observed and faithfully described will throw more light on this delicate subject than a magazine of statistics gathered indiscriminately from good and bad fields, which, like most medical statistics, are nearly valueless as guides in the hour of emergency at the bedside.

No remedies are more generally useful than opiates in the preventive and curative treatment of the reflex convulsions of dentition, in which class of cases the fits depend upon irritation of the trifacial nerve. It frequently happens, however, that when the child is actually convulsed it cannot swallow. Under such circumstances it is usual to give the opiate in the form of an enema. If the hypodermic method of employing hydrochlorate of morphia can be formulated for safe use in the treatment of convulsions in children, it is obviously preferable on account of its much greater certainty and rapidity of effect. 7, Rue d'Aguesseau, Paris.

STATISTICS OF SCARLATINA.

By H. COURTENAY FOX.
No. I.

ANYONE who has taken the trouble to observe the weekly and quarterly returns of the births, deaths, and marriages in the metropolis, published by the Registrar-General, must have noticed that for three years there has been a great scarcity of scarlatina in London; but from the beginning of last August a marked increase in the deaths from this disease has occurred; they are steadily rising week by week, and there is reason to believe that another epidemic is at hand. The present is therefore a good time to take up the statistics of this disease and see what we can learn of its history and habits.

We may arrange our inquiry under the following heads:1. What is the average annual mortality from scarlatina for England and Wales, and for the metropolis? 2. How is it affected by the different seasons? 3. What are the dates of the different epidemics of scarlatina, and is there evidence of regularity in their recurrence? 4. Does this disease appear to be influenced by sex? 5. How is the mortality affected by the different ages?

The data upon which this paper is based are the quarterly and weekly returns for the metropolis (already alluded to), and the annual reports of the Registrar-General of births, deaths, and marriages in England (including Wales). This series commenced in 1839, and now forms a valuable collection of information (that cannot elsewhere be obtained) on the social growth and progress of England, and on the statistics of population and disease.

1. The average annual mortality from scarlatina is a point of much interest. Dividing the number of deaths by the population, and making the usual corrections-for taking the population at the middle of the year as a divisor, for the slightly unequal lengths of years and quarters, and for deaths from causes "not specified," -we obtain the mortality, using this term in its correct sense of the proportion between the number of deaths and the population. It is, perhaps, unfortunate that prior to the year 1859 no distinction was made in the published returns between scarlatina and diphtheria, and that we are unable to study either disease by itself without limiting ourselves to the comparatively short series of years since 1859. But this need not matter, as I hope to show in a later part of this paper that the mortality from diphtheria alone is so small in comparison with scarlatina that we may practically disregard it.

The average annual mortality from scarlatina and diphtheria for the whole of England, on the series of twenty-four years (1848-71), was 1043 to every million of the inhabitants. That from scarlatina only, for the thirteen years (1859-71), was 923 per million. For the metropolis we have had careful records since the year 1840, from which we obtain an average annual death-rate, from scarlatina and diphtheria, of 1029 per million; whilst the former alone, on an average of thirteen years, has been fatal to 1001 out of each million inhabitants. Scarlatina is, therefore, more fatal in London than in the country at large, in the proportion of 1001 to 923 to each million of the population. It may be interesting to observe some fluctuations in the rates of mortality from this disease. The largest annual death-rate from scarlatina and diphtheria recorded in London occurred in 1848, when the deaths were 2135 per million; but last year (1873) has been an instance of

the lowest known death-rate, which amounted only to 278 per million for the united diseases. These figures show what a wide range exists between the opposite extremes.

2. The influence of season upon scarlatina is another point of interest to the physician. We must often have remarked that this form of fever is most apt to come upon our hands some time in the autumn; and this impression is confirmed by a perusal of the statistics of the disease for a long series of years. Thus, we find that the mortality from scarlatina and diphtheria together, on the average of thirty years, in the metropolis is

For the first quarter, 211 per million.

second third fourth

--so that in the last quarter of the year it is not far short of double what it is in April, May, and June.

A comparison of the deaths as they occur in the different weeks of the year confirms this conclusion. The curve made by the total scarlatina deaths of thirty-two years, distributed in their respective weeks, shows a minimum at the beginning of April. The increase is very gradual until August, when it rises rapidly, and reaches its maximum (which it retains for two or three weeks) in October. The decline from October to April is tolerably uniform.

We cannot, therefore, put down cold as a likely factor in this disease, nor-considering the short period of incubation and existence of the complaint before death-can we with any likelihood attribute it to heat. So far as climatic agency is concerned, these two factors-so important in mortality generally -must be excluded from influencing scarlatina.

3. Scarlatina has prevailed in London as an epidemic seven times since the year 1840, when the Registrar-General's quarterly returns commenced. The proper meaning and limitation of the term "epidemic" presents some difficulties; but it seems most convenient in a study of this kind to regard a fever as epidemic whenever its mortality exceeds its average rate (however slight that excess may be), and it is in this sense that we shall use the term. The following are the dates of these successive invasions of scarlatina in London, with their duration roughly expressed in quarters of a year:(the end of an epidemic whose first part is not recorded). duration 4 quarters.

1840 1844 1848-49

1852

1854-55

1858-59

1861-64

1868-70

(intense). "(very slight).

6

(intense in 1858). (intense in 1863).

(intense in 1869, 70).

I have bracketed together two epidemics occurring in 1852 and 1854-55. They were, indeed, separated by an interval of but twelve months, in which scarlatina hardly presented itself; this was so short a break that it seems better to regard them as parts of one larger epidemic that was arrested by some mysterious cause in 1853, and resumed its course in the following year. Taking this view of it, we have then six epidemics distributed over thirty years (1841-70) at somewhat irregular intervals, but having an average period of recurrence of five years. It is a curious circumstance that in the intervals between these successive waves of invasion scarlatina has never actually disappeared from the metropolis; there has not been one week in the whole series without a death from this fever being recorded.

A glance at the above table will convince us that these invasions have steadily increased in duration and in intensity for the long period under review. The first epidemic fully recorded lasted one year; the last one (that we all remember) occupied nearly three years, and in the autumn of 1869 reached a higher death-rate than had ever been recorded. The mortality from scarlatina in the metropolis in that quarter was at the rate of 3400 per annum to every million of the inhabitants. Only once do we know of anything like an approach to this mortality being effected, and this occurred in the autumn quarter of 1848, when the death-rate was at the rate of 3100 per million per annum.

It may be interesting to consider what prospect there is now of our having another invasion of this disease. I took occasion, at the beginning of this paper, to refer to the cir cumstance that for three years we have enjoyed a very unusual exemption from scarlatina in London, but that from the beginning of last August there has been a decided accession

Medical Times and Gazette.

The temperature ranged between 100° and 103°, the evening temperature being mostly the higher; it became normal three days before death. The pulse ranged from 108 to 132. Nightsweats were not observed.

Autopsy, twenty hours after Death.-Body somewhat emaciated; rigidity slight. On opening the abdomen, nearly the whole of the liver was seen to project below the ribs. On raising the sternum and rib cartilages, the pericardium was seen to be exposed to an unusual extent, the whole of the root of the aorta being visible. There were four ounces of fluid in the pericardial sac; the right cavities of the heart were full of blood; left almost empty. Muscular substance flabby and pale; valves healthy. The right lung was removed with extreme difficulty, owing to very firm adhesions, and to the presence of a large tumour seated in the posterior mediastinum, and completely surrounding the root of the lung. This tumour, which was lobulated and somewhat pear-shaped, measured five inches from above down, and had the following relations: -The oesophagus passed in front of the growth, which encircled the tube for its posterior two-thirds and considerably constricted it. The trachea and the arch of the aorta were also displaced forwards by the mass, which narrowed the trachea and the left bronchus by causing a projection of their posterior wall into the tube. The right bronchus was completely buried in the mass, but its main divisions were pervious. The right pulmonary vessels and other structures in the root of this lung were also completely invested. The aortic arch was merely displaced; in no way constricted. Below, the tumour was adherent to the pericardium. On section the growth had a white and vascular appearance, and exuded a copious milky juice, which, under the microscope, was seen to be almost wholly made up of cellular elements, mostly round, and of the size of white blood-corpuscles, but a few were spindle-shaped and branched, with bright glistening nuclei. (Subsequent microscopical examination of sections of the tumour showed it to be of the class of lymphadenomata.) The growth invaded the upper lobe of the right lung to a considerable extent, the inner two-thirds of this lobe being almost wholly replaced by tumour-substance, the rest of the lobe being collapsed, airless, deeply pigmented, and tough, traversed throughout by white lines of the new growth which extended along the bronchioles and pulmonary vessels. The pleura over this lobe was thick and fleshy in consistence. Besides the main mass, there were two other nodules of the size of walnuts; one in front of the right innominate vein, the other in front of the middle division of the pulmonary vein. The remaining bronchial glands were slightly enlarged. The middle lobe of the lung was also infiltrated along the lines of the bronchial ramifications, especially in its lower half; the rest of the lobe being pale and emphysematous. All the lobes were firmly adherent to one another, and the lower lobe, though free from infiltration, was for the lower two-thirds of its extent in a state of grey hepatisation, the solidified lobules standing prominently out from the cut surface owing to marked increase in the amount of interlobular tissue. A layer of recent lymph covered the pleura over this portion of the lung, which was sharply marked off from the remaining one-third of the lobe, which was crepitant, pigmented, and somewhat emphysematous. The left lung was universally adherent-most so at the apex, but it was wholly free from solidification. It was everywhere crepitant, but much congested and pigmented. The lining membrane of the bronchi was injected, thickened, and roughened. There were numerous hæmorrhagic erosions in the stomach, and the intestines were much contracted and empty. The mesenteric and retro-peritoneal glands were notably enlarged, rather soft, and white on section. lacteals proceeding to the mesenteric glands from the intestines were beautifully mapped out, appearing as yellowishwhite lines accompanying the nerves and vessels. (This distension of lacteals was probably due to implication of the thoracic duct in the mediastinal mass.) The liver contained two yellow-coloured nodules of the size of peas, having the characters of lymphadenoma on microscopical examination. The parenchyma of the liver was firmer than natural. The spleen and kidneys were healthy.

The

THE BURNING OF THE BODY OF LADY DILKE.-Those who feel interested in this first instance of cremation will find full details of the procedure in the Deutsche Klinik for October 31, from the pen of Med.-Rath Dr. Friedrich Küchenmeister, who officially superintended the proceedings.

DANGEROUS BURIAL-GROUNDS. OUR great daily contemporary, the Times, has lately given up a considerable amount of space to the discussions excited by Mr. Gladstone's pronunciamento against Ultramontanism and Professor Tyndall's discovery of "Budd on Typhoid Fever." The present Premier may, we suppose, feel somewhat complimented by the very serious and energetic way in which his warnings against Rome have been followed up by the ex-Premier; and we trust that he will feel encouraged and strengthened by the active and widespread interest shown in sanitary questions. There has, indeed, been a lull in the typhoid discussion since the publication of Dr. Beale's able letter on "Fever Germs"; but we hope that another correspondence and discussion on matters affecting the public health will be excited by the description given in the Times of the 17th inst. of the condition of two cemeteries in South London. Some time ago, when drawing attention to the movement in favour of cremation, and giving the arguments that may most fairly be used in support of the adoption of that mode of disposing of our dead, we spoke of the dangers that must arise to the living from overcrowded cemeteries, and that may arise from any cemetery in which the interments are not regulated by strictly observed rules of time and space. And the revelations made of the management, or mismanagement, of the two cemeteries above referred to, not only demonstrate the necessity of such rules, and remind the public that that necessity has been duly recognised by the State-regulations for the management of cemeteries having been provided by the Burial Acts,-but, further, they prove the need of some more active and minute supervision of cemeteries than that which the "Medical Inspector of Burials for England and Wales to the Home Department " has been able always to exercise.

It appears that in April and May there was an unusual amount of sickness, including cases of scarlet fever and diarrhoea, in the neighbourhood of the Battersea Cemetery,

and this was popularly attributed to the overcrowded and therefore insanitary condition of the burial-ground. The increased amount of sickness was a fact, and the Medical Officer of Health for West Battersea reported that the overcrowding was also a fact, and "was assuming dangerous and alarming proportions." The Home Office was communicated with, the Inspector of Burials held an inquiry, and all that had been alleged regarding the state of the cemetery was admitted or proved. It appears that, though there is a Burial Board elected by the Vestry of the parish, the only person responsible for the violation of the burial regulations is the Superintendent of the Cemetery, and his resignation has been required by the Home Office. The public will, however, probably ask, What are the duties and uses of a Burial Board? and does it require a special application to the Home Office to set in motion its Medical Inspector of Burials? The motive which led to the violation of the law was a desire to economise ground and keep down the current expenses. The Medical Officer of Health stated in his report that if all regulations are to be carried out, it does not contain sufficient space for a year's burials, and, in another part, that it must be closed in three years. "This contingency it was which led the Board, with ground drained to the depth of eight feet, to permit graves to be dug deep enough to hold the coffins of fourteen adults or twenty-six children. The percolation of water into these common graves produced decomposition before the graves were filled; and the emanations from them endangered the health of the clergymen and the mourners at each successive funeral up to the fourteenth or the twenty-sixth, as the case might be."

Like motives induced the Burial Board of the other cemetery to which allusion has been made to permit of systematic infringement of the legal regulations. These, under the Burials Act, require that there shall be between each coffin a foot of earth," which shall be closely rammed down, never to be again disturbed "; that there shall be four feet of earth above the top coffin; and that there shall be no second interment in an earthen grave on the same day, unless it be of a member of the same family. Some suspicions as to the proper management of the cemetery led to investigations being made into the matter by the Parish Vestry, which elected the Burial Board, and by the Board of Works of the parish in which the cemetery is situated; and the result showed that the above regulations had been disregarded, and that though the cemetery is drained to a depth of eight feet only, graves had been dug to a depth of twelve feet and fourteen feet. According to the account given in the Times, one of the members of the Burial Board expressed to the Vestry his regret that such pressure had been put on the Board that they would be compelled for the future to obey the law, and one of his reasons for regretting this was “that the carrying out of this regulation in all graves would cause the ground to be filled up in two-thirds of the time it would otherwise have lasted, so that obedience to the law would impose a serious burden upon the ratepayers, which might have been evaded or postponed if the illegal practices of the Board had been ignored." There is something almost grand in the coolness with which all sanitary considerations aro thrust aside, and the audacity with which the law is ignored in pursuit of what such gentlemen as this are pleased to call economy. At the instance of the Wandsworth Board of Works an inquiry into the management of this cemetery also has been ordered by the Home Office.

We understand from the statement in the Times that when the irregularities at this cemetery were first brought under the notice of the Parish Vestry it was stated that the Home Office Inspector was fully aware of all that was being done; but that the Vestry Committee failed to find the slightest proof that he "could be aware of the illegalities that were being practised"; and he himself states that, "in answer

to his inquiries, he was always informed that the regulations were being strictly adhered to." And it is further observed, in the article from which we have derived our information, that "The enforcement of the law and of the existing regulations will, it is said, necessitate an appeal to the Home Secretary for some relaxations in the case of the metropolitan cemeteries, most of which, it is broadly insinuated by the delinquent Boards, have been guilty of the same practices. There is something startling in local boards urging their deliberate breach of well-considered laws as a reason why those laws should be amended. The absorbent properties of soils, the progress of decomposition in different soils, the emanation and diffusion of poisonous gases, the risks of mourners and of adjoining residents, are all elements which have determined the present state of the law, and what is based on scientific fact and experience cannot be changed, to the detriment of the living, for the sake of enabling a local board to pursue a policy of so-called economy." We should say that there is also " something startling " in the insufficiency of the supervision which one not unnaturally supposes to have been intended to be exercised over burial-grounds by a" Medical Inspector of Burials," and which "could not " have made the Inspector aware of such illegalities as have been practised. We do not for a moment suspect that there has been any neglect or perfunctory performance of his duties by that officer; but surely the state of these cemeteries proves in the most absolute manner that frequent, closer, and more minute inspection is necessary.

FEVER GERMS.

THE publication in the Times of November 16 of a remarkable letter from Dr. Lionel Beale on "Fever Germs" must have served at once to keep the attention of the public powerfully directed to the question of sanitation, and to give a rude shock to the theory which was so strongly urged by Professor Tyndall. We had occasion last week to object upon many grounds to the appearance of Professor Tyndall as the public champion of the doctrine of the purely contagious propagation of typhoid fever, and we therefore hail with satisfaction the publication of Dr. Beale's letter, which gives abundant evidence in support of a wider view. The investigations of Dr. Beale on the essential nature of rinderpest or the cattle-plague ought to be familiar to every inquirer in the department of fever; and, whatever the fate of the theory which is founded upon them may be, they entitle their author to the most earnest attention of the profession and of the public at the present juncture. There can be no doubt that it is from these investigations, coupled with abundant clinical experience and the possession of most extensive and intimate acquaintance with the phenomena of normal and morbid life, that Dr. Beale now finds himself in a position to demand a public hearing.

Perhaps the primary point in the argument which runs through Dr. Beale's letter is that fever germs arise within the body, and by a process of degradation from the living matter of the body itself. This is no postulate of the author, but a fact ascertained by the most laborious of all processes-by careful and prolonged investigation throughout the wide field of pyrexia in "idiopathic" and "symptomatic" fevers in man and in animals. And intimately connected with this result is one, if possible, even more important-and at the present moment at least of paramount interest-that fever germs may "arise anew." It is almost unnecessary for us to indicate, to those who are following with interest the present discussion on the nature and origin of typhoid fever, the complete opposition which the practical interpretation of this doctrine presents to that urged by Professor Tyndall. The fever germs, Dr. Beale proceeds to say, are not formed or evolved in the world outside" the body-not directly from filth, for example.

66

They are neither microscopic fungi, nor derived from them. This being the case (although we would here recommend cautious hesitation on the part of the public until the results obtained by other investigators shall have been fairly stated), it follows almost as a necessary consequence that, as regards their essential nature, all the fever poisons of man and the higher animals are closely allied. There is evidence also open to every professional observer, in the occurrence of isolated outbreaks of fever, in favour of the view of the production in this way of a new fever poison.

Home Secretary determined not to liberate the prisoner. During the next ten months Dr. Lavies repeatedly sent in reports as to the gradually declining condition of the prisoner, attributing it mainly, if not entirely, to her incarceration, and urging the absolute necessity of her being liberated as the only means of saving her life. Not one of these recommendations was adopted by the Home Secretary, nor did the Prison Inspector come to see the prisoner until September in this year, when she was dying. The surgeon still pursued the course he had adopted throughout, and again begged that she might be removed, stating that even at that late period she might possibly revive. The unfortunate woman died on the 9th inst. An inquest was held on the 11th, and Dr. Lavies expressed it as his positive opinion that had she been set free, in accordance with his advice a year ago, she might and most probably would have lived. The inquest was adjourned, in order, as the coroner stated, that those against whom it seemed to him serious charges were made might be summoned to offer what explanation they could. The coroner also found fault with Dr. Lavies for not having given him previous intimation of the course the inquiry was likely to take, so that he might have communicated with the visiting justices and the Home Office on the subject. Dr. Lavies-we think very properly

tion. The state of health, or, as it may be otherwise expressed, the power of resistance, may be preserved by good water and well-arranged sewers. For, even though the inhabitants of a town well drained and supplied with good water should be fully exposed to the assaults of hosts of fever germs, in their highest state of morbid activity, they would suffer no injury."

Only a week ago we indicated the danger of the practical adoption of the belief that stinks and foul drains and fæcal accumulations are harmless as long as typhoid fever can be kept away. We have now before us a powerful reinforcement of our argument. We observe, with much satisfaction, that the Times supports the criticism of Professor Tyndall's letter which we then offered, and very powerfully pleads the cause of rational sanitation, and especially of the employment of medical inspectors by the Local Government Board. Speaking of the " numerous and various potential channels" by which an epidemic may be diffused, it stigmatises as "a disastrous blunder" the attempt of that body" to employ its non-medical inspectors for the purposes of health administration." It must have been a source of sincere regret to every intelligent observer of the precarious advance of sanitation in this country to find the plan which is here deprecated very warmly advocated in the Saturday Review of November 7, in an article on "Sanitary Policy." That an inspector of nuisances, who shall make periodical visits to the dunghills of his district, is likely to add much to our knowledge of the nature and origin of fever poisons, is a doctrine utterly unworthy of one of the organs of advanced thought at the present day. A little knowledge is always a dangerous thing; but the practical application of an imperfect truth may sometimes lead to disasters nothing less than national.

SICK PRISONERS AND THE HOME OFFICE. An inquiry that has lately taken place at the Westminster House of Correction concerning the death of a prisoner under penal servitude, affords subject for important reflections. It appears that Dr. Lavies, the Medical Superintendent of the Prison, acting under the rules formed for his guidance, reported to the visiting justices more than twelve months ago that the life of the prisoner was endangered by her continuance in confinement. The visiting justices forwarded this report to the Home Office, and some days afterwards the Inspector of Prisons visited the prisoner. The result of this visit seems to have been that the

private information concerning a public inquiry, and that he could not put himself in the position of an informer against the Home Office. He had made no accusation against nor cast reflections upon anyone, but had simply given a plain statement of facts.

At the adjourned inquest the entire correspondence between the visiting justices and the Home Office was produced and read, and the Inspector of Prisons (Dr. Briscoe) was examined. That gentleman stated that he had twice seen the prisoner-in November, 1873, and in September, 1874-and had not endorsed Dr. Lavies' recommendation, considering that the poor woman would be better cared for in prison than out. The jury returned a verdict of "Natural death from debility."

Now it appears to us that the real question arising out of this inquiry has been nearly, if not completely, lost sight of. The question of comparative care and comfort inside and outside of the prison; the attention of the medical officer and other prison authorities; the progress of the prisoner's disease, or diseases, whatever they were, have little or nothing to do with the points at issue, which are these-Was the report made by Dr. Lavies in November, 1873, a true one? Did it faithfully represent the prisoner's condition-namely, that her life was in danger, not from disease, but from the depressing influence of imprisonment upon her? If this were really so, then we venture to think that the responsibility of declining to remove the only impediment to restored health is a very serious one; and considering the position and large experience of Dr. Lavies in matters of this kind, we think a more suitable verdict would have been-"Death from debility, caused mainly by the depressing circumstances of imprisonment; and the jury beg to express their great astonishment that the frequent recommendations made for the prisoner's liberation were not adopted by the Home Secretary."

PERNICIOUS ANEMIA: A NEW DISEASE. THE advance of knowledge is ever bringing to light new diseases, or rather is disentangling and isolating groups of symptoms formerly confused under one comprehensive title, and showing how they really depend on different causes and on different pathological conditions. "Bright's Disease" and "Addison's Disease" are terms which remind us how symptoms uncomprehended for centuries may be suddenly elucidated by the grasp of minds gifted in co-ordinating facts. The acuteness of a Swiss observer seems to have added another to the