It

Physical education will do much. aims at the root, by commencing with our young growing population, by proposing the teaching of the elementary principles of anatomy, physiology, and hygiene proper, in her schools, and by adding to this knowledge the physical exercise which will develop the muscular system of our boys and girls.

We may reasonably expect to hear, in the future, less about women who can not suckle their own children, or who yield such poor milk that the child does not thrive on it; less of infantile diarrhoea and marasmus, less of patent foods; for, when we have produced a higher physical development, the mother herself will be capable of nursing her offspring.

There is one great agency to which I look hopefully, as it is a practical method of counteracting the great evil, intemperance, so detrimental to our women. The coca-house movement should become a great factor in the elevation of our national character, and the improvement of the physical condition of our population. It must tend to promote habits of sobriety. amongst the people, and must prevent some of the waste of wages at present diverted from proper food-supply, and hitherto expended upon alcoholic products.

If the programme be carried out in its integrity, the working classes, male and female, will have light, airy, cheerful rooms opened to them where they can obtain coffee, cocoa, tea, milk, soups, meat, vegetables, good dinners, at cheap though fairly remunerative prices. Thus, a certain amount of money will be spent upon true articles of food, the workwoman and female operatives will be able at a moment's notice to obtain some nourishing food to support them during their work, where previously they have resorted to the public-house for a stimulus. The ultimate advantages to be derived from placing at the convenience of our female laboring population refreshmenthouses of this class must be of necessity an improvement in their moral condition.

The social revolution which in the metropolis has received a powerful impetus from the medical profession, and particularly from Mr. Ernest Hart, must ultimately be extended to all our large

towns and cities, where it should meet with equal support from members of the medical profession.

It will be asked, is lactation equally defective amongst the higher classes? Are they equally unable to suckle their children? Are they ignorant on the great subject of hygiene? Do their children suffer from the manifold evils which affect the lower strata of society? Setting aside the large number who will not leave the luxury of their lives, fashionable amusements and the rest, to perform that duty which every conscientious mother should fulfil, there is also a larger class who are not able to produce milk. This no doubt arises from a certain high pressure under which they live, from a highly artificial mode of life the product of modern civilization. Their diet is not conductive to produce healthy blood, and we find anæmia, hysteria, nervous disorders, insanity, as a result; so that not only are they unable to reproduce healthy structure for the waste going on in their own bodies, but they are still more unable to furnish a supplemented want of nutrition required by the demands of menstruation, conception, pregnancy, and lactation. Every London physician can pick from his note-book numerous cases of young ladies, who have no useful occupation or amusements, whose bodily health and moral nature are preverted by the atmosphere in which they live, and whose delicacy is systematically fostered by their own mothers: and who thus become totally unfit for the position of mothers. Every accoucheur can tell us of the infants produced, of the care which has to be bestowed to rear them; so that physical education must not be confined to the lower classes.

Amidst the highest and the lowest strata, there is a medium: the great middle class. It is amongst this class I find the best mothers, and the least amount of degeneracy. This stratum is, no doubt, the back-bone of the country, from which is produced both the physical and intellectual material from which our great men are derived. The homely life, the domestic virtues, of this class are great factors in a nation's welfare.

In accordance with the wise ordinance of nature, the female has been endowed

with highly complex organs, for the reproduction and nourishment of our race. Woman's mission, if special organs be any guide, must ever be regarded in its association with motherhood, as purpose seems thereby fulfilled.

For the complete accomplishment of maternity, important physiological changes, evolutional and nutritive, have to be undergone. Facts demonstrate that the forces tending to reproduction are weakened, that the reserve or supplementary materials from which the forces are drawn are not sufficient to meet the drain produced by pregnancy and lactation; or, in other words, that our feminine stock is not improving. Heredity steps in, and perpetuates or intensifies the evil; so that dangers to the race, affecting every stratum of it, are to be apprehended.

To be forwarned is to be forearmed; to recognise an evil is the first step to its removal. These observations will not be in vain if they lead to further discussion and ventilation of the great questions which, I believe, underlie the subject of suppressed or defective lactation in the women of our generation. These conclusions have been purely brought about by my attempt to estimate the therapeutical influence of drugs, during lactation, on either nurse or nursling.—Brit Med. Jour.

J. A. Mackenzie on Rupture of the Heart.

The case upon which the few remarks in this paper are based I met with in the practice of Mr. John Deighton of Cambridge, and I am indebted to that gentleman for permission to make use of the following facts.

J. V., aged 75, of Cambridge, whilst at dinner, appeared to strain very much in endeavoring to swallow a tough piece of meat; and, it being thought he was choking, a messenger was at once dispatched for a surgeon, but, before the arrival of medical aid, death had taken place, the patient, in fact, according to the statements of his friends, not living many seconds after he appeared to strain in swallowing. By order of the coroner for the borough of Cambridge, I made a post mortem examination of the body, at which Mr. Deighton was present. The

body presented a fairly well-nourished appearance. The mouth and upper parts of the air passages were examined, but no trace of any foreign body could be discovered. The existence of a distinct and well-marked arcus senilis was noted. Upon opening the cavity of the thorax, we came upon the pericardium distended into a globular tumor, and presenting a bluish discoloration, as from something shining through the walls of the sac, rendered transparent by distension.

When the pericardium was opened, the cause of death at once became evident, for the great distension of the pericardial sac was due to the presence of an enormous clot, and a considerable quantity of serum. The clot was most accurately moulded upon the heart and commencement of the great blood-vessels. The clot and serum were carefully removed, when the rupture shown in the accompanying specimen revealed itself. The heart was pale and flabby, and presented all the appearances of fatty degeneration. There was no trace of any valvular disease, and, with the exception of one or two very small atheromatous patches, the large vessels were quite healthy. There was considerable atheroma, however, of the coronary arteries. The examination of the interior of the heart showed the existence of yellowish softened patches distributed at irregular intervals over its surface, and in the left ventricle, where the rupture had occurred, these extended deeply into its substance.

Microscopical examination of a section of one of these patches revealed extensive fatty degeneration; in fact, in a section taken from near the site of the rupture, all trace of muscular fibre had disappeared. The other viscera were examined and found to be healthy.

The comparatively small number of these cases that I had seen recorded, together with the improbability that, as a general practitioner, I should ever again have the opportunity of seeing post mortem so rare a lesion, induced me to make these rough notes at the time, and, since then, to embody in a short paper the following remarks on ruptures of the

heart.

Leaving out altogether the question of direct wounds of the heart, I will speak

only of what have been classified as traumatic and spontaneous ruptures (of the heart); and, in order to be able clearly to refer my case to its proper class, it will be necessary briefly to draw attention to the causes, exciting and predisposing, and to the mechanism by which both kinds of ruptures are produced.

In the normal state, the resistance of the walls of the cardiac cavities is evidently much superior to the tension of the blood-current; but this relation, essential to the efficiency of the circulation and to the continuity of the heartwalls, may be disturbed in two ways.

1. Assuming the heart-walls to be sound, the tension of the blood-current is suddenly increased by some force acting from without, and the cardiac parieties, unable to withstand the shock, give way. This is the mechanism of the production of traumatic ruptures, which are found in practice to have been caused by some great violence which imposes a sudden restraint upon the respiration and circulation. A kick from a horse upon the chest, the passing of a wagonwheel over the body, the falling of a heavy log of wood upon the chest, are recorded instances of the means by which the force indicated above has been applied.

2. Before the introduction of the use of the microscope, it was believed that spontaneous rupture could take place without previous alteration or degeneration of the heart-walls; but at the present time the occurrence of spontaneous rupture unassociated with any degenerative change is denied by all authorities. The mechanism of the production of spontaneous rupture differs from that of traumatic in this. In traumatic rupture it is the heightened tension of the bloodcurrent induced by external violence which leads to the solution of continuity: whereas, in spontaneous rupture, the tension of the current remains the same, but the heart-walls, enfeebled by fatty or other degenerative change (brown atrophy), do not offer the normal resistance to the flow of blood, and rupture may take place in consequence of some effort in which the muscles of respiration, etc., are concerned.

The predisposing causes are fatty degeneration of the heart, brown atrophy,

disease of coronary arteries, syphilis, probably from the production of gummatous tumors in the heart-substance, and myocarditis, with its subsequent softening.

The exciting causes were very marked in some of the recorded cases; whilst in others there appears to have been a total absence of any circumstance which could be put down as an exciting cause. I have found the following exciting causes recorded :-Shock of a cold bath, fit of passion, efforts at defæcation, vomiting, epileptic fit, and, adding my own case, the effort put forth in swallowing a tough piece of meat.

The question of age seems to have an important bearing upon the causation, for I find that the mean age in a series of forty-eight observations was sixtyfive years. The influence of sex does

not appear to be very great, though as a matter of fact rupture has been ascertained to have occurred oftener in men than in women. The commonest seat of spontaneous rupture is the left ventricle; the right, upon which we generally find traumatic ruptures situated, appearing to be less liable to the spontaneous lesion.

From these facts regarding the causations and pathology of rupture of the heart, there does not seem to be much difficulty in classifying my case as one of spontaneous rupture of a heart, enfeebled by fatty degeneration and impairment of nutrition, consequent upon atheroma of the coronary arteries, and the advanced age of the subject. Unfortunately, there is not much opportunity in these cases for the exercise of diagnostic acumen, death nearly always taking place before the arrival of medical aid. If seen immediately, a case in which the rupture was not very extensive might be mistaken for angina pectoris. In short, the extreme rarity of these cases, and the rapidly fatal termination, precluding, as it does, any attempt at treatment, make them of more pathological interest than practical clinical importance. Medico-legally, traumatic rupture following a blow, or supposed blow, upon the chest, might be of interest.

In conclusion, I am of opinion that if there were more post mortem examinations, in cases of sudden death, we should

probably find that many of those cases vaguely called "heart-disease," would turn out to be rupture of the heart or of aneurisms. Apart from other considerations, I think it would be a great benefit to the medical profession, from an educational point of view, if coroners ordered more post mortem examinations; as these are, in the majority of instances, the only opportunities that a general practitioner has of renewing his acquaintance with anatomy; and, though it is only really medical anatomy, still an occasional renewance of acquaintance with the exact relative positions of the viscera and large blood-vessels, not to mention the importance of being able to note morbid changes in these organs and their relations, cannot fail to give valuable help to men who have neither the time nor the opportunity for dissection.

As an instance, I may mention that in the town of Cambridge where I noticed that post mortem examinations in coroners' cases were very frequent, during a residence of about a year, I came across two most interesting cases amongst the six or eight which fell to my share. One of these is the subject of the present paper, and the other was sudden death following the bursting of a large aneurism of the arch of the aorta. there been no post mortem examination, in all probability both these cases would have been put down as death from heart-disease."-Brit. Med. Jour.

Society Proceedings.

Had

NEW YORK COUNTY MEDICAL ASSOCIATION.

Etiology of Typhoid Fever.-At a stated meeting, held February 18th, Dr. E. G. Janeway read a paper on the above subject. He said that in rural districts and in institutions typhoid fever seemed not infrequently to spread by contagion, as person after person sickened with the disease; yet in not a few of these instances it could be shown that such contagion was not direct, but indirect. It could not but be admitted that very few cases would stand a rigorous examination and be capable of proving that the disease was spread by direct contact. In order to arrive at a

just conclusion in this matter an inquiry had been made at several hospitals receiving typhoid-fever patients, and the result was in the main negative. All claimed that no nurse or patient in the wards contracted the disease; but in one, some years ago, one of the physicians contracted typhoid fever while residing in the hospital, and in another a domestic sickened with the disease. The small number of cases occuring among those resident in hospitals treating typhoid-fever patients would, therefore, point towards failure of disinfection or to defect in the plumbing of the institution where such cases had occurred.

The principal source of typhoid fever in New York City was to be looked for in defective sanitary arrangements, permitting the entrance of the emanations of the sewers either to the air or to the drinking-water of which the patient made use. It was a great mistake, however, to suppose that invariably when sewer emanations gained entrance to a house, and even when the defects were very great, typhoid fever would appear. The writer had seen marked exceptions to such an idea, which, together with the susceptible character of those exposed, only proved that something more was necessary than ground saturated with water and sewage in order that typhoid fever should occur. In cases of typhoid it was not always easy to decide how the poison gained entrance to the system. If we supposed that germs were floating in the air, the question must be raised, Do they occasion the disease by being received through respiration and taken. into the lungs, or are they by this act simply drawn into the mouth and throat, and thence swallowed with the saliva, food, and drink, to develop in the alimentary canal? To the writer the latter method seemed the more probable. Any one who had examined much the sanitary defects in cases of typhoid fever would find that vitiation of water was in many cases possible, especially at the present time, when the water supply and water pressure were both defective in New York. The drawing of water on a lower floor caused a partial vacuum, which, if stop-cocks were open, or if tanks supplied by ball-floats, which

opened the pipe when the water was lowered, were employed, or if there were defective valves to pipes in water closets with direct supply, caused an aspiration of air into the water pipes of the house. The writer had traced outbreaks of typhoid fever in two institutions to sanitary defects of this nature and operating in this way. Having alluded to other sources of danger in connection with water pipes, he went on to say that a large number of privy vaults were still attached to the tenement houses in New York, and that there was but one form of these places which was devoid of danger, the school sink or trough closet. In such houses in a large city the question of the origin of cases of typhoid fever, with or without the germs from preëxisting cases of the disease, was as impossible of a just decision as in the case of defective sewage. That these privy vaults served to develop the poison of typhoid fever there was sufficient evidence, and the method of action might be in one of three directions: (1) by the use of the place (2) by the leakage from such place, causing saturation of the soil beneath a house, and(3) by the connection of the living rooms of a house with such places by waste pipes. For several years the For several years the Board of Health had refused to allow any new privy vaults to be constructed; but under the law the tenement-house owner had the option of a trough closet or some form of water closet, and the writer had feared that with the defective water supply and consequent deficient flushing of soil-pipes, an increase of typhoid fever might result from the introduction of water closets in the tenement houses on a large scale.

In the upper portion of the City of New York wells, with all the attendant liability of sewage-pollution, were still in use to a considerable extent, and the writer had been able to trace the outbreak of typhoid fever in an institution to use of such water, by the employment of the chloride of lithium test. In this connection Dr. Janeway gave an account of the outbreak of typhoid fever at Princeton College, in regard to which he had made a thorough investigation. The origin of the trouble was traced to a house within which there was a water-closet discharging into a

cess-pool with earth sides and bottom, in a shale soil, forty feet distant from a well, the water of which was found, on chemical analysis, to be seriously polluted. Afterwards the disease was ascertained beyond a doubt to have spread not by the drinking water, by the air, or by direct contact, but by means of the emanations from the sewer and cess-pool into which the passages from those sick with the fever had been thrown without disinfection. As regards the question of origin of this outbreak, whether spontaneous or from a previous case, the writer had been unable to come to a positive conclusion. Other avenues by which the disease might be introduced in a house, and of which the writer had seen possible, though not positive, illustrations, were, by means of refrigerators having direct sewer connections and by contaminated milk and food. He had been able to connect one outbreak in the upper districts of New York with affected milk, possibly diluted with water coming from a contaminated well, as in the cases reported from abroad, especially from England.

Dr. Janeway had reached the following conclusions with refererence to the etiology of typhoid fever : —

(1.) That it is in all probability due to a bacillus.

(2.) That this virus is certainly contained in the discharges from the bowels.

(3.) That it gains entrance to the system through the air coming from places into which the discharges of other typhoid-fever patients have been deposited, or through water contaminated by a similar process, or through milk diluted with contaminated water, or perhaps visited by contaminated air.

(4.) That there are instances which point to the probability that the germs which produce typhoid fever may develop in a suitable soil, but have not been derived from a preexisting case of the disease.

(5.) That it is not necessary to invoke the aid of the rise and fall of the ground water to explain the disease; though a low state of the ground water, by favoring an increase of the impurities in a well or water-supply, may favor the spread of the disease, as may