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this table, we would be inclined to consider that in this epidemic age had no influence in predisposing to particular forms of sequela; in a word, we conceive that the type of the disease determined the form of sequelæ, while from the high mortality exhibited between 1 and 2 years of age, the coincidence of dentition may have influenced their fatality.
3d. Sex, as Influencing Mortality. Of these 170 cases, 75 were boys, and 95 girls; of the boys 3 died, or 4 per cent.; of the girls 13 died, or 13•68 per cent.
It would thus appear that the number of females attacked was greater than that of males, a fact which may be owing to the excess of females in the population, seeing that according to the last census there were 110 females to 100 males living.
The mortality of females is enormously greater than of males; a fact at variance with what is observed in epidemics of fever, in which, although the seizures are fewer than in males the mortality is much less. If we look to the births which take place in this country, we find that 105 boys are born to 100 girls, while the whole population living gives a preponderance to females ; in what way, then, can we account for the enormous mortality of females in this epidemic on such data ? The researches of Professor Simpson have proved that while the whole mortality, of children, shows an excess of males, still that it is limited to the first year of life, and arises in consequence principally of nervous diseases induced during labour by the size of the male head.
In this epidemic we find that during the first year of life, while the condition of male and female are unequal, that no deaths arise ; yet that when we come to a time when the conditions of the two sexes are equal, the mortality is in excess on the female side, we infer, therefore, that in this epidemic sex had a decided influence on mortality; whether it is always so with measles we cannot say, but it is certainly worth the attention of future observers. If we look to the relative number of sequelæ affecting each sex, as a means of explaining these results, we find that of 57 cases of sequelæ of the respiratory system, only 23 were girls, but the whole mortality belongs to that sex. Of 15 cases of sequelæ of the digestive system, we find that, although the seizures were nearly equal, the only fatal case belonged to the female sex. Of 3 cases fatal from toxæmia, we find 2 to be girls. Of 9 cases of typhoid fever 6 are girls, the } only one that recovered being a boy. The conclusion we would be inclined under these circumstances to come to is, that while the total number of sequelæ shows the male sex to be most frequently affected, yet, that the mortality of that sex is notably less in consequence of their superior strength in resisting or overcoming disease when established.
4th. Constitution of Patients' previous Diseases, and State of Health at Invasion of Disease as influencing Mortality.-Upon this subject we will not enter into detail, seeing that their elaboration would
prove neither interesting nor instructive; we will, therefore, only particularly inquire into the constitutional states, etc., of the fatal cases, with such references as may be necessary to understand their relation to the recoveries. Of eight cases in which typhoid fever proved fatal, six were stout and of previous good health ; the seventh was a twin of feeble health, but with no constitutional taint; the eight was a feeble child in consequence of labouring under a severe attack of pertussis at the time of seizure; the only successful case was a robust boy, but of no better apparent health than the six fatal cases. Of four cases fatal from sequelæ of the respiratory system, all were previously in good health ; in none of these cases was there any obvious constitutional taint, for farther on we will show that in the post-mortem examinations tuberculosis was absent in all the sequelæ of the respiratory system. One child, previously of robust health, and no previous disease, died of dysentery. Three children died suddenly from toxæmia ; in two the previous state of health and constitution were good, in the third the state of health was doubtful.
It would appear that the typhoid fever attacked those of a robust constitution generally. The respiratory and digestive sequelæ attacked also the robust and strong, and we accordingly find that the fatal cases belong to that category; the cases of toxæmia are too small to come to any conclusion upon as to the state of health. In predisposing to this form, let me here remark that as the general rule the fatal cases were the most robust, while of the successful cases a great, a very large majority, were feeble strumous creatures; in a word, the epidemic in its mortality bore no obvious relation to a previously debilitated state, but the reverse. Were we to describe the kind of children we most dreaded to take measles, we would specify those in robust health, who either took that form designated as inflammatory, and in consequence bronchial inflammation, of a severe character, or a typhoid fever attended with great depression,
5th. Ventilation-state of dwelling, etc., as influencing Mortality. - The evidence of the influence of these combined causes is also not of a nature which we would have been inclined to expect. In the three cases of sudden recession of rash and blood poisoning, the houses were all ill ventilated, overcrowded, badly lighted, and in one very damp. In the four fatal cases of respiratory sequelæ the dwellings were in three well ventilated, etc., in the fourth ill ventilated and overcrowded. In the only fatal case of sequelæ of the digestive system the dwelling was well ventilated and not overcrowded. In the eight fatal cases of typhoid fever the houses were in six well ventilated, etc., and in two ill ventilated and overcrowded. Generally speaking, no very close connection between the state of the dwelling and its ventilation, as compared with the results or complications of the disease was observed, although in predisposing to the disease, and leading to its extension, their influence was undoubted. In those cases in which sudden recession
of the rash was followed by symptoms of blood poisoning, we would be inclined to consider the state of the dwellings to have borne no unimportant relation to the results observed, but in the other cases the conditions present during the progress of the disease did not seem to cause any particular form of sequelæ, or influence their results. With the above exception we therefore consider that the mortality of this epidemic did not seem due to any hygienic imperfections, but more to the form of the disease taken, with which these imperfections bore no apparent relation.
6th, Period at which Treatment was commenced, and attention of Parents to orders, as influencing Mortality.-Generally speaking, a direct influence was observed between the successful issue and the early period at which the patients were seen, the exceptions being the cases of toxæmia and typhoid fever, in which cases remedies seemed of little avail. Although, from the short time intervening between the first visit and the fatal event, in the cases of blood poisoning, no treatment could have time to develope its effects. Of the 3 cases fatal in this way, 1 died 2 hours after first visit, 1 in 4 hours, and 1 in 7 hours. Of the 4 fatal cases of sequelæ of the respiratory system, 2 were not seen until the evidence of organic change in the lung was present (collapse); in 1 conjoined with croup, which had gone on to exudation; the fourth case was seen from the commencement, but went on to collapse of the lung. In the first three cases in which organic changes were present before treatment was commenced, the remedies prescribed were regularly administered. In the fourth case, seen from the commencement, the remedies were at the first administered very irregularly, and latterly not at all, the mother being engaged all day in field work, while the child was left in charge of one not much its senior.
The only fatal case of dysentery was well attended to, and the treatment was early commenced.
In the 8 fatal cases of typhoid fever, treatment was early commenced; and in most cases the orders given were attended to. It thus appears that of these 16 fatal cases, 7 were not seen until either the time before death was too short to permit of the action of remedies, or the time past for their use, when disease had progressed to organic change, or the remedies prescribed not administered. In these days of therapeutical scepticism, it is, we imagine, a conclusive evidence of the effect of remedies promptly administered in acute diseases, to show that of fifty-four cases in which bronchitis supervened, in many severe, the three cases which proved fatal did so from the want of early treatment; for we find that of these fifty-four cases three were nearly similar in all respects but one, and that being the treatment.
We have now concluded our remarks upon the causes which influenced the mortality in this epidemic, a subject which, no doubt, will be thought by many to have been dealt with too minutely, still by the means adopted only could we have given the proper value to
certain circumstances, generally acknowledged to bear in no small degree upon such a result. To recapitulate the results of these observations, we find-1. That as regards season, the spring months were those in which most fatal cases occurred. 2. That in this epidemic temperature and prevailing winds had probably no influence upon the mortality, but that coincident with the highest mortality a moist state of the atmosphere was observed. 3. That age had no direct influence upon the mortality, but, that as during dentition the highest mortality occurred, that period is unfavourable from the standard of health being lowered. 4. That sex seems to have exerted a powerful influence upon the mortality—the mortality on the female side being enormously greater than on the male. 5. That constitution, previous diseases, etc., evinced no direct influence over the mortality, but may have indirectly predisposed to certain. forms of the disease, attended with complications. 6. That generally the influence of ventilation, state of dwelling, etc., upon the mortality, was not at all conclusive. 7. That generally the time at which treatment was commenced, and the degree of attention given to orders, exercised a powerful influence in diminishing or increasing the mortality. Before entering upon the post-mortem appearances, we would here observe that it is not meant to deny the positive influence of certain causes above enumerated in disease, but to show that in this epidemic the influence of these causes was of a negative kind.
Post-Mortem Appearances.—Of the sixteen fatal cases, postmortem examinations were only permitted in eight. Of the three cases fatal from sudden recession of the rash, one was examined —
1. A stout girl, æt. 2, of previous good health, was attacked with measles. The eruption was scanty and discoloured, suddenly disappearing on the morning of the third day, attended with dyspnca, feeble pulse, and a drowsy semi-comatose state, proving fatal in seventeen hours after the recession of the rash. Post-mortem, twenty-four hours after death. Body stout, and good deal of subcutaneous fat. Thorax-pericardium moist, heart healthy, right ventricle contains dark fluid blood in moderate quantity, left contracted and empty. Pleuræ non-adherent, moist; some vesicles of air between pulmonary pleuræ and lungs in front; lungs generally congested, most so at back part; right lower lobe non-crepitant, infiltrated with blood non-granular; bronchi exude a frothy fluid ; trachea congested. Abdomen-liver large, congested; kidneys and spleen also congested.
Of those in whom bronchitis supervened and proved fatal, three in number, two were examined :
1. A female child, æt. 15 months, previously healthy, was seized with measles, followed by aggravation of the cough, and febrile symptoms on the third day, simultaneous with the fading of the rash. These symptoms were neglected for about fourteen days; at this period medical advice was had recourse to for the first time; the child was found to be labouring under ex. treme collapse of the lung and croupy breathing, and died a few minutes after. Post-mortem thirty-six hours after death. Body pale, subcutaneous fat in tolerable quantity. Thorax-pericardium contains about a drachm of strawcoloured serum; heart valves normal; right ventricle distended, with dark coloured fluid blood ; left ventricle contracted and empty. Pleuræ non-ad.
herent, moist ; lungs both imperfectly crepitant throughout-in the substance of both lungs, numerous lobules of carnified tissue are observed; both lower lobes are condensed by bloody infiltration; bronchial tubes filled with purulent matter, tenacious and in greatest quantity in the smaller tubes ; trachea congested ; larynx, no deposit on free surface, but greatly thickened from a deposit in the submucous tissue of a serous character. Abdomenliver, spleen, kidneys, normal.
2. A female child, æt. 2, previously healthy, was seized with measles, followed on the third day by an aggravation of the cough and fever ; when first seen these symptoms had been allowed to go on, and the child seemed labouring under collapse of the lung, attended with dyspnea and laryngeal cough ; died suddenly, fourteen days from appearance of eruption. Post-mortem thirty hours after death. Body pale, emaciated.' Thorax-pericardium moist; heart valves healthy; right ventricle dilated with semi-fluid dark blood ; left, contracted, empty. Pleuræ non-adherent, moist; left lung, upper lobe, ædematous ; lower, non-crepitant, whole lobe nearly composed of carnified lobules, with here and there a small portion of crepitant lung tissue; right lung, a large emphysematous bulla, size of a marble, is found between lung tissue and pulmonary pleuræ, at base in front ; lower lobe condensed, the lobules generally have the usual appearance of carnified lung, but others are lighter coloured and imperfectly granular (lobular pneumonia)? Bronchi-all exude a tenacious purulent fluid, which is most abundant in the smaller bronchi. Abdomen_liver, spleen, kidneys, healthy.
The case which proved fatal from the supervention of croup was examined :
1. A healthy stout female child, æt. 14 months, was seized with measles, which commenced to recede on the third day, attended by increase of the febrile symptoms, cough, and the physical signs of acute general bronchitis, which yielded, but left a laryngeal cough ; in three days croup commenced, running on rapidly to death in twenty-four hours after the symptoms attracted notice. Post-mortem forty hours after death, Body pale, not emaciated; blueness of nails of hands and feet ; a good deal of subcutaneous fat. Thorax-pericardium moist; heart valves normal; right side gorged with semi-decolorised clots ; left empty and contracted. Pleuræ moist, non-adherent; lungs, left upper lobe crepitant, slightly ædematous ; lower lobe sparingly crepitant, numerous carnified lobules, with ædematous crepitant tissue between ; right upper lobe crepitant, slightly edematous ; middle lobe small, nodulated externally (like as is seen in advanced cirrhosis of liver), hard, non-crepitant. This lobe is made up of these nodules, which seem fibrous on section, and contain no cavity ; between them are pieces of non-crepitant lung tissue, which become crepitant by inflation, the fibrous bodies remaining unaffected; they apparently represent an extreme degree of collapse ; lower lobe imperfectly crepitant, carnified in patches ; larynx and trachea, rimæ plugged by a fibrinous mass extending fully an inch down trachea, non-adherent, of the thickness and shape of an ordinary goose-quill; trachea congested to its bifurcation, no lymph on its surface ; at the bifurcation a yellowish and very tenacious fluid is found proceeding downwards to the smaller tubes of both lungs, which are completely filled. Abdomen—liver, spleen, and kidneys, healthy.
The diseases of the digestive system include one fatal case of dysentery, which was examined :
1. A stout healthy female child, æt. 3, seized with measles, followed on the 3d day (synchronous with recession of the rash) by symptoms of acute dysentery. On 15th day of its duration cancrum oris supervened, destroying part of the upper lip ;- the two upper incisors, and about half of the hard palate, with com