THE 4ustrafian Medical 7ournal MARCH 15, 1885. rigirial Articles.

LIGATURE OF RIGHT VERTEBRAL ARTERY OF AN EPILEPTIC—RUPTURE OF INTERNAL JUGULAR VEIN—RECOVERY. By ROBERT B. DuNcAN, Surgeon to the Kyneton Hospital. Whether the ligature of the vertebral arteries in cases of confirmed epilepsy will ever become a recognised surgical operation may well be open to doubt. When we take into consideration, however, the large number of hopelessly incurable epileptics, and the powerlessness of medicine to afford them any relief, any aid that surgery may promise should certainly have a fair trial. The cases already recorded, and the results achieved by Dr. Alexander of Liverpool, point to a fair amount of success, and would certainly warrant further operations in the same direction. I had not the advantage of being able to consult his article when the present case came under my care. The literature of the subject is otherwise very scanty, and the method of operating is scarcely alluded to in works on systematic surgery. Erichsen, quoting Smyth of New Orleans, devotes a few lines to the method of procedure in his celebrated case. In Stephen Smith's Principles and Practice of Operative Surgery, a pretty full and accurate account of the method of operating will be found. The mere fact of having ligatured the artery would not really merit any special communication, except for the unlooked for and formidable complication which attended it. As no mention is made, in anything I have read of, the occurrence which happened to myself, it may not be uninteresting to those who contemplate performing the operation to place on record a not improbable complication. Whether the rupture of the internal jugular was due to any weakness in the coats of the vein itself from its frequent distension during the fits, or the result of pre-existing disease, I am quite unable to determine ; it suddenly gave way when being cautiously pulled aside, with the other structures surrounding it, at a certain stage of the operation. VOL. VII. No. 3.—NEW SERIES. 98 Australian Medical Journal. MAR. 15, 1885

The patient, a young, healthy-looking man, aged 30, had been subject to epileptic seizures for fifteen years. As is frequently the case, no cause could be assigned for them, nor had any medical treatment been of the least avail in lessening their severity or mitigating their frequency. He was admitted to the hospital in September last, and kept under observation for a month. During that time he had on an average five fits every night, and generally two daily. The attacks were most severe and prolonged. Such, I was informed, had been about his usual state for ten years at least, and for five years previously, the attacks, however, at that time not being of such intensity. On the 10th of October last, the patient having been put under the influence of chloroform, I proceeded with the operation. The head being inclined a little to the left side, an incision three inches long was made along the posterior border of the sterno-mastoid muscle, terminating a short distance above the clavicle, the external jugular vein being divided and secured. The cellular tissue was divided the whole length of the wound, some lymphatic glands pushed aside, and a depth reached on a level with the internal jugular vein. To reach that part of the vertebral artery lying between the scalenus anticus and longus colli muscles, it became necessary at this stage to displace the vein and other surrounding structures which lie immediately over it. As this was being carefully done by one of my colleagues with a retractor, a gush of venous blood took place, of such magnitude immediately as to reveal its source. Almost instantaneously with its appearance a whistling sound was heard issuing from the bottom of the wound, which only too surely denoted the entrance of a considerable quantity of air. The appearance of the blood and the rush of air being almost coincident, no time was of course afforded to prevent it, but on its occurrence I immediately stuffed the wound with a sponge. The patient's face by, this time had become dusky and the heart's action much embarrassed. Artificial respiration was at once commenced and carried on energetically, the condition soon becoming more favourable. How to remove the sponge and secure the vein without permitting the entrance of any more air was the next question. Although this was attempted with the utmost promptitude, a large influx of air again took place, but I succeeded in introducing my index finger into the proximal end of the rent. The patient was now in a MAR. 15, 1885 Australian Medical Journal. 99 condition of extreme peril, the respiration stertorous, face livid, and fluttering pulse. Artificial respiration was again resorted to, with the result of bringing the patient into a more favourable state. While this was being carried out, I found that the vein had given way a little over an inch distant from its union with the brachio-cephalic. My finger completely filled it, and it was torn almost quite across. As the part of the vein in which I had my finger inserted was under the clavicle and out of sight, great difficulty was found in securing it. This was at last accomplished by passing an aneurism needle round my finger outside the vein, threading and withdrawing it. The vein being out of view, the risk of including other structures was very great, but fortunately this was avoided. It was then carefully tied, and an additional ligature above the rent. An opening was then quickly made in the aponeurosis covering the scalenus anticus and longus colli muscles, an inch below the transverse process of the sixth cervical vertebra, and the muscular structures separated. By good fortune the artery was exposed at once and ligatured, the operation not being unduly prolonged. The wound was irrigated with carbolic acid solution, drained with carbolised kangaroo tendon, and closed with the same material. The patient was removed to bed in a critical state, from which, however, he satisfactorily rallied in the course of a few hours. His temperature never exceeded 100° F., and his recovery was rapid and without the intervention of a single bad symptom. The antiseptic dressings were continued for fourteen days, and at the end of three weeks the wound had completely healed. Although the left vertebral still remains to be liga- tured, it is pleasing to note the gratifying results already obtained. For ten days after the operation he had no fits, then one or two slight ones, and now at the end of four months he will be sometimes four days without one. Their regularity and severity have been completely altered, and viewed as merely a palliative measure, there is much to recommend what has already been done. How . far the case will progress favourably, or a cure be attained when the operation is completed, I hope to be able to state at some future time. I ought to have mentioned that I had the assistance of my friends Drs. Langford, Smith, and Ryan, without whose valuable aid the result might have been very different. G 2 100 Australian Medical Journal. Men. 15, 1885

PRIMARY SCIRRHUS—PLEURO-PNEUMONIC AND RENAL. By W. V. Jakins, L.R.C.P. Ed., Fell. Obst. Soc. Lond. The great rarity of this complaint, and the infrequency of its correct diagnosis, render this case of unusual interest. James G., aged 62, a miner, weight about 12 stone, admitted into the Ballarat Hospital 13th July, 1883, for stricture of the urethra ; treated by gradual dilatation, and discharged cured 7th August. He was re-admitted under my care 17th May, 1884, for pleurisy with effusion on right side. Height about 5 feet 7 inches, weight about 91 stones ; pale, but with a little natural ruddiness over cheek bones ; body seems destitute of fat ; hair brown, turning grey, and scanty. Right chest enlarged, intercostal spaces a little prominent, and action inefficient in respiration ; glands not enlarged. On percussion, anterior dulness below nipple, less above it, laterally and posteriorly dulness not absolute ; vocal fremitus defective ; bronchial breathing all over to extreme base. No pain, cough, or elevated temperature ; eyes prominent, pupils exceedingly contracted, eyeballs hard, vision indistinct. These latter conditions were much relieved by eserine locally. As usual he passed his catheter about once a month, sometimes drawing blood. Urine was examined occasionally for albumen and sugar without finding any. Always grumbling. The treatment was pot. iod. internally, iodine paint externally, and fomentations. He left on 30th August very much better. Dulness but slight, breathing less bronchial, eye affection not troublesome. He had taken daily exercise in the garden, and slept fairly. On 17th September he was again admitted, decidedly thinner and paler than on 17th May, signs and symptoms as at that date, save that his eyes did not trouble him. His temperature never rose above 98°, in the evening it sometimes fell to 97°, yet he gradually wasted till 2nd December, when slight bronchitis with dyspncea set in. This was relieved by lobelia and senega, but he gradually became weaker, and died quietly at 2.45 a.m. on 16th January, 1885. At the autopsy, at 3 p.m. on the 17th, the body was still warm, much emaciated, pale, no enlarged glands to be detected. Costal cartilages required sawing. Anterior right pleura had to be dissected off the sternum, was much thickened, and of leathery 101 MAR. 1, 1885 Australian Medical Journal. consistence. Right lung needed dissection from the parietal pleura as anteriorly. The chest was half full of degenerated clots, from the size of a pigeon's egg to an orange, sienna coloured, shaggy externally, internally containing a pale or burnt sienna, thin fluid, a few amber-coloured irregular clots posteriorly. Parietal pleura white, resisting the knife ; lung pleura upper third the same, merging into a similar condition of the lung, a piece of which might have been mistaken for part of a scirrhous mamma. Lesser bronchi patent from apex to base, lung substance deep slate coloured, bronchial glands not enlarged. Left parietal pleura thickened anteriorly, elsewhere dotted with scirrhous masses like split peas. Lung pleura also spotted, especially anteriorly, where in the upper part they were coalescing. Lung substance not remarkable. Left chest about half full of dark sero- sanious fluid, about half a pint of long, amber-coloured clots posteriorly. Heart relaxed, pale, and thin Liver slightly granular. Right supra-renal body matted to kidney, upper two-thirds of which, supra-renal body included, being entirely replaced by scirrhus, ending abruptly in what looked normal tissue. This scirrhus creaked under the knife, and showed the usual creamy juice on scraping. Glands and other organs seemed normal. Remarks.—There was nothing in this case to indicate scirrhous kidney. There never was blood or albumen in the urine. Occasionally there was pain in the right loin, but never severe or persistent, and therefore it attracted no attention. Cachexia was absent, sleep good, cough not troublesome. Dyspncea not beyond what might be expected from the interference with the movements of the right lung. Temperature all through was a little sub-normal. The contracted pupils were suspicious, but a few days' treatment with eserine permanently relieved them. Microscopic examination of sputa would probably have been of no avail, as there was no evidence of softening in any part of the lung tissue. The absence of enlargement of any of the glands was remarkable. A fortnight before his death, as he wished something to be done for him, I aspirated posteriorly. The trochar entered with great difficulty, owing to the tissue resistance, and only about a drachm of bloody fluid came away. Ballarat, 19th February, 1885. 102 Australian Medical Journal. MAR. 15, 1885 ,$orietp of Victoria.

MONTHLY MEETING. WEDNESDAY, MARCH 4, 1885. (Hall of the Society, 8 p.m.) Present : Drs. Allen, Jamieson, Webb, Snowball, Stirling, J. P. Ryan, Gray, Girdlestone, Workman, Bowen, Willis, Moloney, A. G. Black, Bage, and Griffith. The President, Dr. Moloney, occupied the chair. The minutes of two previous general meetings and of one special meeting were read and confirmed. Three gentlemen were nominated for election. Mr. GIRDLESTONE then read the following :— CASE OF INJURY TO SPINAL CORD IN CERVICAL REGION, UNACCOMPANIED WITH FRACTURE OR DISLOCATION. Reported by Dr. C. J. SHIELDS, Resident Surgeon. S. D., a t. 15, was admitted to the Melbourne Hospital on 19th October, 1884. About two hours before admission, while bathing in the Yarra, he had dived into shallow water and struck his head against a stone, inflicting a scalp wound of four or five inches in length. The skull was not injured. He never lost conscious- ness either at the time of the accident or afterwards, but he lost power over his arms and legs immediately on receipt of the injury, having to be pulled out of the water by another boy. When admitted he was perfectly sensible, could talk and answer questions correctly. He was suffering from severe shock. Pulse 64, feeble. Respirations 15, regular, but entirely abdominal, there being no costal breathing whatever. Skin and extremities cold. He complained of pain in his neck, but was able to move his head somewhat, though with difficulty. Motion caused pain in the neck, but no irregularity of the line of the cervical spine could be made out. He had complete loss of power in both arms and legs. Sensation was lost completely in the extremities except over the deltoid regions, where the prick of a pin could be felt. Sensation was present behind as low as the second dorsal spine, and in front as low as the second intercostal space. Below these boundaries sensation was absent. Patient had priapism, which persisted; also had loss of power over bladder and rectum. During the succeed- 103 MAR. 15, 1885 Australian Medical Journal. ing period he suffered from sleeplessness and from severe griping pains in the belly, accompanied with a good deal of distension. He was always able to take a fair amount of liquid nourishment and stimulants, but he gradually lost flesh, and bedsores soon appeared over the sacrum and trochanters. About four weeks after admission he got occasional attacks of dyspnoaa, which were very severe, and appeared to be relieved by brandy. He lingered until January 11th, 1885, when he died quietly, apparently exhausted. While in the hospital no alteration in the paralysis occurred, either for better or worse. Autopsy. —Body very emaciated and bedsores very severe, one exposing the trochanter major and opening the hip-joint on the - right side. Spine.—Cervical spine was very moveable and a pro jection could be produced in the middle cervical region by bending the head forwards. No fracture could be discovered, and the posterior arches of the vertebrae were intact. By bending the head into certain positions the body of the fourth cervical vertebra could be made to press backwards on the cord. It was also deformed; on its posterior surface were two lateral raised portions, the centre around the vena basis vertebrae being depressed, ap- parently by absorptive processes. The anterior aspect of this body was very shallow from above downwards. The cord was almost completely destroyed opposite the fourth cervical vertebra, the pia mater being shrunken and enclosing a little turbid yellow pulp. Lower down the cord filled the spinal theca, but there was pronounced softening as far as the lower border of the sixth vertebra. In the lower part of the area of softening there was brownish colouration of the right posterior cornu, the softening also being more marked on the right side. There were no distinct traces of haemorrhage, and no inflammation of the membranes. Mr. GIRDLESTONE exhibited the specimen, and read the follow- ing notes of a CASE OF INJURY TO THE CERVICAL SPINE FROM INDIRECT VIOLENCE. Reported by Dr. MOORE, late Resident Surgeon. J. H., vet. 52, tailor, admitted into hospital on the 21st October, 1883. He stated that in the night previous to admission, while going down stairs he slipped and fell down about a dozen steps, 104 Australian Medical Journal. M. 15, 1885

striking the back of his head either against the floor or the bottom step. He was unconscious for about an hour. On recovering consciousness, he found that he was quite unable to move, and remained on the floor for about two hours, when he was found. There was no change in his condition until he was brought into the hospital some hours later. On examination, there was complete loss of both motion and sensation in all the limbs. On the trunk there was no sensation below the second intercostal space, but above that, sensation did not seem to be much impaired. Some sensation in upper part of arms. There was no facial paralysis ; tongue protruded in mesian line ; could puff out both cheeks ; breathing markedly dia- phragmatic; no thoracic movement ; face not livid ; faeces passed involuntarily ; urine retained ; complete loss of all reflex action ; was quite conscious and able to answer all questions. No marked change occurred ; he gradually became very livid ; was unable to cough or expectorate ; his pupils were contracted ; bowels open ; drank very well, taking plenty of milk. On the 23rd the temperature of right leg was 99.6°, left 98.8°. On the 24th his breathing was very difficult ; sloughs were beginning to form on the back ; his urine was dribbling away. On the night of the 25th he died. TEMPERATURE. Morning. Evening. October 21 100° 22 98° 98.6° 23 .. 101.4° 103° 24 102.8° 102° 25 100.8° 99.8° Prof. ALLEN supplied the following pathological description:— At the autopsy the body was found to be muscular, rigor mortis well marked. There was deep purple discoloration on the point of the right heel, and a bleb containing blood-stained fluid had formed on the inner side of the left foot. The skin over the prominences of the sacrum was slightly abraded. The muscles of the back in the cervical and upper dorsal regions were infiltrated with extravasated blood, especially on the right side, where many fibres of the longissimus dorsi were actually ruptured. On carefully reflecting the muscles the ligaments uniting the posterior arches of the fifth and sixth cervical vertebrae were found extensively lacerated, especially on the left side. The ligamenta subflava were torn across ; the articular capsules were 105 MAR. 15, 1885 Australian Medical Journal.

much stretched, and partly opened ; the rudimentary ligaments, connecting the spinous processes to each other and to the ligamentum nuchae, were partly torn and infiltrated with extra- vasated blood. The disc of cartilage between the fifth and sixth cervical vertebrae was torn across, and the body of the sixth vertebra was somewhat bruised, its substance on section being deep red, and its cancellous spaces infiltrated with extravasated blood. A little clot was found beneath the anterior and posterior common ligaments, opposite the injured cartilage. The extra- vasation of blood outside the dura mater was but trifling, and the arachnoid cavity only contained a little clear fluid. Opposite the injured intervertebral disc, the cervical enlarge- ment of the cord was much bruised ; it surface was yellowish, and on section its central substance was found deep purple, very friable and blood-stained ; the white substance was comparatively little affected ; the anterior columns in particular retained their whiteness, but the grey substance in the centre was completely broken up, and the posterior columns and the lateral columns, especially on the right side, were also bruised, discoloured, and softened. The injury to the cord was very limited in extent, the primary lesion being confined to about half-an-inch of its length opposite the fifth and sixth cervical vertebrae ; but for a slight distance upwards and downwards the nervous substance was yellowish and succulent. The heart was relaxed, all its cavities containing a little dark fluid blood ; its muscular walls were rather friable. The lungs were emphysematous anteriorly, congested and friable posteriorly; there were old-standing pleural adhesions on both sides, especially the right. The trachea and larynx contained blood-stained mucus and partly digested food, but were themselves uninjured. The cortical substance of the kidneys was broad, opaque and streaky ; the capsules were slightly adherent. The liver was congested and friable ; the spleen was large, flabby and congested. Remarks.—Both cases afford examples of severe injury to the cord caused by a sudden bending of the cervical spine, and although there was no fracture of bone in either, the laceration of ligaments and of the inter-vertebral substance found in one case, and the abnormal mobility of the body of the fourth cervical vertebra in the other, show that the bones of the column must 106 Australian Medical Journal. MAR. 15, 1885

have been sufficiently displaced at the moment of the accident to inflict serious injury on the cord, the bones regaining their proper position immediately afterwards. In the case of the boy S. D., I think it is remarkable that after an injury which had to some extent displaced and loosened the 4th cervical vertebra, and destroyed the cord in this situation, that the patient should have lingered from the 19th October till the 11th January ; and as the above vertebra bore the brunt of the violence, we cannot suppose that the 5th cervical nerves escaped serious damage. Dr. ALLEN said that the most remarkable thing about these cases was the absence of either fracture or displacement at the seat of injury, though the cord was so seriously damaged. It was well known that in a young child the elasticity of the spine allowed a large amount of bending without fracture or dislocation, but it was rare to find the condition of things shown in these cases. The first case certainly was a very remarkable one, the wonder being that the boy survived the injury at all for such a long time. There must have been injury of the spine as high as the 5th cervical, the 3rd and 4th escaping, or death must have resulted. The bed-sores too were both large and deep, extending into the hip joint. Dr. WEBB referred to the case of a jockey who had been under Mr. Fitzgerald's care. He had been thrown to one side from a horse and had struck against a fence. There was as nearly as possible complete paralysis of the whole muscles of the trunk and extremities. I-le lay for two years helpless, contracting enormous bed-sores ; he had both pneumonia and bronchitis ; and his fingers had become so rigidly flexed that the nails were piercing the palms. An operation was performed, the injured vertebral processes being removed, and he recovered so as to be able to go about. Alto- gether it was perhaps the most remarable case of which he had ever seen a record.

Mr. GIRDLESTONE also read, with a description of the post- mortem examination by Prof. Allen, NOTES OF A CASE OF FRACTURE OF THE PUBES. W. C., mt. 31, admitted 22nd February, 1885. Patient while under the influence of liquor, at about 11 p.m. on Feb. 21, tripped over some ropes and fell a distance of about 16 feet down the hold of the s.s. Titus. He does not know how he fell, but says that he at once felt pain in the lower part of the back and MAR. 15, 1885 Australian. Medical Journal. 107 abdomen. He walked some distance after the accident to the hotel where he lodged, where he lay down, but felt unable to get up again by himself. On admission patient was in a state of collapse, pulse rapid and feeble, there was extensive bruising of the lower part of the abdo- men on the right side, and on the upper part of the right thigh and scrotum. The perinmum was bruised, but not at all swollen. There was great pain attending all movements of the body, and tenderness over the lower ribs, abdomen, and pelvis. Fracture of ribs, and of pelvis also were suspected, but could not be made out. There was no crepitus to be felt, neither was there any unevenness of the rami of the pubes or ischium. The patient suffered from persistent retching and vomiting, which continued till his death, on 27th February. His bladder was kept empty by the catheter, and the urine for the first few days contained a good deal of blood intimately mixed with the water. February 25.—As he could not retain any food in the stomach peptonised beef tea enemata were administered, and morphia was given hypodermically. February 26.—Urine passes freely through the catheter, but it is now clear and free from blood. He died on the morning of the 27th. Urine passed just before death was not bloodstained. At the autopsy there was extensive ecchymosis in the right groin, and in the upper part of the right thigh. There was a comminuted fracture of the right os pubis ; and a comminuted fracture of the posterior part of the right ilium, opening the sacro- iliac articulation. There was copious extravasation of blood in the cellular and muscular tissues of the abdominal wall, both below in the true pelvis, and upwards in the right iliac fossa, and around the right kidney. The specimen now shown consists of the anterior wall of the pelvis, with the bladder and part of the urethra. There is an almost transverse fracture of the body of the right os pubis, the line of fracture extending from the inner surface of the pubis near the symphysis, outwards to the external surface at the commence- ment of the ilio-pectinea. The inner end of the outer fragment is displaced backwards, penetrating the wall of the bladder and carrying that viscus backwards and upwards away from the sym- physis. The end of this fragment, however, remained imbedded in the vesical wall, apparently occluding the rupture completely. 108 Australian Medical Journal. MAR. 15, 1885

The space left between the back of the symphysis and the displaced bladder measured about an inch, and contained thin blood-stained fluid, not distinctly urinous. Another fracture involved the descending ramus of the right pubes. This fracture was also very oblique, running from above and in front, downwards and backwards. There was slight com- minution at the upper part of the fracture. The lower fragment, carrying with it the attachment of the right crus penis, had been .displaced downwards and inwards, so as to produce severe lacera- tion of the sub-pubic portion of the urethra. The laceration extended from the anterior part of the prostate, immediately to the right of the veru montanum, forwards through the membranous portion, and for a short distance into the spongy portion. It was limited, however, to the inner coats, so that haemorrhage could occur into the urethra without extravasation of urine. From the torn surface of the prostate, a round process of clot projected forwards into the membranous portion. The wall of the bladder is much hypertrophied ; its mucous membrane is swollen, edematous, ecchymosed. The 7th, 8th, 9th, and 10th ribs on the left side were fractured close to their articulations with the corresponding cartilages. The fracture of the 7th rib was imperfect, being limited to the inner aspect of the bone, the outer surface being intact and free from extravasation. Concerning the fracture of the pubes, it is noteworthy that such extensive displacement of the fragments, with laceration of the bladder and urethra, would have been impossible, but for the concomitant fracture involving the right sacro-iliac articulation.

Dr. SNOWBALL then read notes of a

CASE OF INJURY TO THE HAND, OCCURRING IN A SUBJECT WITH HEMORRHAGIC DIATHESIS.

F. S., aged 9 years, admitted into the Children's Hospital on November 11th, 1884. On July 7th, 1884, the patient was brought to the hospital as an out-patient, suffering from haemorrhage from the kidneys. He was treated with ergot and acid sulph., and by the time of his next visit, in the following week, the urine was again of normal colour. On November 11th, 1884, he was again brought to the hospital, with a large sloughy contusion on the forefinger of the left hand, 109 MAR. 15, 1885 Australian Medical Journal. about 11 inches from the end. There was a good deal of bleeding from the contusion, which the mother said was caused by some boys at school slamming the lid of a desk on his hand. The mother also stated that she had lost one boy from uncontrollable hemorrhage, that another began bleeding from very slight causes, and that the patient was the third, while all the girls of the family were strong and without any similar hemorrhagic symptoms. On admission, the finger was dressed with strong liq. ferri perchlor., and the hemorrhage ceased. On the 14th was dressed again, looked healthy. On the 16th blood began oozing from under the dressing, and it was found that the slough was spreading down the finger ; patient complained of a good deal of pain; mist. ferri perchlor. and liq. opii. sed. Miij. The bleeding ceased till the 28th, though the sloughing continued, and at a consultation held the same day, it was decided to amputate at first metacarpo-phalangeal joint on the following day. On 29th the bleeding burst out again, pressure was applied to the brachial without effect, and ergot Mxx. given ; as bleeding still continued, fore-arm was Esmarched and tourniquet put on brachial ; bleeding stopped till 10 p.m., when chloroform was administered, and Dr. Bennie applied acupressure to each side of finger, and dressed with ferri perchlor. and ergot 3ss. every four hours. On 30th ergot changed for pot. bromid grs. x. 4 tis horis. On December 3rd started oozing again, and continued till 2.30 p.m. on December 4th, when Dr. Snowball removed the finger, and stopped hemorrhage with actual cautery. Bleeding began again on December 5th, and was stopped with collodion ; started again on the 6th, and stopped with the cautery again. On the 7th bleeding and cautery, hazeline used as dressing, and given tinct. hamamelis internally. Bleeding now ceased until January 25th, the wound having granulated up, the granulations being so exuberant as to almost resemble a fungous growth, any attempt to check the growth by caustics being followed by bleeding. On the 25th Dr. Snowball removed the mass of granulations with the actual cautery, and continued the hazeline dressing. 110 Australian Medical Journal. MAR. 15, 1885

On the 27th, bleeding broke out again, and was stopped by cautery. On the 29th, the same. On the 30th, cautery was found ineffectual, and a pad of collodion, cotton wool, and styptic colloid restrained the bleeding till the following morning, when it began again. Cautery restrained the bleeding till 3rd February, when it started again. Chloroform was then given, the exposed part of the metacarpal bone scraped away with a Volkmann's spoon, as well as the surface of the wound, and a soft dry sponge tightly bandaged over the wound. On the 6th, sponge removed, slight haemorrhage, and another applied. On the 10th, the hand feeling tender, sponge was removed, and a quantity of pus made its escape, no haemorrhage, and wound dressed with ungt. eucalypt., but exuberant granulations again growing. Dr. SNOWBALL explained that he had brought the boy, and read a short account of the case, chiefly with the hope of getting information. Nearly everything had been tried, and as he was just about at the end of his resources he would be glad to get suggestions for further treatment, which, he feared, was likely to be needed. Dr. WEBB referred to the case, reported not long ago in the Lancet, of a whole family of boys subject to bleeding, where danger had been averted by the free use of sulphate of iron internally. Dr. WORKMAN mentioned the old-fashioned, perhaps quack remedy, Ruspini's styptic, which had at one time a great reputation in such cases. Mr. GIRDLESTONE said that it had never been his fortune to have a case of the kind under his care. He thought that possibly the tincture of larch bark might be tried with advantage. Dr. MOLONEY said that he had seen a good deal of anemia, lately, and had learned something from his experience. Among other things, from what he had seen he was inclined to think that, from whatever cause, sea-air was injurious to those who were anaemic in a high degree. He could not very well see what benefit was to be expected from the use of bromide of potass., which, as a saline, independently of other properties, was more likely to do harm than good. He had noted what was remarked long ago by Graves, that the pulse was considerably quickened Max. 15, 1885 Australian Medical Journal. 111 when the sitting posture was assumed by one who had been lying down. Open-air exercise he had also often found to be injurious to anaemic persons, though it was so constantly recommended. His recommendations in this case would be to have the boy removed to the country away from the sea, to have him placed in the recumbent posture, to give him iron freely, the ammonio- citrate by preference, and if bleeding recurred to try hazeline, which he had often seen remarkably beneficial in various kinds of bleeding Dr. SNOWBALL explained that the boy came from the country, and that for the first two months he had been kept lying on his back with the hand constantly elevated, being allowed up at last from fear of bedsores. The bromide had been tried at the suggestion of Dr. Bennie, who thought that there was periodicity in the attacks of bleeding, associated with increase of arterial tension. The remedy was given with the view of reducing that tension, but it proved as little effectual as other things which had been tried. Dr. STIRLING thought that the application of plaster of Paris in the form of a paste, which would harden and fit exactly on and around the bleeding surface, might be useful, as it had been found to be in bleeding from the navel in children. Dr. ALLEN said that, with reference to the use of iron, which had been mentioned, it should be remembered that, in some persons, its administration brought on an actual liability to bleeding, It was an old medical doctrine that iron was not a safe remedy in phthisical cases, from the risk of hnmoptysis being excited. He had observed in his own person repeated attacks of epistaxis following the use of iron, on the only occasion on which he had taken it as a remedy. Some further remarks on the hereditary transmission of the hmolorrhagic diathesis through the female line, but with almost invariable restriction to males, were made by the President and Dr. Webb. Dr. WEBB read notes of a case of ANEURISM OF THE THIRD PART OF THE AXILLARY ARTERY. Reported by Dr. A. S. AITCHISON, House Surgeon. J. W., wt. 45, quarryman, admitted December 8, 1884. Patient states that eleven months ago he was quarrying on the Goulburn 112 Australian Medical Journal. MAR. 15, 1885

railway, and while lifting heavy weights he " strained himself," and felt a sharp pain just where the tumour is now situated‘ This pain went away immediately and patient continued his work s He noticed nothing further for about three weeks, and then when working one day he felt a severe pain on the inner side of the. arm. At this time he also began to feel pain at the back of the shoulder and on the inner and outer sides of the arm, but not in, the forearm ; this pain became more and more severe, and he lost all power in the arm, so that he had to leave off work ; he has, done no work since this time. He then went to a medical man, who gave him some liniment, but this did him no good. About two months after the " strain" patient noticed a small tumour, about the size of a pea, below the clavicle at the junction of its middle and inner thirds ; this tumour did not pulsate at first, but it soon increased in size and became pulsatile. As the tumour increased in size the pain became greater, and now patient is never• free from pain. Three weeks after the tumour appeared a doctor treated it by galvano puncture, but this treatment did no good. Since this he has been to several doctors, but has had no treat- ment, and was at last advised to come to Melbourne. He came the whole distance, about 400 miles, on foot, the journey taking five weeks. When walking he has often had to stop and rest because of the pain. Patient has followed his occupation as a quarryman for years, and has always been accustomed to work hard. He has never had any previous illness, and there is no history of rheumatism, gout, or syphilis. On examination, there is a tumour under the middle third of the right clavicle. This tumour is rather larger than a hen's egg,, and can also be felt behind the anterior fold of the axilla. It is soft, pulsating, and dull on percussion. A bruit can be heard over the tumour, and can also be heard more distinctly above the middle third of the clavicle. The veins over the tumour are enlarged. There is no appreciable difference between the two radial pulses. Patient complains of great pain about his right shoulder and arm, and is unable to use his arm. Urine is normal., Heart.--There is a loud bruit with the first sound, audible at both apex and base. Lungs healthy. December 3, 1884.—Patient slept comfortably last night after an injection of morphia. Temperature normal. Pain continuous down the arm, as far as the elbow and round the shoulder.

MAR. 15, 1885 Australian Medical Journal. 113

December 15.—Patient was an aesthetized, the antiseptic dressings which were placed on the aneurism yesterday removed, the adjacent tissues thoroughly cleansed with acid carbol. ; the skin was drawn down over the clavicle, and an incision about three inches in length made. The tissues were dissected till the external jugular vein was reached, and this was held out of the way. The subclavian artery was then felt for, and the intervening tissues having been carefully divided a ligature was placed round the artery. At this part of the operation the haemorrhage was very great, some large vessel having been divided, probably the posterior scapular coming off in an abnormal position. The ligature was tied, and the bleeding stopped by means of two of Spencer Wells' scissor-bladed forceps. These were left in the wound, which was stitched up and dressed antiseptically under the spray. The right arm was then wrapped up in a flannel bandage from the fingers upwards. The forceps were packed round with antiseptic dressings. Patient was placed under the influence of morphia and kept perfectly quiet in a special ward. December 19.—Wound redressed under the spray and one of the forceps loosened. There is no haemorrhage and no discharge. Patient has feeling in all the fingers. Hand is keeping warm. Has an injection of morphia nightly. December 20.—Tinct. verat. virid M ij., aquae ad 3 ij., omni hora sumend. December 21,'1 a.m.—Patient has been vomiting. Veratrum P. stopped. December 21.—Veratrum started again, but patient started vomiting, so veratrum stopped. Patient's temperature has been 99, night and morning since the operation. He complains of numbness down the arm, but can feel in all his fingers. Forceps were removed and there was no hemorrhage. There is slight pulsation in the aneurism. Dressed antiseptically. December 22.—Tinct. aconiti M j., aquae ad 3 j., fiat, hst. ; 3 ss. every 20 minutes. Temperature normal. Feels fairly well. Pulse 84 full. December 23.—Not much change in condition. Complains of pain in right shoulder. Pulse 78. Repeat draught. December 24.—Tinct. verat. virid (IJ.S.Pa. ) M ij., aqum ad 3 ij. Fiat. hst. ; omni secunda hora sumend. Vomiting came on again. January 3, 1885 (18 days after the first operation).—On examination yesterday there was found to be strong pulsation in

114 Australian Medical Journal. MAR. 15, 1885

the aneurism, and it was decided to tie the subclavian a second time. Patient was anesthetized, an incision made above the clavicle, the external jugular vein was divided and both ends ligatured. The artery was picked up after some difficulty, and a kangaroo tendon passed round it and tied tightly. All pulsation in the aneurism was annulled, the wound was then stitched up with wire sutures and dressed antiseptically, the whole operation being performed under the spray ; the skin over and adjacent to the tumour being thoroughly cleansed previous to the operation by turpentine and carbolic lotion. After the operation morphia gr. was injected hypodermically, and repeated at night. Arm wrapped in cotton wool and flannel bandage. January 4.—Temperature : night 98.4, morning 100. No pulsation in the tumour. There has been oozing to some extent

• from the wound. January 5.—Temperature : night 98.4, morning 100. Wound dressed antiseptically and is perfectly sweet. Patient has injec- tions of morphia at night. Complains of a good deal of pain in the neck. Can feel his fingers. January 7.—Temperature normal. Pulse 96. There is no pulsation in tumour. Patient has not so much pain. There is still slight oozing from the wound which is perfectly sweet. January 9.—Pulse 96. There is no pulsation in the tumour. Patient sleeps at night Has not so much pain as formerly. January 15.—Wound is still dressed antiseptically. It has not quite united, but there is very little discharge from it. Patient complains greatly of pain in the shoulder extending down the arm. Has injections of morphia daily. There is no pulsation in the tumour, which has become smaller and firmer. January 19.—Antiseptic dressings discontinued. Wound dressed with vaseline. January 22. Wound dressed with boracic ointment. It has almost healed. There is no pulsation in the tumour, which has diminished in size. Patient still complains of pain in arm, and cannot rest without morphia. January 29.—Flannel bandage removed from arm. There is no radial pulse. Patient allowed to get up. February 2.—Morphia injections discontinued. Not so much pain as formerly. Shoulder and fingers are rather stiff. February 19.—Patient was anesthetized, and the arm extended and flexed, and the shoulder moved in all directions. Ice applied afterwards. MAR. 15, 1885 Australian Medical Journal. 115

February 25.—Patient is able to move his arm upwards midway to the height of the shoulder. Dr. WEBB said that this case had special points of interest. In the first place it was unusual to have reported a case in which an artery was twice tied in the same situation ; and in the second place the fact that a kangaroo tendon had dissolved and disappeared in five days was of very considerable interest. Mr. GIRDLESTONE said that a proper kangaroo tendon ligature, in an ordinary healthy wound, could not dissolve in five days, and he did not believe that it would do so, even in an offensive suppurating wound. There was often want of care in selecting a proper ligature, though life might depend on the selection. If an unsuitable or damaged tendon was used for tying a large artery like the subclavian, a bad result was just what was to be expected. Whatever happened in this case of Dr. Webb's, he was quite sure that the knot round the artery had not dissolved. Mr. James had once thrown the blame of failure on the kangaroo tendon, the truth being that the one selected was actually in a decayed condi- tion from bad preparation. Of course any ligature which was defective in that or any other way ought not to be used. He had seen for instance a ligature drawn out of the tray from the carbolic solution in which it was lying along with knives, and it might readily be notched, and so made practically useless. Dr. WEBB insisted that the tendon had certainty dissolved, as it had completely disappeared. And with regard to the matter of selecting a proper ligature, he could only say that in this particular case the tendon was selected by Mr. Girdlestone himself. Perhaps there was a mistake committed in soaking these ligatures in carbolised water for a time just before using them, as softening might thereby be produced. Mr. GIRDLESTONE held, on the contrary, that the soaking, far from doing harm, was really desirable. Dr. STIRLING exhibited the specimen, and read notes of a CASE OF EPITHELIOMA OF LEG—AMPUTATION OF THIGH—RECOVERY. This specimen was taken from Mrs. R., Pet. 72, who was admitted into the Melbourne Hospital February 10th, 1885, with the following history :- Two years ago a small papule was noticed on the inner side of the left leg, four inches below the knee. This rapidly increased H 2 116 Australian Medical Journal. MS11. 15, 1885

in size, ulcerated, and became studded with fungous granulations emitting a sero-purulent discharge. I saw her in the early part of September, 1883. She was then attending occasionally as an out-patient of the hospital. The ulcer was about the size of half-a-crown, with reddened infiltrated edges—very painful at night—and with a foetid discharge. Her general health was unaffected. September 24, 1883.—I administered chloroform, and Mr. Girdlestone, with Volkmann's spoon, thoroughly removed the diseased surface of the ulcer, applying a strong solution of chloride of zinc to its base. The granulations which sprung up after this operation rapidly cicatrised, and for a time all went well. In September, 1884, I again saw her. The ulcer had by this time doubled its former size, the discharge was copious, watery, and foetid. I examined the tumour under the microscope, and found it distinctly epitheliomatous. On September 22, Mr. Girdlestone operated with the raspatory as before, afterwards applying the zinc chloride. The relief to pain and discomfort from this proceed- ing was very marked, but the malignant characters of the ulcer soon returned. State on Admission.—There is a large epitheliomatous ulcer on the inner aspect of the left tibia, just below the knee-joint ; for some distance around the edges the tunics are thickened and infil- trated. The fcetor of the discharges from the sore is unbearable. The glands of the popliteal space are not affected, but beneath Poupart two small indurated glands can be felt. Although the old lady has been a heavy drinker of colonial beer for many years, her urine does not contain a trace of albumen. Heart and lungs sound. February 11.—Amputation of the thigh above the condyles was performed under Listerism ; the long anterior flap obtained from the front of the knee-joint, and a short flap posteriorly. The femoral artery was secured by a tendon ligature ; the vein was also ligatured. Not more than two drachms of blood were lost. February 18.—Patient has done well until now, when there is slight sloughing at the edges of the anterior flap. The carbolic dressings were then discontinued, and the stump syringed out with a solution of Condy's fluid, eucalyptus and vaseline (3j —si) applied twice daily. Under this treatment union took place rapidly for so old a subject. She is at present, March 1, quite convalescent.

MAE. 15, 1885 Australian Medical Journal. 117

Microscopic examination, for which I am indebted to Dr. Allen. Sections of the tumour display the typical structure of epithelioma; columns of epithelial cells, usually with sharply defined contour, run downwards into a matrix, either clear and finely fibrous, or more or less densely infiltrated with small round cells. Epidermic globes or " nests " are extremely abundant, even scrapings from the surface containing them in considerable numbers. The nests can be found in all stages of growth ; some are very young, one or two plump dark epithelial cells being surrounded by a few rows of flattened spindle cells ; others are old and large, the central cells becoming dry and horny, and being surrounded by numerous concentric lines, in which the separate elements of structure cannot be distinguished ; others again are thoroughly corneous, dry, and hard, sometimes being fused together into masses of considerable size. In some cases the whole of a club-shaped epithelial ingrowth has undergone similar corneous transformation. Photograph of the specimen is supplied. Dr. ALLEN also exhibited the following specimens :—(a) gun- shot injury of skull ; (b) scrofulous lesions of spleen ; (c) obstruc- tion of intestine ; (d) suppuration of middle ear ; (e) carcinoma of bladder. ritis tbitai Association.

VICTORIAN BRANCH. ORDINARY MONTHLY MEETING. WEDNESDAY, FEBRUARY 18, 1885. (Hall of the Royal Society.) The President, Mr. Rudall, in the chair. NEW MEMBERS. The Hon. Secretary announced the election, as members of the Branch, of Dr. John Marchbank, of Terang, and Dr. W. H. Owen, of South Melbourne.

The first paper read was : " ON TWO CASES OF HERNIOTOMY," by Mr. J. T. Rudall, F.R.C.S. Eng. A special circumstance in one of the cases was the unusual situation of the stricture, which was considerably outside the ordinary point of its occurrence. The antiseptic agent used in both cases was corrosive sublimate, in a solution of chloride of sodium. The advantage claimed for this 118 Australian Medical Journal. MAR. 15, 1885

preparation was its' extremely unirritating quality, and its perfect suitability as an antiseptic. Iodoform was also used for dusting over the wound, and this was not followed by any unfavourable consequences. The strength of the sublimate solution was 31--6 per cent., with per cent. of common salt. Dr. HENRY drew attention to the recent formation in Melbourne of a District Nursing Society. He referred to the working of a similar society in London, and gave some particulars of its opera- tions. A conversation followed, and the opinion was expressed that the principle of such a society commended itself to the approval of the Association.

The next paper read was : " ON THE SELF-POISONING OF CHIL- DREN," by Louis Henry, M.D. The object of the author was to show that the swallowing of the sputum by children, in some diseases notably in fever, pneumonia, phthisis, and measles, acted as a poison upon the system. The natural excretions when retained, instead of being eliminated, had a toxic effect. It was very difficult to teach a young child to expectorate. He had found children to die without any sufficient explanation, and he had been driven to accept this sputum poisoning hypothesis as the only solution of the mystery. In the discussion which followed, the theory:brought forward by the author was considered worthy of investigation. It was suggested that the use of emetics might sometimes act as a cor- rective of this difficulty of expectorating experienced by children. Regret was expressed that a post-mortem examination was not obtained in the cases adduced by Dr. Henry. The subject of "THE TREATMENT OF TYPHOID FEVER" was brought up by Dr. McMillan. He summarized the usual course of an ordinary case, and spoke briefly of the treatment, both dietetic and therapeutic, commonly employed. With reference to the latter he had found that sometimes in the earlier period there was constipation, and that, therefore, mild aperients were occasionally indicated. In the later stages he regarded quinine as the sheet-anchor of treatment. He usually avoided stimulants, but they were at times of value. He did not think the average run of cases in this country was of a grave type. An antiseptic, such as boracic acid, might be employed with benefit now and then. The causation of typhoid might at some future time profitably occupy the Association. Excreta, sewage-gases, infected water or milk, were all charged from time to time with being MAR. 15, 1885 Australian Medical Journal. 119 carriers of the disease. It would be a great gain if some common basis of treatment could be agreed upon. Concerning the cold bath treatment, he was aware that in Germany it had been insisted upon as an absolute cure, but it had its disadvantages, one of which was its liability to produce failure of the heart's action. Moreover, it was often objected to by the friends of patients. The PRESIDENT pointed out the improvement in the rate of mortality in typhoid fever during the last twenty years. The diagnosis, too, was now more complete than formerly, and special dangers could more readily be avoided. Dr. SPRINGTHORPE alluded to an opinion by Dr. Broadbent that it was criminal not to use the cold bath in typhoid fever. He also made mention of a remark by Dr. Carpenter, that the infective agent must go through some other nidus before its activity is developed. After some further conversation, it was suggested by the President that the subject might advantageously be brought up again, but he trusted that those who resumed the discussion would bring evidence from actual cases that had been treated.

SOUTH AUSTRALIAN BRANCH. The ordinary Monthly Meeting was held on the 29th January, 1885. The President reported that a copy of the motion respect- ing the appointment of City Health Officer, carried at the previous meeting, had been sent to the Mayor of Adelaide and the President of the Central Board of Health respectively, and the following was

the substance of the reply from the latter: —" In case of a vacancy the Health Act permits the Town Council to appoint (subject to the approval of this Board) a legally qualified medical practitioner or a properly qualified analytical chemist to the office of Health Officer (Clause 27, Act of 173). Whether there is in Adelaide a chemist ' properly qualified' to carry out the instructions of the Central Board of Health is open to question. I do not know one, and I think I may venture to speak for the other members of the Board, that they will not be likely to consent to a bogus appoint- ment. I have noticed that there is before the City Council a proposal to reduce the salary of officer of health to such a figure that it is doubtful if any qualified gentleman could accept it. This Board has no voice in fixing the salary." 120 Australian Medical Journal. MAR. 15, 1885

The members present thought that it was only right that a suitable salary should be attached to the duties, and that it would be a great mistake for medical men to perform them gratuitously. They were also of the opinion that the public would be more likely to be better served if the Health Officer were a paid official, than if the work were done for nothing ; as in the latter case there would not be the same control over his actions, and he would feel himself less accountable to the authorities.

EXHIBIT. Dr. C. GossE showed an infant, aged one month, that had a congenital cystic tumour involving the buttocks, rather larger than the child's head. It had been punctured, and a considerable quantity of clear straw-coloured fluid had escaped, after which about 30 drops of Morton's solution was injected. This had been repeated on three separate occasions without any appreciable effect upon the size of the tumour, nor had it affected the child's health at all.

A discussion of typhoid fever was opened by Dr. HAYWARD, in the absence of Dr. Dunlop. He limited himself to questions of treatment, and expressed the hope that since rheumatism had become so manageable under the influence of salicin and its com- pounds, it was not unreasonable to hope that a remedy would yet be discovered equally potent against typhoid. On the whole he favoured the expectant method, but thought he had seen cases in which an impending attack had been checked by repeated doses of salicylate of soda. If these cases were doubtful, at least he was sure that he had mitigated the headache and other initial symp- toms by the same drug. After about week or ten days, drugs are of little or no use for the disease, per se, but small doses of morphia are often useful both against an irritable condition of the bowels, and to allay the hunger of convalescence. With reference to methods for abstracting heat, he used the bath only when the temperature rose to 106°, putting the patient into the bath at 98° and rapidly cooling it to 70°. This was generally both effectual and grateful to the patient, and it was repeated if the temperature again rose to 105°. Two cases, however, in which alarming symptoms by shock supervened, showed him that it was not devoid of danger. In most cases all that is needed is sponging with tepid water, with packing of the arms and legs if the temperature showed a tendency to run high. As regards diet, milk is of course the main thing to be depended on, but it sometimes disagrees, and 121 MAR. 15, 1885 Australian Medical Journal. then he had found weak broths or small quantities of meat extract useful. Cold water was always given at the patient's pleasure. Alcohol he did not consider often necessary, most cases, indeed, being better without it ; but still it may be needed to tide over emergencies. On the whole, similar opinions were expressed by other speakers, the energetic use of cold baths not being favoured, and quinine recommended rather in small than in large doses, when it is used at all. Both Dr. Gosse and Dr. Poulton insisted that the disease in the colony is not so mild as is commonly supposed, delirium and a temperature of 105 ° not being at all uncommon. Dr. Gosse said that the use of ice internally is very pleasant to the patient, and he had not found it to have an injurious effect on the bowels.

Nos 1a1 Ppotts.

Under the direction of R. A. STIRLING, M.B., L.R.C.S.E.

BRISBANE HOSPITAL. Four Cases of Gunshot Wound. Under the care of Dr. BANCROFT, Senr. Reported by E. S. JACKSON, M.B., Ch.B. Case I. A. J., wt. 8, schoolboy, was admitted into the Brisbane Hospital, on June 25, 1884. Two days before admission, while his elder brother was playing with a six-chamber revolver it accidentally exploded, and the ball struck him on the left malar bone, about one inch below and slightly external to the orbit. On admission there was a small black scab over the wound, and some swelling around it. The patient was partially conscious, extremely restless, and occasionally wandering ; pupils dilated ; no paralysis. The scab was poulticed off and revealed a sinus, extending through the malar prominence backwards, slightly inwards and upwards. At a consultation with the visiting surgeon a long probe was passed along the sinus right to the back of the brain, but no bullet was met with. The wound was then dressed with carbolic oil daily, and the patient kept in quiet and darkness, with occasional doses of bromide of potash and chloral, and an ice-bag to his head. 122 Australian Medical Journal. MAR. 15, 1885

Five days after admission a note was made to the effect that he was much quicker and more conscious than when first admitted. He had been passing water without assistance. On the 19th of July, twenty-four days after admission, his only symptom was slight loss of memory, and he was able to sit up in bed a little daily. He was then allowed to get up, and from that time continued to improve as before till his discharge on August 23, when he was in perfect health, but still had a sinus in the cheek, at the bottom of which, a distance of about one and a half inches, some small pieces of bare bone were to be felt.

Case II. J. H., set. 29, bullock driver, single, admitted July 21, 1884. The day before admission his friend while loading a six- chambered revolver discharged it accidentally, and the bullet struck his right knee, which was in a flexed or semi-flexed position. On examination there is a slight swelling of the right knee ; on the inner side of the joint, just over the prominence of the internal condyle of the femur, there is a small bullet-wound leading by a sinus, about an inch and a half long, straight into the osseous tissue, and not communicating with the joint which was slightly distended with fluid. No bullet could be discovered with the probe, which was used with the least degree of violence. The patient was ordered to be kept in bed, and have the knee fomented. On the 1st of August, eleven days after the injury had been inflicted, he had done so well that he was allowed to get up. He limped slightly, and complained of stiffness in the knee. A week after last date (August 8) he was discharged at his own urgent request, with the wound healed, and able to walk with little or no limp. There was still, however, slight impairment of the power to flex the limb.

Case III. M. P. H., vet. 28, cook, married, admitted September 5, 1884 ; said to have attempted to shoot his wife, and then to commit suicide by shooting, and finally by cutting his throat with a razor. The affair occurred an hour previous to admission. On examination there is a small irregular wound, with slightly blackened edges, just a little to the right of the midline of the Max. 15, 1885 Australian Medical Journal. 123 ii forehead, and just above the frontal eminence. On probing this, bare bone can be felt beneath the scalp, between which and the cranium a probe can be passed around for about an inch and a half on the right side of the wound. A small lead mark is obtained with Nelaton's probe. There is bleeding from the right ear, and within it a blackened pistol wound, through which a probe can be passed slightly downwards and inwards into the throat, where the probe point can be indistinctly felt through the soft tissues with the finger introduced by the mouth. On pressing the right tonsil, the probe can be moved slightly out of the ear. His throat being also wounded, exploration was not persevered in, as it seemed likely to set up bleeding, from the patient's attempts to vomit. The throat wound, which has been made with a sharp instrument, is about three and a half inches long, extending transversely above the thyroid cartilage, and at its central part into the pharynx, the posterior wall of which can be indistinctly seen through the wound. Liquids pass through the wound upon arrival in the pharynx. He is, however, still able to swallow liquids when the wound is closed and the head slightly flexed. His consciousness is complete. A consultation was held, at which it was considered inadvisable to explore further for the bullets till more urgent symptoms developed. The wound in the throat was thought to add to the danger of the patient's being anaesthetised. Treatment consisted in syringing the ear daily, as necessary, with a disinfectant solution. The throat wound was brought into apposition by flexing the head ; no sutures were used ; dressed with a clean towel, changed as often as necessary. September 21.—A note is made that beyond slight earache he has not had a bad symptom, and can hear a watch ticking with his right ear. Wound of throat closing fast. September 24.—He was treated for gonorrhoea, of which he complained for the first time. November 2.—The throat wound had nearly healed, and there was still purulent discharge from the right ear. November 10.—He was handed over to the police, and entered in the ward book—discharged, improved. The medical officer of the penal establishment, in which he is now undergoing a life sentence, informs me that the throat wound is quite healed, as also that in the forehead. There is still some discharge from the ear. 124 Australian Medical Journal. MAR. 15, 1885

Case IV. E. H., wt. 25, wife of Case 3, was brought in by the police on the 15th September, said to have been shot by her husband. States that she woke in her bed this morning thinking that her husband, who was with her, had struck her in the right ear. Found that there was blood trickling from her ear. After admission to the hospital there is found, on examination, a small blackened irregular wound, just in front of and on a level with the right tragus and auditory canal. Through this wound a probe can be passed nearly two inches straight inwards. Small pieces of bone can be felt, but no bullet. Patient is perfectly conscious, but inclined to be a little hysterical. After consultation it was decided that exploration of the wound was advisable, and two days after admission—Dr. Bancroft being away at the Sydney Convention—I enlarged the wound, under chloroform, by a forward incision until the finger could be used for exploration. The loose fragments of bone were removed and were found to consist of shattered portions of the condyle of the lower maxilla. A further portion of the jagged ramus of the jaw was then removed with bone forceps, so as to permit of digital exploration as far as the styloid process, near which some pieces of bone were found and removed but no bullet, though careful exploration was made in all directions with the finger. The wound was syringed and dressed with carbolic acid applica- tions, and gradually became smaller, till on the 1st October she was made an out-door patient. Since then, during my absence, she returned, and exhibited a piece of lead resembling a bullet which, she said, had fallen out of the wound, and which she subsequently lost. She has also been admitted for hysterical simulation of tetanus. I saw her to-day, December 30th, and found the wound perfectly healed, but leaving a considerable depression or pit in the side of the face. The movement of the jaw is considerably impaired, as she is only able to open the mouth barely an inch.

George Mayo, F.R.C.S. Eng., has been appointed president, and Dr. C. Gosse a member, of the South Australian Medical Board. These appoint- ments, we believe, will be viewed with approval by the profession throughout the colony. 125 MAR. 15, 1885 Australian Medical Journal. Australian Pebital MARCH 15TH, 1885

LOCAL BOARDS AND PUBLIC ANALYSTS. As might have been anticipated, no great time has elapsed before trouble has arisen over the appointment of public analysts. If the average borough or shire council makes difficulties about a health officer, still more may it be ex- pected to object to appoint and pay an analyst. And so it has been, the difficulty having arisen chiefly from the objection offered by some rural district authorities, when pressure was made by the Central Board. The clause of the Health Act, bearing on these appointments, is to the effect that the local board of any district may, and when required so to do by the Central Board shall, appoint one or more persons, possessing competent knowledge, skill and experience, as analysts, and shall pay to such analysts such remuneration as may be mutually agreed on, and may remove him or them as they deem proper. It is further provided, by way of safeguard, that such appointments and removals shall be subject to the approval of the Central Board, who may require satisfactory proof of competency. What is the weak point in this clause, as has now been found, is the absence of the provision that the Central Board shall finally decide whether or not the remuneration offered is sufficient. First of all local boards make no appointment till called on ; then they protest that it is unfair to compel them to act ; and when they see that there is no choice but to obey, they make what is to all intents and purposes a sham appointment. It is perhaps more difficult than in the case of a health officer to fix the amount of remuneration, but that difficulty is lessened by the per- mission given to two or more boards to appoint the same officer. The matter came up at a recent meeting of the Central Board, and it was plainly stated that appointments had been made at a rate of remuneration, which showed clearly that it was not intended that real work should be done. It is evident that a detailed analysis of a complex 126 Australian Medical Journal. MAR. 15, 1885

article of food or drink cannot be satisfactorily performed for ten shillings and sixpence, the fee allowed by the Act, unless there is salary sufficient to make up for the deficiency. It may happen that, in some country town, the health officer or the local druggist is competent to perform such analyses but it must none the less be rare to find such a man, having the needful apparatus, and also possessing the necessary skill, knowledge, and leisure. Though there was no room for doubt that some of the appointments made were mere evasions of the spirit of the Act, it was felt that the Central Board could not refuse to confirm them on the mere ground of the smallness of the remuneration, and that action could only be taken after proof has been supplied that the duties are not properly performed. This then is another point, respecting which some amendment of the Act will be needed, if the end comtemplated is to be attained. Another striking instance of the perversity of local boards is reported from Adelaide, where the City Council has indicated its intention to appoint an analytical chemist as health officer. We presume that the intention is to save money, by throwing two appointments into one. But the first thing needed in a health officer is medical knowledge, though, of course, the more chemical and other scientific knowledge he may also possess the better. If the local authorities of a capital city show such imperfect appreciation of the qualifications necessary for the efficient direction of sanitary work, what is to be expected from the average borough council ? What is clearly shown is the amount of educating which public opinion needs, before it is fairly realized that sanitary work pays, and that it pays only when carried on under proper direction and on scientific principles

S.A. MEDICAL BENEVOLENT ASSOCIATION, INCORPORATED.—The annual meeting was convened in January. The balance-sheet showed £238 2s. 5d. in hand ; and that the money received during the past year was £12 lls. 7d. The objects of the association are to relieve distress occurring in the families of medical men practising in the colony of South Australia ; to aid in educating and bringing up their children ; and to form bursaries, &c., for the assistance of medical students, the sons of medical men. The payment of 10s. and upwards annually, or one payment of £10 or upwards, constitutes membership. 127 MAE. 15, 1885 Australian Medical Journal.

MEDICAL TRAVEL NOTES,* BY J. DAVIES THOMAS, M.D., F.R.C.S.

I. The Ceylon Medical College, and the General Hospital, Colombo. By the kindness of Dr. Kynsey, the Principal Civil Medical Officer and Inspector-general of Hospitals for Ceylon, I was provided with a letter of introduction to Dr. Vanderstraaten, who is Principal of the Ceylon Medical College and Physician to the General Hospital. This gentleman very courteously took me round the two institutions under his special care. Both the college and the general hospital are situated in the Maradana quarter of Colombo, about three miles from the " Fort." The Ceylon Medical College was opened on June 1st, 1870, the inaugural address being delivered by James Loos, Esq., M.D., and the prospectus announced that " its design is to inculcate on the native youths of this island the principles of rational medicine, as known and practiced in Europe and among the civilised nations of the world." That the Ceylon Medical College has supplied a great need is unquestionable ; for although the Imperial Govern- ment had already established hospitals in the principal towns of the island, yet the masses of the people in the interior were, in many places, utterly devoid of medical aid of any kind, whilst in others they could only resort to the native doctors, many of whom were ignorant even of their own system of medicine. Among the Cingalese and Tamils, medicine, as is usual among primitive and uncivilised peoples, is intimately connected with their religious systems, and consequently charms and incantations constitute essential elements of the treatment of the sick. The enormous demand for coolie labour, due to the great increase of the coffee trade between 1825 and 1845, and with certain fluctuations until the appearance of the " coffee-leaf disease," caused by a minute fungus (Hemileia Vastatrix), produced a great influx of Tamils from Southern India. The population has thus, within the last 70 years, increased from to 1 million up to 2,850,000 souls. • Of this increase the European element constitutes but a trifling part. To meet the medical requirements of this great increase of the * Before leaving Adelaide, on a visit to Europe, Dr. Thomas kindly promised to supply to the Journal occasional Notes on points of Medical interest. The first of these is here given, and we hope to receive others of a similar character for regular publication. 128 Australian Medical Journal. Mss. 15, 1885

native population, the Ceylon Medical College was founded by Sir Hercules Robinson in 1870. It was heartily supported by his successor, Sir W. H. Gregory. Its prosperity was materially increased by liberal endowments of two Cingalese gentlemen, Messrs. De Soyza and Razepakse. Out of some 200 Ceylonese students entered, about fifty (50) have qualified and obtained licenses to practise medicine and surgery ; about as many more are hospital assistants and dispensers ; some have taken service under the Straits' Government ; while others have gone home to qualify in Great Britain. The college has now a staff of seven lecturers and a principal. The curriculum extends over three years, and it is now intended to extend it to a four years' course. The college is situated within extensive grounds of its own, planted with cocoa-nut palms and various native trees. Near the entrance into the grounds is a detached clock-tower, erected to the memory of Dr. Koch, a former teacher at the college. The college itself is of a character well adapted to the conditions of the climate and the present requirements of the school. It contains lecture rooms, a good chemical laboratory, and a convenient museum. A small dissecting room stands detached in the grounds. An ample supply of subjects is procurable, inasmuch as the Ceylonese have no serious prejudices against post-mortem examinations. The bodies are injected with arsenic, and the "parts" are kept 48 hours. It appeared to me that a competent knowledge of human anatomy is required and obtained by the students. At the time of my visit there were 40 students of all grades. Under the guidance of Dr. Vanderstraaten the " De Soyza Museum " was visited. This was so named in acknowledgment of a benefactor, Mr. De Soyza, who contributed the sum of £1500 for the establishment of this museum. This gentleman bears the highest title that can be conferred by the Governor upon a Cingalese, viz., " IVIudalyar of the Governor's gate." Among the museum specimens that especially interested me were, models in plaster of Paris of limbs distorted by Elephan- tiasis ; specimens of the native materia medica of the Island ; of bones necrosed by the ravages of elephantiasis ; of the native pottery of Ceylon ; of trees invaded by various diseases. The last-named collection has been formed by Dr. Vanderstraaten, in illustration of Sir James Paget's able lecture on " Vegetable Pathology," delivered a short time ago. There is also a series of the snakes of Ceylon, including pythons, rat-snakes, cobras, &c. MAR. 15, 1885 Australian Medical Journal. 129

The smaller snakes have been ingeniously mounted in long glass tubes containing spirit. The entire length of the animals can in this way be well seen and closely inspected. Dr. Vanderstraaten informs me that the venomous snakes of Ceylon are the cobra and the " sic-polonga " (Daboia Russellii), the latter being the more rapidly‘destructive of life. The principal symptoms of its poison are, extreme nervous depression, vomiting and purging of blood, and, upon post-mortem examination, an extremely liquid condition of the blood ; cobra poisoning being marked by early respiratory paralysis, followed by secondary coma. Out of a total number of 53,680 deaths, which took place in 1883, 143 were due to snake-bites. After a brief stay at the college, a visit was paid to the general hospital, which is separated from the college only by the width of a road. It makes up 212 beds, and at the time of my visit it contained 181 patients, viz., medical 69, surgical 97, merchant seamen 1, lock patients 14. The last-named cases were all Cingalese. The hospital is divided into 20 wards, and an administrative block. The wards are allotted to various classes of cases according to sex, nature of disease, and nationality of the patients. For example, there are separate European and native wards, diarrhoea and dysentery wards, lying-in and lock wards, &c. The general arrangement is that of separate blocks, connected only by long covered pathways freely open to the air. The wards themselves are practically open sheds of good height, with side walls about four feet high, for the purpose of screening the beds from draught. It is needless to remark that the ventilation is perfect. The cubic area allotted to each bed varies from 1500 to about 4000 feet in different wards. The beds themselves are cane network supported by wooden frames, and covered either by mats or mattresses at the option of the patients. The floors are of Portland cement, and the walls are white-washed. Without exception the wards visited by me were of one story in height. From this it will be seen that the hospital is well adapted to the climate, which in Colombo is an equably warm and moist one , the average temperature being 81° Fah., with but little variation in the different seasons. The water supply is from wells, and before use it passes through a series of three sand-stone filters, containing charcoal, gravel, &c. The latrines are entirely detached from the wards, and the dry-earth system is employed. This 130 Australian Medical Journal. Max. 15, 1885

is excellent in a country where coolie labour is cheap and abundant. In the short time at my disposal it was impossible to acquire more than a very slight acquaintance with the prevalent types of diseases or methods of treatment in favour. However, the follow- ing resume supplies some facts, for which I am indebted to Dr. Vanderstraaten. The natives of Ceylon are essentially a peaceful and temperate people. The alcoholic stimulants are "toddy," the fermented sap of the cocoa-nut flower, and a distillate of toddy called " arrack." Being free from caste prejudices there is no difficulty in supplying a diet for the hospital patients. As in other tropical climates, diarrhoea and dysentery are very prevalent ailments, in fact six wards are allotted in the general hospital to cases of this description. Ipecacuanha is very highly esteemed for the treatment of diarrhoea and dysentery. A favourite prescription is pulv. ipecacuan. 60 grains, plumbi. acet. 20 grains, pulv. opii. 2 to 3 grains, with eight or ten ounces of boiling water. The mixture to be allowed to cool and to be slowly injected per rectum night and morning. This for the acute stage. In the chronic form the acetate of lead to be replaced by twenty grains of nitrate of silver. Phthisis is very common in Ceylon, the inhabitants of crowded and dirty parts of the towns especially suffering in great numbers, the prevalent type of the disease being " scrofulous pneumonia." Phthisis appears to have the average course and duration here. Elephant- iasis and leprosy, separately or conjointly, are extremely common. The latter is usually treated by Chaulmogra oil, taken as an emulsion internally, and applied as a linament outwardly. Limbs frightfully distorted by elephantiasis and crippled by leprosy are striking features in hospital practice in Ceylon. As regards parasites, filaria sanguinis hominis is occasionally met with ; but hitherto, I believe, no connection between filaria and elephantiasis has been actually traced in Ceylon; trenia solium is said to be common, and ascarides are certainly very common. As far as I have yet been able to learn, echinococcus is rare, but special enquiry into this matter is being made on my behalf. Malarial disease is common, especially in the districts between the bases of the Kandyan Mountains and the lagoons near Colombo—where " paddy " is extensively grown. Enlarged spleen is consequently often met with. Hepatitis and tropical abscess are by no means rare. For the latter repeated aspiration is preferred to incision. Calculus is not common, but in the De Soyza Museum there is a prepara- MAR. 15, 1885 Australian Medical Journal. 131

tion consisting of four large phosphatic calculi. All show facets, and are of about equal size ; their united weight being ten ounces. They were removed (post mortem) from the bladder of a man who entered the hospital in a moribund state. The anaesthetics in use are chloroform, or a mixture of alcohol, ether and chloroform. Dr. Vanderstraaten has been 20 years connected with surgical practice in Ceylon, and has seen no death attributable to chloroform. Strict Listerism is employed whenever prac- ticable, and pymmia is rare. Tetanus, however, is very common even after slight injuries or trifling operations. This is most marked at Colombo during the prevalence of the north-east monsoon, which is of course a land wind on the western side of the island. Tetanus occurs frequently in puerperal women, chiefly after instrumental labours; but puerperal fever is rare. The nursing staff consists of a lady superintendent and ten female Cingalese nurses ; these are assisted by male attendants in the men's wards.

gthitbas.

SWANZY ON DISEASES OF THE EYE.* Mr. Swanzy's book is chiefly intended for students attending an Ophthalmic Hospital, but he trusts " it may also be of use to them when they cease to be students in name, and when, in the course of their practice, they require a book of reference on the subject." We have no doubt that this hope will be realised. After a few pages on elementary optics, normal refraction and accommodation are explained, then acuteness of vision, and its determination and the angle A. The numbering of trial lenses by dioptres is set forth, and also the method of measuring the field of vision. Abnormal refraction, hypermetropia, spasm of the ciliary muscle, accommodative asthenopia, myopia and its complications, the different forms of astigmatism, anisometropia, and the anomalies of accommodation are treated of, and are followed by a chapter on the ophthalmoscope, retinoscopy, and focal illumination. There are some slight errors in the lettering of the diagram of the erect image (fig. 37), and it is not mentioned that this image, inverted

* A Handbook of the Diseases of the Eye and their Treatment, by Henry R. Swanzy, A.M., M.B., F.R.C.S.I. London, H. K. Lewis. 2 132 Australian Medical Journal. MAR. 15, 1885 on the retina of the observer, is mentally projected by him as erect. We do not like the recommendation of poultices in acute granular ophthalmia. With a careful diagnosis, and in skilled hands, they may be harmless, or even beneficial, but in acute suppurative ophthalmia of infants or in gonorrhoeal ophthalmia (in which of course the author does not recommend them) their effects are so disastrous, that for safety we should prefer to see them entirely banished from ophthalmic practice. The author speaks rather favourably of jequirity in chronic granular ophthalmia, and says there is little or no danger connected with its use, severe as the resulting inflammation seems to be. After mentioning the treat- ment of phlyctenular ophthalmia, ring ulcer, &c., Mr. Swanzy gives a paragraph which we cannot forbear from quoting, in the hope that it will thus reach some who may not have the opportunity of reading his book. " In all forms of phlyctenular ophthalmia those favourite remedies, blisters, setons, and leeching, should be avoided. The first two worry the patient, give rise to eczema of the skin, and are not to be compared with the measures above recommended; while leeching gives at best but temporary relief, and deprives the patient of blood which he much requires." There is no necessity to give here any detailed account of the chapters on diseases of the eyelids and of the lachrymal apparatus ; these subjects are clearly and well dealt with by the author. The operation of the late Mr. Critchett for staphyloma anterior by abscission is described. We believe that this operation, notwithstanding the ingenuity of its inventor, and the favour it formerly received, is now not often performed, owing to its inherent risk of giving rise to sympathetic ophthalmia, which is well known to have occurred from it ; enucleation of the eyeball we consider far preferable. In reference to iritis, the descriptions and directions for treatment are carefully set forth in accordance with received opinions, and this subject is also one of those upon which a good knowledge is essential to every general practitioner. Comparatively few members of our profession are required nolens volens to perform extraction of cataract or even iridectomy, but almost any of us may have temporary charge of a case of iritis, and it is of the greatest importance that we should all be able to detect the disease, and know besides that the immediate and repeated instillation of atropine is the essential beginning of treatment. A chapter on the pupil in health and disease, in which myosis, mydriasis, the Argyll Robertson pupil, &c., are discussed at some length, MAR. 15, 1885 Australian Medical Journal. 133 need not be entirely mastered by the junior student. Diseases of the retina and choroid are not treated quite so fully as in the manual of Mr. Nettleship, and more might have been said upon the association of optic neuritis with fevers, in which the optic neuritis so commonly runs its course unheeded and undetected, and only late, and in the condition of more or less advanced atrophy of the optic nerve, is the attention of an ophthalmic surgeon called to the patient's loss of sight. But these criticisms notwithstanding, we must admit, and we do so with pleasure, the favourable impression made on us by Mr. Swanzy's work. Mr. Swanzy had the advantage of being formerly associated with the late Professor A. von Graefe, one of the great masters in ophthalmology, and he writes from a long experience and with such evidence of originality, that his book has a raison d'être, although appearing not long after several other works of undoubted excellence on the same subject. The handbook is well got up, being printed in clear legible type on toned paper, with scarcely a typographical error, and is creditable both to the author and the publisher. J. T. R.

THE INDEX CATALOGUE.* There is good progress being made in the production of this most interesting and valuable work, one which puts medical men and scientific inquirers generally all over the world under obliga- tions to the United States Government. There can of course be no thought of reviewing a book of this kind, of over a thousand quarto pages, in double columns of small type. Its scope and thoroughness may be estimated by the fact, that it contains 15,555 author titles, having under them entries of 5755 volumes and 12,596 pamphlets ; while under subject titles there are 8069 books and 34,127 journal articles. The learning, skill, and labour, involved in the production of such a work, are enormous, and the authorities of the United States are to be congratulated on having undertaken, and so well continued, under the hands of Dr. Billings, what could hardly by any possibility have been produced on private responsibility. At the present rate of publication, a volume a year, probably at least six or seven years will be required to complete the work, which will remain a standing monument of American erudition and industry. J. J. * Index Catalogue of the Library of the Surgeon General's Office, U.S.

Army : Vol. V. Flaccus to Hearth, Washington, Government Printing Office, 1884.

134 Australian Medical Journal. MAR. 15, 1885 extracts front t4c Attbical ratrprals.

Under the direction of F. D. BIRD, M.B., M.R.C.S.

Trladinzirof's Operation.—Dr. Wladimiroff, a Russian surgeon of Kasan, in 1872 brought forward an osteoplastic operation, designed to remedy certain diseased and injured conditions of the foot. To the December number of the Revue de Chirwrgie, Professor Sklifossowsky, of Moscow, contributes an article on the operation. He believes, with true surgical feeling, that to sacrifice the anterior healthy portion of the foot, because the os calcis or the cuboid or the medio-tarsal joint is diseased, or because incurable or malignant ulcers exist on the heel, cannot be good surgery. There are undoubtedly many forms of disease in the foot, which none of the recognised operations, save amputation of the leg, will relieve. Wladimiroff's operation avoids this sacrifice of healthy parts, consisting as it does in the application of the anterior portion of the foot to a section of the bones of the leg at their lower extremities, in such a manner as to leave the dorsal surface of the foot in vertical line with the anterior aspect of the leg, the patient resting his weight on the heads of the metatarsal bones, with the toes in forced extension. The operative procedure is as follows : A first incision passes right across the sole, from border to border, down to the bones at the level of the middle of the scaphoid and cuboid. From the ends of this incision two lateral cuts extend to the tips of the internal and external malleoli respectively. Finally a transverse incision, immediately above the tuberosity of the os calcis, joins the lateral incisions. The ankle joint is opened behind by this calcanean cut, and the foot enucleated, the soft parts of the dorsum of the foot being separated from the bones with care, in order to avoid the dorsal artery. Two bone sections are now to be made, one through the middle of the scaphoid and cuboid, the other directly above the articular cartilage of the tibia and fibula. The cut surfaces of the bone are applied to one another, and two strong sutures unite them. Deep and superficial sutures are required for the soft parts. Splints are applied, and in time solid union takes place between the opposed bony surfaces. Holding in one hand the anterior part of the foot, and with the other fixing the leg above the cicatrix, slight movements of

MAR. 15, 1885 Australian Medical Journal. 135 flexion and extension can be made out, produced apparently at the line of the transverse cicatrix, but really at the tarso-metatarsal joints. This small preservation of the natural elagticity of the foot nullifies to some extent the fatigue felt upon long standing or walking, and must be of much benefit in the general use of a lower limb possessing no joint at the ankle. Mensuration shows very slight difference in length, not sufficient to necessitate a raised heel. An account of this operation appeared in Langenbeck's Ardtiv. in 1881, but as yet it does not seem to have been much practised.—Revue de Chirurgie, December 1884. F. D. B. 0Ophorectonty and its results.—At a meeting of the Obstetrical Society of New York on March 4th, 1884, Dr. Mande related two cases in which he had removed the ovaries and Fallopian tubes from patients affected respectively with dysmenorrhcea and hystero-epileptic attacks, and with paraplegia and ovarian pain associated with prolapse of the left ovary. In both cases something like a complete cure followed. But by way of pendant, Dr. W. R. Gillette told of a patient suffering also from prolapse of the ovaries, with dysmenorrhcea, pelvic pains, and epileptic attacks. Both the patient herself and her mother wished oophorectomy performed, as she had suffered for several years, and had been in nearly all the hospitals in the city. Wishing to try the effect of mental influence, Dr. Gillette made all preparations for the operation, but made an incision only into the subcutaneous fat of the abdominal wall, and then closed up the wound. The patient improved wonderfully after the operation. He had heard, however, that she had lately had a return of the symptoms, and had been asking to have something more than the ovaries removed. Dr. W. M. Chamberlain said that he had been told of another case, in which an incision had been made nearly to the peritoneum, and then sewed up. For six weeks afterwards the patient was entirely relieved of dysmenorrhcea and other symptoms. The subsequent history was not known.— American Journal of Obstetrics, November 1884. J. J. Prolapse of Rectum.—Dr. Boeckel, of Strasburg, brings forward three interesting cases of prolapse of the rectum induced by congenital stricture of that organ, an arrest of development of which very slight mention is made in our chief text-books. As is well known, the rectum in the foetus is formed by an involution of the integument of the perinmum upwards to meet the gut at 136 Australian Medical Journal. MAR. 15, 1885

the sigmoid flexure. When these two segments do not coalesce there results atresia of the rectum. A degree of slightly fuller development would cause a stricture, having its seat at the junction of the rectum with the sigmoid flexure, and Dr. Boeckel's three cases illustrate this position. The prolapse doei not necessarily show itself immediately after birth ; for in one case, one month, in a second two, and in a third three months, was the age at which it first presented itself. This may be explained by the fact that at such an early period of life the faeces are semi-liquid, and can easily be forced through the narrow channel of the stricture. However, greater intestinal contraction than normal is necessary for their expression, with the result of the pushing down of the strictured portion en masse into the rectum, and its ultimate extrusion through the relaxed anus. Thus the relaxation of the anal fibres is the result and not the cause of the prolapse. This form of prolapse, Dr. Boeckel states, may be recognised almost at once by the conical form of the herniated portion, the stricture forming inferiorly the apex of the cone. The indications for treatment are the dilatation of the stricture, and the maintenance in its proper position of the prolapsed gut. These Dr. Boeckel fulfils by the introduction of a rectal bougie with a central canal for the passage of gas and liquid f aeces, and an air-pad fitting and supporting the anus. This instrument is introduced under chloroform and maintained in position for two days, and, as a rule, the child is not much inconvenienced by its presence. This short treatment is apparently sufficient for a cure, but, as a precautionary measure, the pessary may be worn for another period of two days. The three cases quoted were radically cured by these means, and Dr. Boeckel hopes to cure more, as he believes this cause of prolapse to be decidedly common. —Revue de Chirurgie, January 1885. F. D. B. Velbournt

At a special meeting of the University Council, on the 3rd inst., some recommendations of the committee on extension of teaching were adopted, and among others, that there should be a re-arrange- ment of the work at present done by Professors M'Coy and Kirkland, whereby all students of the University taking up the subject of chemistry shall attend the lectures of the professor on that subject. This will necessitate the delivery of three courses 137 MAE. 15, 1885 Australian Medical Journal. of lectures by the professor of chemistry—one on the elements of chemistry, to be attended by the students in arts, medicine, and engineering ; another to be entirely given up to medical chemistry proper, and a third to metallurgical chemistry. Professor M'Coy can use the time thus gained by enlarging his courses of botany and mineralogy. The Council concurred with the committee in thinking that a demonstrator of practical biology should be appointed, to carry out yearly the course of instruction and practical laboratory work set down in Huxley and Martin's work, A Course of Elementary Instruction in Practical Biology, with additional similar treatment of a fish, a bird, and a mammal ; and that Professor Huxley should be asked to select a gentleman already experienced in such instruc- tion. The Council were of opinion that a salary of £400 will require to be offered. The Council agreed that there will be required a laboratory, with microscopes, &c., where the demonstrator can take the students in practical work in biology. This will involve an outlay of £400 for fitting up, and an annual grant of £50, for botanical and zoological specimens for dissection, and for materials. A new lecture theatre will be necessary, and one of the present lecture rooms can meanwhile be used as a laboratory. Further, the Council considered that a demonstrator in natural philosophy is required, in order to give the senior students practical work in a physical laboratory. They think a sum of about £400 annually for a demonstrator, and £200 annually for apparatus, will be required for this laboratory, and that a special grant of £600 for fitting up and purchasing apparatus and tools will be necessary. The demonstrators in practical biology and experimental physics will work in conjunction with the professors of natural science and natural philosophy. It was also agreed that the following new appointments should be made :—A lecturer in veterinary science at £500, and a demon- strator on the same subject at £250 per annum ; and a lecturer on practical agriculture and agricultural chemistry at £500 per annum. The Council agreed with the recommendation that an executive officer should be appointed at a salary of £500. The Council also passed the following clauses in the committee's report :- " Further facilities for instruction in special medical and surgical subjects have been indicated as desirable. The committee are of 138 Australian Medical Journal. MAR. 15, 1885

opinion that instruction in diseases of the eye and ear, of the skin, and of other special organs, may be obtained by proper arrange- ments as part of hospital practice. Instruction in hygiene should be given in connexion with therapeutics. Whether this arrange- ment can be effected without any increase in the number of medical lecturers is a subject for further consideration. " A certificate of knowledge of vaccination from a public vaccinator should be demanded, and could easily be arranged for. The most pressing need in connexion with our Medical School is some control, by the Council or Faculty, over the appointment and work of medical officers of the hospitals. A special grant of £3,000 will be required for furnishing and fitting up the new Medical School." The report of the Faculty of Medicine concerning medical education was referred to the medical members of the Council, the Vice-Chancellor, Drs. Cutts, Fetherston, and Motherwell, Professor M'Coy, and Mr. Ellery. The ordinary examinations in medicine for the February term have been going on, and the Honour Examinations and those for the degrees of M.D. and Ch. M. begin on the 16th inst. In next number we hope to print some at least of the examination papers, and the pass and honour lists.

Nospitat

MELBOURNE HOSPITAL. At the meeting of the committee, on the 24th ult., the following resolutions, adopted at a meeting of the honorary medical staff of the hospital, were considered, viz.:—" 1. That an honorary chloro- formist be appointed by the staff, to attend on operation days, for a period of six months. 2. That it is desirable that an oculist should be appointed, and a few beds set apart for his use. 3. That in the opinion of the staff there should be a Lock hospital attached to this hospital." The resolutions, together with a letter from the Medical Superintendent on the appointment of a ehloroformist, were referred to the Visiting Committee. The sub-committee, appointed to consider the best means of providing separate accommodation for patients suffering from phthisis, submitted recommendations on the subject. They found that the average number of patients in the hospital suffering 139 MAR. 15, 1885 Australian Medical Journal. from this disease was about 20. As they could not refuse admission to such patients, the sub-committee were of opinion that a deputation should wait on the Government, in order to ascertain whether it is possible to obtain a site for a phthisis hospital. They also thought that if a site were obtainable the public might be appealed to, to furnish the funds for building the proposed hospital. It was decided to make further inquiries, and consider the matter at next meeting. At the meeting of the committee on the 10th inst., further leave of absence until January next was granted to Mr. E. M. James. It was decided that, for the future, notice of all operations requiring the administration of chloroform should be sent to the physicians as well as the surgeons, in order to secure their presence in the operating theatre. The Visiting Committee reported having made inquiries into the question of providing separate accommodation for cases of phthisis, with the result that in their opinion the arrangements of the institution did not admit of space being set apart specially for consumptives. The committee reported with pleasure that Mr. George Godfrey had offered to give nine acres at Frankston, which, if found suitable, might be utilised as a site for a hospital for consumptives. A sub- committee was appointed to inspect this land, and report as to its suitability at next meeting.

AUSTIN HOSPITAL. Lady Loch formally opened the new cancer ward of the Austin Hospital for Incurables on the 9th inst. This addition to the main building was rendered necessary by the presence of cancer patients in the general wards. Two airy well-lighted rooms, which will accommodate ten females and six males, have been built of brick in uniformity with the architectural features of the hospital. The female ward is 32 ft. long, 21 ft. wide, and 18 ft. from floor to ceiling ; and the male ward is 21 ft. x 21 ft., and 18 ft. high. The cost is estimated at £1,000. Dr. M'Crea, president of the hospital, and His Excellency, on his own and Lady Loch's behalf, expressed sympathy with the committee in their work, and said he would continue to take an interest in the hospital as long as he remained in the colony.

It is stated on authority that, for the year ending December 31, 1883, out of 11,173 births in South Australia, 9,895 were successfully vaccinated, as shown by fees paid for returns. This is equal to 88.5 per cent. of registered births. 140 Australian Medical Journal. MAR. 15, 1885 Vital Statistirs.

The Government Statist's monthly report on the vital statistics of Melbourne and suburbs for January states :—The births of 987 children—viz., 493 boys and 494 girls—were registered in Melbourne and suburbs during the month of January. In the month of December 961 births were registered, or 26 fewer than in the month under review. The births were 252 above the average of the previous ten years, but only 147 above that average, if allowance be made for the increase of population. The deaths registered in January numbered 592—viz., 321 of males and 271 of females ; the births thus exceeded the deaths by 395. The deaths were fewer than those in December by 84, but exceeded the average of January during the previous ten years by 19. If, however, allowance be made for the increase of population, they will be found to have been lower than the average in those ten years by 63. To every 1000 of the population of the district the proportion of births registered was 3.24, and of deaths registered 1.94. The highest temperature in the shade recorded at Melbourne Observatory during the month was 98.4° on the 12th, and the lowest was 42° on the 28th. The mean temperature of the month (64.2°) was nearly 1I° below the average. The greatest range of the thermometer in any one day (46.4°) took place on the 3rd, viz., from a maximum of 94.4° to a minimum of 48.0°. The mean atmospheric pressure (29.888in.) was a fraction above the average. Males contributed 54 per cent., and females 46 per cent., to the mortality of the .month. Children under five years of age contributed 48 per cent. to that mortality, as against 44 per cent. in January, 1884. Twenty-five deaths were ascribed to external causes during the month, of which 17 were set down to accident, two to homicide, and six to suicide. Twenty-one persons died during the month who had attained the age of 75 years and upwards, eleven of them being above 80 years, and one 92 years of age. Eighty-nine deaths, or 15 per cent. of the whole, took place in public institutions, viz. :-43 in the Melbourne Hospital, 8 in the Alfred Hospital, 1 in the Children's Hospital, 8 in the Lying- in Hospital, 6 in the Immigrants' Home, 7 in the Benevolent Asylum, 4 in the Yarra Bend Lunatic Asylum, 6 in the Metro- 141 MAR 15, 1885 Australian Medical Journal. politan Lunatic Asylum, 3 in the Austin Hospital, 1 in the Melboune Gaol, and two in the Prostestant Refuge. The deaths of children under five years of age numbered 287, of which 163, or 57 per cent. were of males, and 124, or 43 per cent., were females. Of those who died, 242 were under one year of age, 31 were between one and two, 8 were between two and three, 2 were between three and four, and 4 were between four and five. The persons who died at a more advance age than five years numbered 305. Of these 158, or 52 per cent., were males, and 147, or 48 per cent., were females. The following table shows the causes of death of persons of both sexes, and the proportions per cent. of deaths from each cause in Melbourne and suburbs during the month under review :—

Number of Deaths. Proportions Total. Classes. Causes of Death. per cent. Males. Females.

129 21'79 I. Zymotio diseases .. 69 60 53 109 18'41 II. Constitutional diseases 46 101 231 39'02 III. Local diseases .. 130 98 16'56 Developmental diseases 55 43 iv. 25 4•22 v. Violent deaths 21 4

592 100'00 All causes 321 261

As compared with the previous month, a decrease took place in all classes of disease except the developmental, chiefly, however, in the zymotic and local classes, which fell from 153 to 129, and from 284 to 231 respectively. Under the former head, deaths from small-pox fell from 2 to nil, those from measles from 19 to 3, and those from dysentery and diarrhma from 74 to 64. Under the latter head, deaths from diseases of the brain and nerves fell from 94 to 75, those from lung and chest affections from 68 to 46, and those from bowel and stomach complaints from 80 to 65. Only 6 deaths occurred among child-bearing women during the month, and comparing this number with the births, which num- bered 987, it follows that 1 death of a mother took place to every 164 infants born alive. In the previous month 11 deaths were due to circumstances attendant on child-birth, or 1 death of a mother to every 87 infants born alive. The births registered in the metropolitan and suburban registra- tion districts, in the weeks ending 14th, 21st, and 28th February, 142 Australian Medical Journal. MAR. 15, 1885

and 7th March, numbered 197, 202, 224, and 252 respectively. The deaths numbered 158, 157, 138, and 123, in the same weeks, those of children under three years numbering 68, 77, 63, and 53, and those of children under one year 60, 60, 51, and 43 respectively in those weeks.

orresponb MU,

TREATMENT OF SYPHILITIC SORE THROAT. To the Editor of the Australian Medical Journal. Sir,—During the debate which followed the reading of Dr. Moloney's paper on the treatment of syphilitic sore throat, and which was reported in the Journal for February, no mention was made of bicyanide of mercury as a local application. Having had recent experience of the rapid effect produced by this drug upon a very obstinate case, I would strongly recommend its trial. Ten grains to an ounce of water, painted on twice a day, and combined with inunction of calomel ointment, cured with startling rapidity a case which had resisted all other treatment for three months. I am, yours faithfully, CHARLES SMITH. Casterton, March 3rd, 1885.

COCAINE. To the Editor of the Australian Medical Journal. SIR,—The note appended to my letter in the February number of the Journal seems to me calculated to convey, and I know actually has conveyed the impression that Dr. Bowen had a priority in the use of cocaine. If I had known, when I wrote that letter, at your request, that Dr. Bowen " on several occasions employed the comparatively new therapeutic agent, cocaine, both at the Eye Hospital and in private practice," I should have referred you to him for particulars. I was, however, under the impression that Mr. Rudall first used it in the case which he saw in consultation with me, and on which I operated on the 19th January, 1885. As far as the Eye Hospital is concerned, I have not been able to find any records but those contained in the following extracts :—" January 21, 1885. Four operations by Dr. Gray ; cocaine used. January 28, 1885. Four operations by Dr. Bowen ; cocaine used." Present—Drs. J. P. Ryan and MAR, 15, 1885 Australian Medical Journal. 143

Bernays, and the Dispenser. There is no record whatever of its use prior to 21st January, 1885, or on any other occasion, and the gentlemen named have no recollection of its use prior to that date. About cases in private practice, of course, I cannot speak, but it would have been interesting if Dr. Bowen had published his experience in these cases, with dates. Mr. Rudall informs me that he was unable to obtain cocaine till about the 10th of January, although he repeatedly applied at several of the leading druggists in Melbourne. I am, yours &c., Collins-street East. ANDREW S. GRAY.

fatal-,$ilhittis.

OFFICERS OF HEALTH.—The Central Board of Health has approved of the undermentioned appointments :—Shire of Avoca, John McMahon, L.C.P.S., Lower Canada ; Shire of Barrabool, William Shaw, M.R.C.S., Eng.; Shire of Towong, William Gillespie, F.R.C.S., Edin.; Shire of Yarrawonga, Charles William Rohner, M.D.; Shire of Kara Kara, Matthew Brisbane, L.R.C.P. Edin. PUBLIC VACCINATORS.—The following gentlemen have been appointed : Frankston, Geoffrey Frederick Travers, Esq., M.R.C.S., acting, vice W. H. Johnson, Esq., surgeon, left the district ; Stawell, William Holland Syme, Esq., L.R.C.S., Ireland, vice A. Bennett, Esq., M.D., resigned ; Ballan, Joseph Bell Marr, Esq., L.R. C.P., vice J. W. Smith, Esq., L.R.C.P., resigned; Nhill, Edward Ryan, Esq., M.B., vice M. Herdegen, Esq., M.D., resigned ; Tungamah, Noel Crawford A. Vance, Esq., M.B., vice R. R. Rimmington, Esq., M.B., resigned ; Edenhope, Edmond M'Causland, Esq., L.F.P.S., vice F. D. Hayman, Esq., M.R.C.S., resigned ; Darlingford and Jamieson, C. F. Lethbridge, Esq., M.R.C.S.E.; Hamilton, W. M. Dickenson, Esq., M.B., during the absence on leave of W. E. L. Hearn, Esq., M.B. ; Gaffney's Creek and Wood's Point, C. F. Lethbridge, Esq., M.R.C.S.E., vice G. M. Cole, Esq., L.S.A., resigned. ANALYSTS.—The Central Board of Health has approved of the under- mentioned appointments by the Local Boards of Health concerned: Borough of Clunes, Alfred Mica Smith, B.A., B.Sc.; Borough of Port Melbourne, Frederic Dunn ; Shire of Euroa, John Tuthill, L.R.C.S.I., &c.; Shire of Kowree, Samuel Connor, M.D.; Shire of Kyneton, Timothy Bernard Ryan, M.B., &c.: Shire of Merriang, John Kruse : Town of Ballarat East and Borough of Creswick, Alfred Mica Smith, B.A., B.Sc.; Borough of Hamilton William Miller Dickinson, L.R.C.S., Edin.; Borough of Kew, Cuthbert R. Blackett, J.P.; Borough of Stawell and Shires of Ballarat, Grenville, and Ripon, Alfred Mica Smith, B.A., B.Sc.; Shire of Romsey, Edward Harvey Bird Nickoll, L.R.C.S., Edin. John D. Tweeddale, Esq., M.R.C.S.E., has been appointed a member of the Central Board of Health. 144 Australian Medical Journal. MAR. 15, 1885

The resignation of Dr. W. L. Smythe as Surgeon in the Naval Reserve has been accepted. At a recent meeting of the Central Board of Health the insufficient salary provided for analysts by some of the local boards was mentioned. It was to be expected, of course, that when such appointments are made unwillingly, some local authorities, being unable to see the use of such an officer at all, should try to make sham appointments. The Central Board, unfortunately, can do nothing in the matter until it has been shown that the duties are not properly performed. If necessary that might soon be tested, we think. The subject of the water supply of some towns in the colony has also been under consideration, and Mr. Newbery has directed special attention to that of Geelong, which he has found to be excessively bad. The Yan Yean water supplied to Melbourne, on the other hand, is reported to be good, at least so far as concerns contamination with organic matter. The following are the medical officers attached to the New South Wales contingent despatched to the Soudan :—Staff-Surgeon Williams to be chief medical officer, and Drs. Glanville and Proudfoot to be surgeons, with the relative rank of captain. Sir Saul Samuel, the Agent-General, sent the following telegram :—"London, February 18. A number of Australian and other medical students at Edinburgh have offered their services for the New South Wales contingent. Are they required ?" To this Mr. Dailey promptly replied :—" Thanks to the medical students of Edinburgh for their offer to meet the troops in Egypt. Our medical arrangements are complete." Dr. Archibald Watson, late of Charing Cross Hospital, London, and who is, we understand, an Australian by birth, has been appointed Professor of Anatomy at the New School of Medicine, Adelaide University, and is expected to arrive by the P. & 0. S. Pekin, about the 15th of March, and will commence his first course of lectures this term. Several gentlemen have already intimated their intention of commencing the study of medicine this year at the University, and it is not improbable that others in actual practice may take advantage of the dissecting-room for further research. Dr. Rennie, Sc. D. (Lond.), the newly-appointed Professor of Chemistry at the University of Adelaide, has taken up his residence there in anticipation of the coming year's work. South Australia is to be congratulated on having a chemist of Dr Rennie's attainments attached to its University, and it is to be hoped his class will be a large one.

BIRTHS. ADAM.—On the 5th inst., at 52 Powlett Street, East Melbourne, the wife of Dr. G. Rothwell Adam, of a son. O'Sum.ivaN.—On the 4th inst., at " Lismore," Brunswick, the wife of M. U. O'Sullivan, M.D., Numurkah, of a son. MARRIAGE. DOHERTY—EADES.—On the 2nd inst., at Christ Church, South Yarra, by the Rev. H. Tucker, Thomas Wells, third son of John Doherty, Longfield, Rent, England, to Florence Maranda, third daughter of the late Richard Eades, M.D., F.R.C.S.I. DEATH. RAE.—On the 24th ult., at his residence, Bacchus Marsh, after a lingering illness, William Rae, surgeon, in the 50th year of his age.

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Title: Australian Medical Journal 1885

Date: 1885

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