849, it was 1-81 per 1000 living; in 1852, 1-65, in1863, 1-64; in 18G9, 1,W; iu 1870, ri44. The largestmortality in any given month has been after a con-

tinuance of hot weather, often closely following uponheavy rains, though rain itself does not increase the

tendency to the disease, for a continuous wet season hasbeen comparatively free from it. This fact correspondswith observations made by Dr. Ballard. The heavy rainsmust come after a hot, dry season to be most effectual.Then the badly made roads become swampy; the badly laidsewers have the deposit stirred up in them, and developedgases find their way in a comparatively concentrated form

into the houses, both by,means of unventilated sewers, andthrough the soil of the foundations of the new cottages.The children of the poor suffered most, being compelled tolive in an impure atmosphere, by which the member y inthe equation became inordinately increased, and this classtherefore afforded the largest number of victims.

This theory is borne out by my own experience. I havehad under my care during the last ten years 286 cases. Thegreater number of these have occurred in children betweenthe ages of six and twelve, very few infants having sufferedat all. About one-fifth have taken the disease at school;others have fallen ill after visiting a neighbourhood inwhich it has been prevalent. In only two instances hasthere been a spread of the disease to other members of thefamily. Not one of these 286 cases terminated fatally.Four had renal dropsy as a sequence, and two acute rheu-matism. Those were all cases which were brought homefrom other places. Very few suffered much from throatmischief.These facts do not support the view which is often ex-

pressed, that mild cases are more likely to have sequelsethan severe ones. The freedom from fatal results whichhas attended these cases arose from the fact that they alloccurred among the comparatively wealthy classes; theywere all well fed, had pure air, pure water, and had not im-bibed any of those matters which increase the amount of y yin the system. A moderate system of isolation and disin-fection only was adopted. In a few cases the symptomswere severe; but that severity was always accompanied byevidence of imperfect ventilation, either of the house itself £or of the sewers belonging to the house, or dirty habits. Thecases were distributed in all parts of the parish, fairly mixed upwith the poorer populations, and notwithstanding the highmortality among the children of the poor and the completeabsence of any kind of isolation and disinfection amongthem. When the disease appeared in the residences of theirricher neighbours, the type was changed into one of a mildform ; the constitutions of the new recipients of the infec-tion not having been lowered by an increase of y frombreathing a sewer atmosphere, by drinking impure water,or inhaling anything derived from the products of cess-pool or animal putrefaction. Several of the cases are believedto have been produced in children after playing about themanure heaps deposited in the gardens, two or three dis-tinct and very suggestive instances having presented them-selves of children suffering after slaughterhouse and pigmanure had been so used. Great difficulty has also beenexperienced in keeping blood out of the sewers; when itdoes get in, it cannot be flushed away, as it often adheresto the surface of the sewer until decomposition enables itto separate, and it then gives out products correspondingto z in the equation.*

I believe that scarlatina would be shorn of its fatal ten-dency if blood was not allowed to be shed in our towns andvillages, except with certain precautions, so that none shouldenter our sewers; if our houses were built on proper founda-tions and well ventilated, and if pure water were alwaysprovided for the people; if sewers were so constructed asto be self-ventilating, and that continuously, and so arrangedthat the products of excrement putrefaction could not pos-sibly pollute the air of dwelling-houses.The record of 28G cases, extending over a period of ten

years, being all the cases I have continuously attendedupon without a fatal result, and that in a district in which403 fatal cases did occur during the same period of time,the mild cases mixing with the severe ones, and derivingtheir origin from corresponding sources, must point tosome exceptional cause for such an exceptional result. Ibelieve the exceptional causes to be the circumstances men-tioned; and that searlatina is as amenable as typhus tosanitary operations; that it can be gealerated de novo; and

* I should have meutioned here the frequent connexion between scar-latina, Hnd puerperal fever, All cases of that disease which I have metwith, and which have arisen without good evidence of infection, have beenattended by the presence of putrid blood in an uxcontracled womb. Insome cases in which scarlatina, has been developed in lying-in houses, therehas been evidence ofneg!ect in removing the re,ults of haemorhsge, clotsof blo<.’d being’ left abotet the bed, or blood has soaked into the bed and notremoved. In some casas I have had reason to doubt the wisdom with whichThe nurse has disp, sed of the placenta and clots of blood following upondelivery; for outbreaks cf scarlatina are so often coincident with confine-ments m various locdities that I think the medical attendant would dowell to inquire as to its disposal, and not allow it to go into the cesspoolor the sewer. Placenta: are often found at our outfall.

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that if the portion represented by the member z falls intothe blood of a patient which is not loaded with impuritycaused by defective sanitary measures, and here representedby y, then its effects will be comparatively harmless, andthe xy z will give scarlatina of the mildest possible type,and will be quite free from danger to the recipient, sequelaewill not follow, and very moderate means of isolation anddisinfection, with&mdash;most important point of all-free venti-lation and fresh air, will be quite sufficient to prevent anyspread of the disease.

HERNIA IN COUNTRY PRACTICE.

BY WILLIAM MORRIS, M.R.C.S.

CASE 1. Strangulated Femoral Hernia; opening of sac; re-covery.-Mary H-, aged fifty-six, housewife, residing atRiver, applied to me on March 8th, 1869. She stated thatfor about twelve years she had occasionally had a swellingin the right groin, which had hitherto been reducible. On

March 3rd she commenced to suffer from an attack of

bronchitis, and on the 6th, during a fit of coughing, thetumour came down and could not be returned; she was sickfrequently, and between this date and the evening of the8th some of the vomited matter was stercoraceous. Opiumwas administered and ice applied, and the taxis in thehot bath was employed fruitlessly; but consent to an opera-tion was refused.March 9th.-With the assistance of Dr. Turner, I ope-

rated by making a vertical incision along the inner side ofthe tumour, laid bare the sac, and divided Gimbernat’sligament, and again used taxis, but to no purpose. Thesac was then opened, and found to contain a coil of light-claret-coloured intestine, which was returned after dividing ’,a stricture at the neck of the sac. The wound was dressedin the usual way.On the 12th the bowels acted, and a large quantity of

solid f&aelig;ces was passed. In a fortnight from this time thewound had nearly healed, but there had been and still wassome discharge from it. She still suffered from bronchitis,but on April 3rd was able to leave her bed and get abouther room. She is now quite well.CASE 2. Strangulated Inguinal Flernia opening of the sac ;‘

recovery.-Sarah C-, aged sixty-three, housewife, livingat Petworth, had for several years a small irreducible herniin left inguinal region. Towards the evening of Feb. 5th1870, she was suddenly seized with severe pain about theswelling, and vomiting. She applied at once for relief. Thetumour, which was the size of a walnut, was very tense, butgave decided impulse on coughing. Taxis was at once em-ployed, but failing, opium and ice were resorted to. Next

morning, as the hernia still resisted taxis, and the vomitedmatter was stercoraceous, an operation was suggested, butnot acceded to till the evening, when it was performed byme, assisted by Dr. Turner and Mr. H. Morris. The sacwas opened, and a small knuckle of ileum, nowhere highlycongested except around the portion constricted by the neckof the sac, was returned.For a fortnight afterwards there was considerable dis-

charge of pus from the wound, but by the beginning of thefifth week from the day of operation a truss was worn, andthe patient able to get about. She is still living and well.CASE 3. Strang2clated Femoral Hernia; sac, containing a

large piece of omentum enclosing a coil of ileum, opened; ;sloughing of the bowel and apposed surface of omentum, withadhesions between the two; omentum removed; rupture ofthe bowel within thirty-six hours after operation; recovery.-Mrs. R--, residing at Lavington, had had for eight yearsan irreducible femoral hernia, forming a tumour in theleft groin as large as a hen’s egg, and which she had allowed’to go unnoticed till the morning of March 9th, 1870, whenshe awoke with pain in the left groin, and a feeling of sick-ness followed by actual vomiting. Between this date andMarch llth she vomited three or four times, and towardsnight the vomited matter became stercoraceous. Therewas considerable pain about the tumour and tenderness atthe lower part of the abdomen. Opium was administeredand taxis employed before and after the application of ice.An operation was then proposed, but declined.

On March 12th Mr. Henry Morris saw the patient withme. She was then tolerably free from pain except alongthe lower margin of the ribs; the abdomen was somewhatdistended and tender; her bowels had not acted since theattack commenced; her tongue was slightly furred; pulse84, regular and full. An operation was again urged uponthe patient and her friends, but positively refused at thattime.

Early in the morning of the 13th, on visiting her withDr. Turner and Mr. H. Morris, we found she had passed aquiet night and had not vomited, but was suffering painabout the swelling, the skin over which was of a deep-redcolour, and there was much tympanites and tenderness ofthe abdomen. Operation was now permitted, and performedby Mr. H. Morris. An incision, rather more than threeinches in length, was made through the skin and subjacentstructures along the axis of the tumour, and the sac reached.This was laid open and found to contain a piece of omen-tum, spread out so as itself to form a complete sac of thesame thickness everywhere except at the inner and lowerfront part, where it was so thin as to allow a coil of highlycongested bowel which it contained to be seen through it.The neck of the sac having been freed from all external ad-hesions and constrictions, the sac of omentum was laid openfrom end to end, and the " bend" of the contained ileumwas found adherent to the fundus of the omental sac bybands of soft lymph. On separating these, an ashy-grey,sloughy, and uneven-looking patch, about the size of asmall almond, was seen at this part of the bowel, whichappeared almost perforated; and the inner surface of theomental sac opposite to this part of the ileum was alsorough and sloughy-looking. The omentum was now drawna little further out of the abdomen and tied by one firmlyapplied ligature, the ends of which and the tied piece ofomentum were cut away, and the pedicle returned justwithin the abdominal cavity. The intestine was left with itssloughy portion protruding without the crural ring. Twosutures, one at the upper and one at the lower part of thewound, were inserted, and the whole covered with a warm,soft napkin. Between the time of operation and the even-ing she had vomited four times, the vomited matters beingonce stercoraceous ; her pulse was 86 and regular ; therewas inability to void urine, so a catheter was passed, and apint drawn off.In the evening of March 14th, about thirty-six hours after

the operation, a loud report, as of wind escaping suddenlyfrom a distended bag, was heard, and, on examining thewound, fsecal matter was seen escaping from the rupturedgut, which remained still in stht.March 17th.-Pulse 100; tongue somewhat dry; abdomen

generally distended and the seat of much pain at intervals;the discharge, which was abundant from the wound tillyesterday, is now very scanty, and she has been sick onceor twice during the morning; there is considerable rednessof the skin around the wound. Both sutures removed, anda warm bread poultice applied to the part; opium givenby the mouth every three or four hours, and a little brandyand light farinaceous diet taken regularly.

April 3rd.-All evacuations from intestines pass throughthe wound, the skin around which is eczematous. Thereare two small sinuses, one large enough to admit a good-sized probe, through which fine coils of greenish, non-offensive matter pass.17th.-To-day faeces have passed by the rectum, for the

first time since operation; there is still some slight dis-charge from the sinus in the groin. No aperient medicinehas been given throughout.24th.-No discharge from groin; all is healed except a

sinus of hair-breadth fineness. She now gets up and abouther room.27th.-Wound entirely healed.She is still well, and walks occasionally eight or ten miles

a day.CASE 4.-Direct Inguinal Hernia; sac opened; omentum

ligatured and removed; recovery. - Ann M aged sixty-seven, housewife, living at Teglease, was hoeing in hergarden on April 20th, 1870, when she felt a sudden impulseand pain in the left groin, and, on putting her hand to thepart, discovered a swelling as large as a hen’s egg. Laterin the day she vomited some clear fluid.

April 21st.-Sickness ceased, but pain continued, and shesought advice. On examination, the tumour was found to