"measles and elementary school closure."

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"IS INSTRUMENTAL DELIVERY A CAUSE OFIDIOCY."

To the Editors of THE LANCET.SIRS,—My attention has been called to a paper by Drs.

Winkler and Bollaan on the Forceps as a Cause of Idiocy.The importance which it has received by a reference to it inyour columns leads me to call the attention of the profes-sion to what I wrote in a paper entitled the "Obstetrical

Aspects of Idiocy," published in the Obstetrical Society’sTransactions, 1876. "I find, from an examination of allmy cases of idiocy about which positive information couldbe obtained, that in only 3 per cent. were the forceps em-ployed. In every case, however, where they had beenemployed, the friends of the child believed that the instru-ment alone was the cause of the disaster, while in nearlyevery case I could discover quite sufficient to account forthe mental defect in the neurotic history of the progenitors.In a very few cases, only a small fractional percentage, couldI arrive at the conclusion that the use of the forceps wasthe principal cause of the calamity. I find in a very largenumber of my cases that the labour was stated to be un-usually tedious and prolonged. Dr. Playfair has shownthat the employment of the forceps does not interfere withthe viability of the offspring; and that a prolonged labouris more compromising to the life prospects of the child thana, judicious and timely application of the forceps. " Whenit is borne in mind how frequent is the association of sus-pended animation with idiocy, it cannot, I thinly be toostrongly enforced that the mental integrity of the child ismore likely to be compromised by a prolonged pressure inthe maternal passages than by skilled employment of arti-ficial assistance. The accoucheur who postpones instru-mental help often does so at the risk of terrible consequencesto the nervous system of the little one he is solicitous toprotect." In my somewhat recent Lettsomian lecturesdelivered before the Medical Society of London I was ableto confirm by additional experience that which I had sostrongly enforced before. I am convinced that injury islikely to result from a reception of Drs. Winkler andBollaan’s tea,china’. I am, Sirs, yours faithfully,

J. LANGDON DOWN.

"ALBUMINURIA IN PHTHISIS AND ALPINEWINTER CLIMATES."

To the Editors of TIIE LANCET.SIRS,—On my return from a Christmas visit to the

Grisons, I found in THE LANCET of Jan. 5th, 1889, aninteresting communication from Sir Andrew Clark entitled"The Peril incurred in Alpine Winter Climates of RenalComplications in Phthisis," in which complimentary allusionis made to my paper on " The Treatment of Consumptionby Residence at High Altitudes," published in vol. lxxi. ofthe Medico-Chirurgical Transactions. I am very glad tohave from Sir Andrew Clark’s large experience such im-portant confirmation of most of my conclusions, and I muchregret that he was prevented from being present at thediscussion which followed the reading of the paper. SirAndrew Clark draws attention to "a remarkable and in-’explicable omission in both paper and discussion "-viz.,that no notice is taken of the peril of sending cases ofphthisis complicated with albuminuria to high altitudes.My answer to this is simple. I have never counselled,sending such patients to high altitudes; and whenever Ihave been consulted in such cases, have done my best todeter them from going; but to warn medical men againstwhat appeared to me obvious-viz., the inadvisability ofsending these cases—has hitherto seemed to me unneces-sary. Now, when does albuminuria intervene in phthisis?Generally within a few months or weeks of the patient’sdeath, except in the fibroid form, when it may appear earlier.It surely would be a doubtful proceeding to send to ahigh altitude Alpine station an advanced case of phthisis,with a necessarily small area of breathing space, and in whomthe intropulsive action of a cold climate would tend to pro-duce congestion of internal organs, including the kidneys.In the fibroid variety of phthisis, especially if the amountof induration is large, as Sir Andrew Clark says truly,albumen does sooner or later make its appearance ; but thisis a class of cases which I exclude in my paper under the

, heading of "Cases of Phthisis where the Pulmonary Areaat Low Levels hardly suffices for Respiratory Purposes."This does not apply to all cases of phthisis where fibrosis ispresent, but only where the changes so well described bySir Andrew Clark are the chief feature. Therefore, whilecordially endorsing the proposition that no cases of phthisisand albuminuria should ever be sent to high altitudes, I

L have thought this too self-evident to require formulation. I- wish any readers of THE LANCET who may be sceptical asl to the benefits of the high altitude treatment of phthisis,

could witness, as I did recently at Davos and St. Moritz,the weather-tanned consumptives pursuing their vigorous

l and enjoyable life in the clear buoyant diathermic climate,free from fog and wind, and rejoicing in sunshine and

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brightness. Owing to the early and comparatively smalli amount of snowfall, the lakes of Davos, St. Moritz,

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Silvaplana, and Sils formed splendid sheets of dark ice freer from snow, and capital for skating and picnics. The recentr fall of snow has ended most of the lake skating, but the

rinks and toboggan runs are in full swing. The weatherhas been magnificent for sleighing excursions, and the whole

e outdoor life at high altitudes has been carried out underexceptionally favourable conditions, and I was pleased to

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find that the patients had improved accordingly.If any of your readers should desire a copy of the above-1 mentioned paper, which gives the results of this treatmentr in 141 cases of consumption, I shall have great pleasure in

forwarding it to them.-

I am, Sirs, faithfully yours,C. THEODORE WILLIAMS, M.A., M.D., F.R.C.P.C. THEODORE WILLIAMS, M.A., M.D., F.R.C.P.

January, 1889.

"MEASLES AND ELEMENTARY SCHOOLCLOSURE."

To the Editors of THE LANCET.SIRS,—I note in a recent issue of THE LANCET these

words: "It is very desirable that the matter [closure ofschools for measles] should be carefully studied." Will youallow me to add, the closure of schools for any epidemicdisease? I send you some information on the subject,gained by myself as a member of a School Board havingunder its control eighteen blocks of school buildings, withan average attendance of 7800 children, for publicati0n ifyou consider it of any value. It is important to note thatin Burton the notitication of infectious disease is com-pulsory, and that of the two diseases with which elementaryschools are most concerned-scarlet fever and measles-the former is scheduled and the latter is not.

Scarlet fever.-By the courtesy of the sanitary authority,the clerk to the School Board obtains returns of the casesnotified, and sends a list of all such cases as may affect theelementary schools to the various head teachers. As aresult of this arrangement, the Board becomes aware of theexistence of an epidemic of scarlet fever before it has timeto influence the school attendance, and is enabled to takemeasures to prevent the spread of the disease, such as theexclusion of all children from infected houses and theregulation of the return of convalescent children.

Schools not closed for scarlet fewer.—It has been thepractice of our Board, with the concurrence of my colleague,Dr. W. G. Lowe, and myself, not to close schools during anepidemic of scarlet fever, believing that to close the schoolwhere the first cases appear simply has the effect of spreadingthe epidemic throughout the district. And, as a matter offact, two epidemics which have occurred in the schooldistrict during the past five years have practically been con-fined, in each instance, to a small portion of the town, andhave at the most affected only two blocks of schools.

Irz. measles schools closed early.—Experience has taughtus that, in dealing with measles, the sooner we close aschool or schools where the disease is rife (and here notethat we have no means of knowing of the existence ofmeasles until it affects the school attendance), the soonerthe disease is stamped out, and the less the school attend-ance, in the long run, suffers.

Effect of closing for a month.—The following figures willgive some idea of the effect of closing schools on account ofthe existence of measles. A block of schools with accommo-dation for 1000 scholars had its average attendance reducedto about 75 per cent., and was closed for a month. Theschools opened at the end of that time with an attendanceof 88 per cent. in the boys and girls’ department, and 68 in

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the infants’, and the attendance continued good. In anotherblock of schools, with accommodation for 700 scholars, theattendance being reduced to under 75 per cent. by measles,the schools were closed for a month, and then opened withan average attendance of 86 per cent. Other instanceswould show similar results.Length of closure.-We have always found that, to be

effective, a closure for measles must last three weeks atleast, and usually a month.Duty of visiting officers.—During the time of closure the

visiting officers of the Board make a point of finding out asfar as possible every house in which measles exists or hasexisted, in order to regulate the return of the convalescentchildren. No child is allowed to return from an infectedhouse until a full fortnight has elapsed from the commence-ment of the last case.Sunday schools.—It is certainly of no use to close day

schools unless the Sunday schools are also closed, and herewe have always met with ready help from the managers inthis matter. Sunday schools collect their scholars accordingto religious belief, and not according to location, and conse-quently they not only spread infectious disease, but theyalso tend to scatter it to previously untainted districts of atown. I have met with several very clear instances of this.Sanitary authority and the schools.—Without doubt the

real interests of the schools are identical with the interestsof sound sanitation, and the best results will be obtainedwhere the sanitary authority and the school authority, re-cognising this, work together. Here our School Board hasnever waited for the interference of the sanitary authority,but at the same time it has always been able to obtain thevaluable help of the medical oflicer of health in its en-deavours to check the spread of epidemic disease.

I remain, Sirs, yours truly,Burton-on-Trent, Dec. 26th, 1888. HENRY E. BRIDGMAN.

"THE RELATION OF CHOREA TORHEUMATISM."

To the Editors of THE LANCET.

SIRS,—In last week’s discussion upon this subject at theRoyal Medical and Chirurgical Society, I mentioned theinfrequency of chorea preceding rheumatism, contendingthat the rare instances where the two affections occurred inthat sequence were probably all recognised, inasmuch as itcould not be said of the chorea, as is well said of therheumatism, that it was likely to escape notice. Whilequoting the general testimony of writers to this effect, Ineglected, in the hurry of the moment, to add a specificillustration. It is this. In the recent report uponrheumatism by the Collective Investigation Committee,prepared by Dr. Whipham, chorea preceded in only 15 outof 655 cases--that is, in less than 2 per cent.

I should not have troubled you to supply this omissionwere it not for the remarkable rejoinder of Dr. StephenMackenzie later in the discussion, that chorea was un-noticed in the literature of rheumatism only because it isassumed to be one of the manifestations of that disease,not needing separate mention. Dr. Whipham’s reportnegatives that contention; and we are in this dilemma :either clinical statistics of this kind are not trustworthy,in which case the whole discussion goes by the board ; orelse the connexion between chorea and rheumatism, whichno one denies, is less intimate than some physicians contend.

I am, Sirs, yours faithfully,Wimpole-street Jan. 14th, 1889. OCTAVIUS STURGES.

MR. CHAVASSE ON INGUINAL OR SIGMOIDCOLOTOMY.

To the Editors of TIIE LANCET.SIRS,—It is really very gratifying to me to find that

Mr. Chavasse, in his lecture in your issue of Jan. 5th, hasfollowed out in almost every detail the new points in theoperation of inguinal colotomy first described by me in apaper read before the British Medical Association in 1887.Prior to the appearance of my paper the inguinal operationhad been somewhat in abeyance on account of the badresults which followed the procedure of opening the peri-toneum, treating it in a haphazard way, and immediately

opening the gut. Latterly, however, the operation hasbeen frequently performed on my lines with such successas to bring it into considerable favour. There are severalpoints in Mr. Chavasse’s paper which I think cannot beallowed to pass without comment.

1. Mr. Chavasse says, in speaking about the manner inwhich the gut should be secured to the wound : "That willdepend on whether the malignant growth is causing completeobstruction or not. If so, then on each side three inter-rupted carbolic silk ligatures passed through the peritonealand muscular coats of the bowel, and secured to the edgeuof the parietal peritoneum and skin incisions, will suffice.Should the obstruction not be complete, itisbetter to attemptto form a spur." In my opinion, in all cases it is absolutelyof the utmost importance to make a good "spur," and, ifpossible, more necessary when the obstruction is complete,and for this reason : when no spur is formed, the motionconstantly passes beyond the opening in the groin into thepart of the rectum below, and sets up great irritation,tenesmus, and pain by its contact with the malignantgrowth; and if the obstruction be not complete, this maybe washed away by syringing from the anus and from thegroin wound ; but if it be complete, you cannot washthrough from the anus, nor can you wash away theaccumulated faeces from the cul-de-sac formed between theinguinal opening and the growth.

2. Mr. Chavasse passes a piece of silver wire through thetwo outer coats about the middle of the gut, to act as aguide in the second stage of the operation, and so preventpassing the knife through the posterior wall of the gut. Iam quite at a loss to see the utility of this, for if the opera-tion has been properly performed there is amply sufficientwhen drawn out of the wound to prevent the posterior wanbeing injured by the knife ; and, further, if such a blunderwere committed, no harm would accrue, as the posteriorwall of that part of the gut to be opened should be outsidethe abdomen.

3. Under the heading of the advantages of the operation,Mr Chavasse says "it is readily performed," and then pro-ceeds to cite a case in which, the patient’s abdomen beingvery distended, he opened the colon in the iliac region. Now,from my experience, this is one of the class of cases for whichinguinal colotomy should not be performed ; for when theabdomen is distended it is next to impossible to bring theparietal peritoneum to the skin and firmly suture it. Fromthe distended condition of the gut it is necessary to open itat once, and there is great likelihood of fæces and gasescaping into the peritoneal cavity ; moreover, the safetyresulting from performing the operation in two stages islost. When the large intestine is greatly distended there isusually no difficulty in finding it in the loin ; and, as Mr.Bond of Leicester has pointed out, it is then that the colonis more likely to be opened on its non-peritoneal surface.Mr. Chavasse is of opinion that the tendency for the gutto prolapse is greater after lumbar than inguinal colotomy.In this I am not in accord with him ; and I have just writtena paper, which will be published shortly, dealing with thisunfortunate and disagreeable result of some of the inguinaloperations. I am. Sirs. vours obedientlv.

, yours obediently,

HERBERT WM. ALLINGHAM.

GENERAL PARALYSIS OF THE INSANE INGENERAL HOSPITALS.

To the Editors of THE LANCET.

SIRS,-I need not at any length occupy your valuablespace with my reply to Dr. Handford’s letter. I am not

surprised that he should differ with me in opinion about a,disease varying so much in its methods of onset and sovery difficult to diagnose in its earliest stage as generalparalysis. It is not, however, necessary that I should enterupon this question, or do more at present than ask those ofyour readers who may be interested in the subject underdiscussion to read for themselves, with that rigid attentionand care which Dr. Handford complains I have not bestowedupon them, the accounts of cases described as generalparalysis by him in THE LANCET of December 15th last,and to form their own opinion upon the desirability orotherwise of treating such cases as present grave mentalsymptoms longer than can be helped in the wards of a,

general hospital. It was hardly necessary for Dr. Hand-