symptoms exhibited by the patient when he first came under notice. Owing to the urgency of the symptoms, an immediate gouging of the mastoid was performed by Dr. Plowman, and pus was evacuated. A thorough irrigation and subsequent drainage of the mastoid had been sufficient to completely remove all symptoms, although these, accompanied as they were by severe headache and raised temperature, were very suggestive of intra-cranial mischief. Dr. MOORE, in reply, said that he felt quite certain that there was an abscess at the time of the first operation, and that he had missed it. He wondered whether the soft brain matter had filled the groove, and so prevented the escape of the pus; but at the second operation the pus escaped readily at the first attempt. Some four years ago, assisted by Mr. Syme, he had removed a large tumour from the brain, but it was buried deeply in the brain-substance. The man recovered from the operation, but the growth was malignant and recurred, the patient dying about four months after operation. The relief to pain obtained by removing a portion of the skull was the most striking feature of the case. Prior to operation, he required large and frequent doses of opium. Subsequently he had a few small doses, while the craving for it was still present, but he had no more severe pain.

The following paper was then read :—

SOME NOTES ON THE ETIOLOGY AND PATHOLOGICAL ANATOMY OF SUMMER DIARRHOEA

IN INFANTS.

(WITH CHART.)

By R. R. STAWELL, M.D. Melb., D.P.H. Lond. Honorary Medical Officer to Out-patient Department, Melbourne Hospital for Sick Children.

The continued high mortality-rate among infants, in consequence of diarrhoeal diseases, and the fact that there is still among medical men diversity of opinion as to the causation of the diarrhoea, are sufficient grounds to justify me in recording some observations on the subject.

The chief object of my paper is-first, to discuss at some length the etiology of the summer diarrhoea of infants; and secondly, to show that there exist in many of the fatal cases well marked pathological changes. The majority of those medical men who are especially interested in the diseases of children agree, that far and away, the chief ætiological factor in diarrhoea is the ingestion of food which is bad or has commenced to decompose. In con

sequence of the increased temperature of the summer months, fluid foods, especially milk and broths, begin very rapidly to undergo putrefactive changes, and as no extra care is taken by most mothers and nurses during this time of the year to prevent these changes, infants and children are frequently given food sufficiently affected by bacterial growth to act as a poisonous irritant. Nothing could be more definite than this opinion, and I shall now discuss the evidence upon which it has been formed.

Following the example of many other observers in different parts of the world, I have made out a series of charts, which show -(1) The number of deaths from diarrhoeal diseases that have occurred in Melbourne during each month for the five years, 18891894 (1889 to 1893 only published); (2) the number of cases of diarrhoeal diseases in children under two years of age which have been admitted to the out-patient department at the Children's Hospital for the same years; (3) the mean monthly temperature in Melbourne for each month of the same quinquennium. From these charts, it may be readily seen that the term " summer diarrhoea" is no misnomer, for the charts show graphically enough that, with the rise in temperature of the beginning of the summer, there is an excessive rise in the mortality-rate from diarrhœa, and of course also a greatly increased prevalence of the disease. I will just call attention to a few figures to accentuate this point. The five years' average number of cases of diarrhoea admitted to the out-patient department of the Children's Hospital in August is about 14, in January this number has risen on an average to 195, an increase of fourteen times; again the average number of deaths from diarrhoea in the month of September is, according to vital statistics here, about 16, by December this number has risen to 177, a sudden increase of eleven times the number of fatal cases. I must mention here that this number should really be higher, because a large number of certificates are given in which the cause of death is stated to be primarily "marasmus," when really the child has died from summer diarrhoea and secondarily exhaustion; for instance, in September 1889 the number of deaths from atrophy and so-called marasmus was 28, in December of the same year these cases had increased to 125. I shall return to the consideration of the meaning and the gross misapplication of the word marasmus.

Just as in the case in Melbourne, charts published in New York, Berlin, and in Dresden, all show the same sudden rise in

the mortality and prevalence "curves," when the summer heat begins. It has been stated that for these three cities a certain mean elevation of temperature is necessary before diarrhoea becomes epidemic; this elevation is found to be about 60° F., and when near this critical point a difference of only 1° or 2° has a very marked influence in increasing the amount of diarrhoea. I have made the same observation here, and have drawn a line in the charts which indicates the mean temperature of 60° F. In November 1889, the mean temperature was 61.8° F., and the mortality 191; in November of the following year the mean mortality was 58.7°, and the mortality was only 47.

Through Mr. Ellery's kindness, I have been enabled to search through meteorological records for each day for the last five years, and I have carefully investigated the atmospheric conditions associated with the various number of cases admitted each day for treatment at the out-patient department of the Children's Hospital. I have, however, not been able to satisfy myself that any atmospheric condition, other than increased temperature, has any appreciable or constant influence upon the disease under consideration. I am, it is true, inclined to think that, provided the temperature is high, an increase in the humidity does help to increase the prevalence and mortality of the disease. I am comforted to find that Emmett Holt says that the unanimous conclusion reached independently by different observers is that neither barometric pressure, humidity, nor rainfall has any influence upon the prevalence or mortality from infantile diarrhoea. Neither the direction nor the velocity of the wind can be shown to have any constant influence. I at one time thought that I could show statistically that an east wind, or a sultry still day increased the prevalence, but there is no constant curve to show any relationship.

Temperature then is the only atmospheric condition which we can at present safely consider. How then does increased tempera

ture cause diarrhoea? Does the direct action of heat cause a terrible depression in young infants, or is it only that increased heat acts as a causative factor, because at about 60° F. putrefactive processes and toxicogenic germs first become very active? If the summer diarrhoea was due to the depressing influence of increased atmospheric temperature, we should expect to find the greatest prevalence of the disease always and only at the time of greatest heat, but all statistics in various parts of the world show that this

is not the case. A glance at the charts which I have made out further show that here, too, no such absolute correspondence exists. Again, if the direct effect of the heat was the chief cause of diarrhoea, we should expect to find the youngest infants most affected, and also that those who were fed on the breast were equally affected with the others. But observation and figures show that it is not so; it is not because infants are very young or delicate, but because they are artificially fed that they get diarrhoea. Out of 1943 fatal cases which have been recorded, only about 3 per cent. had the breast exclusively. As Emmett Holt says, "these facts speak volumes." I think it probable, however, that there is a very small number of delicate children particularly susceptible to depressing influences, who suffer from diarrhoea in the summer, in consequence of putrefactive changes occurring in the food after it has been swallowed. Although sound when given, the food is not sufficiently rapidly acted upon by the digestive juices of the depressed child, but lies in the stomach and intestines undigested and quickly undergoes putrefactive changes, with the result that the child has all the symptoms of summer diarrhoea. Such cases are very rare. In regard to this direct depressing influence of heat, it is remarkable to observe the tonic influence of cool weather; after most of the irritating poisonous material has been removed from the intestines, a series of cool days, or a change to a cooler atmosphere, are infinitely the most efficient curative agents. If a mere diminution in the temperature has this effect, we are not right in not recognising the influence of an increase in the temperature. I am sure that many a so-called diarrhoea mixture and drug has gained an altogether too high a reputation in consequence of a fortunate change in the weather.

Among atmospheric influences, Dr. Musket regards the gaseous unwholesome condition of the air of a metropolitan city as having a direct influence upon the summer complaints of children. This is a most misleading view to take of the case. No doubt, in country districts, diarrhoea is less prevalent than in towns, chiefly, I believe, because the milk supply is less contaminated, and the milk is consequently less liable to turn sour. Of course, every influence, which favours the growth of putrefactive organisms in the food, may be said to have a direct influence in causing diarrhoea. It seems to be useless to consider schemes for giving children a breath of fresh air, when the next bottle the child gets at home will be probably poisonous. The only proper way to

contend with the evil is, that medical men should recognise the cause of the disease, that the milk supply should be less badly and less dirtily arranged than at present, and that mothers and nurses should be made to take extraordinary care to see that in the summer months the infants are not fed with poisonous, unsound, unsuitable food. Such a pleasant state of things is hardly to be expected, however, for even now a mother far prefers to use a feeding bottle with an indiarubber tube, in which are growing countless toxic organisms, than to use a bottle which can be efficiently cleaned, because it is a little more troublesome. During my work at the Children's Hospital and at inquests, I have frequently heard from mothers and nurses that the child took bad with the diarrhoea, and when she went to a friend or the chemist, or sometimes to the doctor, she was told that the child was teething, and that the diarrhoea was good for it. Such evidence have I heard at many an inquest!, I think, on the whole, that chemists are most to blame for the propagation of this pernicious belief. Is it possible, I may ask, that even severe peripheral irritation in the gums could directly cause intestinal disorders or inflammation? No doubt many, in fact most cases of diarrhoea in children occur during the period, or just before it, of active dentition, but there is no causal relationship between the two conditions. Children cut their teeth in the winter, and yet there is practically no diarrhoea among them then. A child who is fretful and irritable when cutting teeth, frequently does get diarrhoea, because by way of soothing it much unsuitable food is persistently given. Emmett Holt, whose work on diarrhoeal disease is excellent, writes "that too much cannot be said in contradiction of the wide-spread belief among the laity, that diarrhoea occurring with dentition is normal and beneficial. Such a view costs many lives every year."

About six or seven years ago, the ordinary question put by every anxious mother was--Has the child got consumption of the bowels? indeed, it was frequently given as a piece of information "the child has a touch of consumption of the bowels." Now, however, the term "consumption of the bowels" has given place to the nice sounding term "marasmus." Children now frequently "have a touch of the marasmus," or we learn that a fatal case started as 66 marasmus." I find, too, that many medical men seem to regard marasmus as indicating some very definite disease which manifests itself in a strong predisposition to diarrhoeal disease. The term 66 marasmus is used much in the same way