AUSTRALIAN MEDICAIL JOURNAL. 975

USTRALIAN RADIUM. 7 representing the Australian specimen, and as 19 is to 27 when the interceptor was a mild leaden MAN LA \V'1: I? NCR. ALR.C. l'., Ëdiu. one, both experiments at a distance of 14 inches from the electroscope. Hon. Dermatologist, St. V incent's Hospital.) It will be a great help to Australian medical men About two months ago Mr. Jones, managing di- if a local supply of therapeutical radium is obtain- rector of the Radium Hill Co., South Australia, able, and as there is now such a great demand sent a ten milligram specimen of radium bromide to abroad for radium. on account of its being used in me, asking me to examine same therapeutically. In the treatment of inoperable malignant growths and order to compare the result of the therapeutical likewise being applied after operations for cancer, action of this specimen with the therapeutical ac- tion of a :to milligram specimen of pure radium 'bromide (imported), I took for one experiment a case of generalised psoriasis, the patient having numerous small spots and patches of psoriasis, more or less bilaterial and symmetrical, situated on the sides of the body and on the arms and legs. I had the specimen of Australian radium applied to four or five spots upon the left arm, giving 15 minutes exposures, and imported specimen applied to simi- lar spots upon the right arm. The time of exposure and preparation of the specimens were exactly simi- lar. In the same way, spots were treated upon the left side and left leg with the Australian specimen, several exposures of thirty. forty and sixty minutes being made; and similar exposures both as re- gards time and preparation Of radium specimen were made upon the right side. :All spots thus treated with Loth specimens cleared np in much about the same time, and by making examinations twice a week for three weeks, I was able to make a comparative examination as regards the reaction of the times acted upon by the different specimens of radium. No. 2.—Radiograph taken as in above I also treated cases of keratoses, rodent ulcers, illustration. epithelioma, lupus eryt:hematous, chronic patches of lichenification, and some other chronic condi- etc., in order to try and prevent a recurrence of the tions of skin trouble,. with this specimen of Aus- disease, there should be plenty of demand for all tralian radium, and the results have been very satis- that can be produced in Australia, and as I under- factory. stand the radium carrying ore exists in large quan- Professor kyle, of the Melbourne University, tities, it may yet be a valuable export. kindly made a comparative examination of these The accompanying illustration shows the pene- specimens for me with the electroscope, and the re- trating power of the specimen of :Australian radium. sults of this examination showed the Australian 'l'he photograph shows the specimen placed upon an iron weight (4 lbs.). this was placed over a penny and key. which were laid upon a negative plate as shown in the ph o tograph. The second illustration shows the radiations from the specimen have produced a radiograph of the key and penny. In a similar way I recently took a similar radio- graph through five of these iron weights, making - a column of six- and one-half inches of iron. The radium used being about too milligrams of im- ported radium. No. 2.—Australian specimen of radium placed upon iron weight. I understand Professor Pollock, of the Sydney University, has found that the specimen of Aus- tralian radium bromide submitted to him for ex- specimen was within about five to ten per cent. of amination gave a radioactivity equal to 94 per the imported specimen as regards its radioactivity. cent. when compared with the specimen of pure - My own examination with the electroscope gave, radium bromide (imported), and in use at the with mica interception of the rays, as 7 is to 8y. Sydney University. 976 AUSTRALIAN MEDICAL JOURNAL. April 5, 1913.

Whilst Dr. Alurphy always has a long list of CHICAGO: DR. MURPHY'S CLINIC. operations, he did not get through anything like the number of operations that many other surgeons did. But to the visiting surgeon there is ample \V ^ . 1\10OIL E , M.D.. M .S. compensation. In the first place he goes fully into the cases-on which he is going to operate, and he discusses the steps of the operations. Further, he \ly remembrances of Chicago are not all shows patients on whom he has operated weeks or pleasant. I reached the great city the first months before. This is most instructive, as it time On a Saturday morning after a dreadful night gives the visitor who is only going to remain a few journey from Rochester. No one knew the hotel days a chance of seeing results in cases similar to I wanted, so I had to go to one I knew nothing of, and struck the wrong one, a large crowded, inhu- sonic that he is witnessing and the results of which he would very much like to know. I)r. Murphy's man hotel, in a crowded, busy part of the city. list on my first visit was However, Saturday was one of Dr. Murphy's clays, and I found my way to the Mercy Hospital, but I. Acute appendicitis. Dr. Murphy was not there, and the man who was 2. Neurofibroma of breast. there had no interest for me. I went back into the 3. Pyloric obstruction—gastroenterostomy. city, but I found it unendurable. Chicago was the 4. Fracture and luxation of neck of humerus. first great city I had ever been in, excepting Syd- 5. Anchylosis of knee—arthoplasty. ney, and it is much larger than Sydney. The rush 6. Metastatic Neisserian arthritis of knee (Inj.) of traffic seemed simply terrible, the din of the 7. Gastric ulcer—gastroenterostomy. overhead railways, the rush of the street cars or 8. Recto-vesical fistula. trams, and the motor and other vehicular traffic 9. Multiple arthritis. got so much on my nerves that I began to think I to. Abscess of broad ligament. alight get killed or lose any wits I had, so I de- II. Subacute gastric ulcer—gastroenterostomy. cided to leave Chicago the same clay as I entered it. 12. Tuberculosis of knee. When I returned I was a more experienced travel- 13. Carcinoma of cheek. ler: I had been in Philadelphia and in New York, 14. Anchylosis of elbow—arthroplasty. and London was quite familiar to nie; so, although This list is put on a board, and I did not see it there is no place quite as big and important as until Dr. Murphy had been talking for some time; Chicago, I was not so overawed, and I took up then it amused me. It was rather formidable for my quarters at the Congress Hotel on Michigan one man to get through in one morning. He did Avenue, and determined to see things through. It the first four in order, and by then he had done a was on Tuesday morning, and 1 did not employ that fair thing. He then showed to cases that had been day very profitably ; but I found out that L)r. Cooke operated on previously, and at the end injected two Adams was not in town, and I located the P.O., a knees with formalin in glycerine. railway station and several hospitals, at one of Dr. Murphy's remarks whilst doing the case of which I unfortunately learned that Dr. Bevan, to appendicitis were interesting, and they are typical whom I had a letter from Dr. Crile, was in New of his talk. "A rise in temperature is a manifesta- York. tion of the absorption of material, not of the pre-

'l'he next morning (Wednesday) I went to the sence of pus." "A chill indicates the presence of a

Mercy Hospital, not a bad tram ride, to see Dr. germ that quickly gets into the circulation through

_Murphy, and this time there was no mistake. 'I'he the lymphatics—a streptococcus—with such a germ amphitheatre is very large, it would seat some you do not get gangrene. "Sometimes symptoms hundreds, and though the attendance was good, do not correspond, e.g., here there was no rise in there was always a tremendous amount of wood temperature; when such is the case examine the urine, as a stone passing along. the ureter gives exposed to view.. Here on the three occasions on which I was present I never managed to get a very much the sane symptoms as appendicitis." "The leucocyte count is important." "Make your diag- good seat, though Iwas always able to see fairly well. Dr. Alurphÿ is a tall, elderly man, remind- nosis and operate on your diagnosis" (don't be try- ing to minutely differentiate the pathological con- ing me a little of Professor Watson, of Adelaide, and 1 could easily imagine Professor Watson talk- dition, "Diagnosis is more certain in the first 24 ing to a crowd in much the same way as Dr. Mur- hours and operation is safer in the first 24 hours." phy did. He is thin and somewhat round-shoul- 1 le made his incision through the rectus sheath; covered any raw area about the appendical stump; dered, and wears a short greyish moustache and he everted the peritoneum by using a kind of run- beard. He talks much and well. His voice is ning mattrass suture. I afterwards found that high-pitched, and probably from over-much talking. Ochsner was very particular about the same thing. Um he is a great teacher of surgery—one would think there could be few greater; his knowledge of In connection with the mammary tumour, he detailed facts and figures is simply surprising. He is said : "Trauma is a most common cause of cancer "very- dogmatic, no doubt in some cases too clog- of the breast—one moderate injury; this is unlike matic, e.g., when he says, "Whenever you drain a carcinoma in other places, where the cause is an

joint you know you are going to have a broad oft-repeated irritation." anchylosis ;" but if he were not dogmatic I pre- 'I'he pyloric obstruction was in an elderly man, sume he would not be the great teacher that he is. who had had symptoms for over 3o years. He had

April 5, 1913. AUSTRALIAN MEDICAL JOURNAL. 977

been operated on for gall-stones, but none were _A child who was born with both hands behind the found, and the gall-bladder was drained. The ap- back. Each humerus was rotated 180 deg. Dr. pendix had been removed. There was a mass at the Murphy nine days ago had divided one humerus pylorus, which Dr. Murphy (lid not thing was between the insertions of the pectoralis major and malignant, and did not remove. He did a pos- latissinus dorsi; then rotated the lower end through terior gastro-enterostomy, put in almost as many ISo deg., and fixed the ends with nails. This was sutures as most surgeons do in an ordinary sutur- the first dressing, and the wound looked well and ing operation, then used an oblong- (the latest the arm in good position. (h) A girl with a tuber- fashion) Murphy's button. cular wrist. She had had two injections of forma- The finest bit of surgery on this morning was the lin (2 per cent. in glycerine) ; she was also taking treatment of the fracture and luxation of the head of tuberculin. "a most valuable drug, but it is most the humerus. A number of X-ray pictures of the important to give the right dose, and the dose is condition were shown ; according to some of them regulated by the reaction (temperature, malaise, the head appeared to be in the socket; according chill) : a most destructive drug improperly used." to others out of it. A long incision was made on Several other cases were shown, and both knees in the outer side of the upper part of the arm, separat- a case of recurrent hydrops were injected with ing the deltoid fibres. An elevator was then used, formalin (2 per cent). exposing the bone. The head of the bone was 'l'he next day I had the privilege of seeing Dr. found broken off and split into two unequal por- d tions; the smaller portion remained in the glenoid urphy operate on a case of anchylosis of the right The smaller knee, bony of patella to femur, fibrous of tibia to cavity, the larger was posterior to it. femur. The patient was a young vvoman, who had piece was removed. :Attempts were made to get the had an acute synonitis, the cause of which was not larger piece into position ; eventually it was re- apparent, and the knee had been fixed in a plaster moved, but was kept for. replacement. Some bone had to be cut off the lower fragment with a bone- splint. Ether anaesthesia. Dr. Murphy first tried to manipulate the patella free, but could not. He cutting forceps. Then the portion of head was re- then trade a vertical incision five or six inches placed in the glenoid cavity, and the ends were long a little to the outer side of the patella and brought into position, and fixed there by several dissected up skin flaps with scarcely any fat. He nails. 'l'he arm was drawn out to a right angle next cut a flap of fat and fascia on the outer with the body: the wound was carefully sutured deep without drainage and dressed. The shoulder v-vas side and above the joint, with its base of attach- then firmly fixed in a plaster of paris bandage. Dr. ment below at the articular surface of the tibia. The same thing was clone on the inner side of the Murphy did not think that the replaced portion of limb. The the head of the humerus would live, but that it two flaps of fat and fascia together were would remain and form a frame-work on and in able easily to reach across the joint. The patella which the bone would develop, and so a good head was now chiselled away from the femur. The joint would eventually be formed. was located exactly by very slightly moving the knee, and the capsule was divided on each side by Dr. Murphy then showed a number of cases that an antero-posterio r incision. A flap of fat and had been previously operated on : (a) Anchylosis of deep fascia was m a de over the outer side of the the lower jaw since seven months old. Thé youth lower end of the femur with its base near the outer can now open his mouth fairly well. (b) Anchy- condyle; a flap was cut over the inner condyle also. losis of knee, operated on a month ago ; can now The inter-condvloid groove vvas deepened by chisel- walk "without crutch • or stick" (she had two ling. Then with a broad concave chisel some bone crutches) ; she could move her knee a little. (c) was removed from the articular aspect of the tibia Old fracture of lower end of humerus in a child on both sides, the leg being flexed whilst this was aged seven. Lower end of humerus drawn back done. The limb then easily came straight. The and united in bad position. Divided humerus by long outer flap of fat and fascia was now sutured a V-shaped incision two weeks ago; result good. with fine cat-gut to the crucial ligaments and to (d) First dressing of case of operation for anchy- the capsule of the joint near the head of the tibia losis of elbow due to fracture, operation, and infec- and to the corresponding flap on the inner side, a tion ; dressed with carbolic acid to prevent decom- threaded needl e being passed through the end of position of the discharge. It looked very well. (e) the outer flap and carried through the joint to be Bony anchylosis of knee, first dressing. Dr. Mur- put through the inner flap at its end. The inner phy at the time of the operation was afraid that flap was then sutured like the outer and then they some of the skin on the our side of the knee might lay beautifully together over the upper end of the die from enudation of its fat and from tension, tibia; the other smaller flaps were sutured to- and, on exposing it, it looked doubtful, Clark and gether between the patella and the femur. Subcu- blistered; but Dr. Murphy came to the conclusion taneous cat-gut sutures were put in to lessen the that it was all right and that the discoloration was tension on the skin edges, which were brought to- clue to iodine. This patient—the operation had gether by a continuous horse-hair suture. The only been done about ten days—was able to move wound was dressed with carbolic acid powder, her knee slightly. (f) Pony anchylosis of elbow. gauze, etc., and put in a wire cradle. Extension Arthroplasty six weeks ago -; now has good flexion was to be applied as soon as the patient was in and extension. Dr. \lurphy did not try to get bed. The limb would be kept quite still until the pronation and supination, he will do that later. (g) soft parts were united. 978 AUSTRALIAN MEDICAL JOURNAL. April 5, 1913.

This operation was done in a small theatre whose to separate the stomach and jejunum, so as to de- space was taxed to the utmost by the number of termine if there was an opening between them. visitors. We then went downstairs to the main He found that it was little larger than a pin's amphitheatre, where there was quite a large as- point. He enlarged the opening by excising tis- semblage. Dr. Murphy then devoted some time to sue; he did not separate the posterior attachment. the teaching of students. He asked them questions He next put a suture through all the coats; then and he criticised their replies. Patients were a sero-muscular suture, but the serous membrane brought in, and students were called down to ex- had been removed in separating the surfaces; then amine them. and Dr. Murphy kept asking, "What he put in an extra row that really brought the is the matter with him, and why?" Other oft- serous surfaces together, and the transverse meso- repeated phrases were, "Let the records show," no colon was included in this suture. Dr. Murphy doubt meant for the lady stenographer; and, said that notwithstanding the importance of ad- "Thank you, thank you," in .quick sharp tones. A hesions, he believed that we were attaching too patient about forty years of age with an abscess in much importance to them, and attributing to ad- his foot was brought in for the students to exam- hesions what was really due to a more definite ine. They could not tell what was the matter, and lesion, as in this case. they certainly shaped very badly in trying to find The second case was that of a woman who had out, and Dr. Murphy kept calling out, "What's the been ill for some time, had been yellow (not jaun- matter with him, and why?" It was obvious from diced—Dr. M urphy) , He had given her a large the patient's expression that he was enjoying him- sei(llitz powder, as it showed the size of the stom- self. Afterwards we learned that he was an army ach, its patency, and the presence or absence of medical man, who had been himself an interne at pain. He made a long vertical incision in the the Mercy Hospital. He had had an abscess of the right rectus, and at once felt a gall-stone. There foot when a child, and it had taken many months was no ulcer, and no stenosis of the pylorus (Dr. to heal. Then recently, after much hard work, Murphy had thought there was an obstruction at trouble had started again in the old place. Dr. the pylorus) ; there was no obstruction at the com- Murphy afterwards operated on a case of disloca- mencement of the jejunum, there was no stone in tion of the patella outwards, and did the second the common duct. I-Te freed the gall-bladder from stage of a plastic operation on the hand, and, adhesions, drew it out so that he might get all the though it was clone after freezing, it seemed to hurt stones. "Should I remove it? No, because I want very badly. On my last visit to Dr. Murphy's to drain." A very poor argument, it struck me, but clinic his list was as follows:— one I heard in others of the great American clinics. I-Ie made an entropion of the opening in the gall- I. Pyloric stenosis—Gastro-enterostomy. bladder and dropped it back into the abdomen with 2. Exploratory laparotomy. a drain in it. Thus fixation to the anterior abdom- 3. Anchylosis of knee—arthroplasty. inal wall by adhesions is avoided. He had had a 4. Gastric ulcer. case in which a mulberry calculus appeared in the 5. Subacute gastric ulcer. comtnon duct after removal of the gall-bladder. "A gall-bladder stone rarely causes a rise in tem- 6. Injection of knee. perature, but cystic and common duct-stones do. 7. Multiple arthritis—Injection of finger joints. This is because of their supply of lymphatics." 8. Tuberculous arthritis. The third case was one of the most interesting 9. Chronic osteo-myelitis of femur. that I saw anywhere. It was a case of anchylosis to. Tuberculosis of hip. of the left knee after severe burns ; the right limb it. Abscess of broad ligament. had been amputated in the upper third of the thigh. The left leg was flexed at the knee and absolutely 12. Chronic appendicitis. fixed, so that. the patient said that if he got a 13. Multiple arthritis. stiff knee with the limb straight. as a result of the 14. Teno-plasty of fingers. operation, he would be better off than he then was. Dr. Murphy did six of the cases. Some were of There was much scar-tissue and there was prac- great interest, as were also some of Dr. Murphy's tically no fat about the knee. Dr. Murphy had much remarks. The first case was that of a woman who misgiving about the result of operation in such had had a gastro-enterostomy done some time be- a case. On making his incision at the side of the fore; she had been relieved for a time, but re- knee-joint he found at once that it would be im- cently symptoms had returned, and now food was possible to get a flap to put across the joint from being retained in the stomach. On opening the anywhere near the knee, and he therefore decided abdomen many adhesions were found; the pyloric that he would take it from over the trochanter of zone was adherent to the anterior abdominal wall. the amputated limb. He separated the anchylosed He mobilised the stomach, freed the pylorus, be- hones by driving a large concave chisel or gouge— fore examining the old gastro-enterostomy. He concavity towards the femur—between the femur then found an ulcer of medium size on the lesser and tibia: he next took 3/4 inch off each side of curvature. On examining the site of the old gas- upper end of tibia with the gouge concave towards tro-enterostomy he was unable to find any opening. femur. Using a chisel, he split the bone vertically He now detached the mesocolon from the margin to save the inter-condyloid ridge (spine of tibia). of the anastomosis, packed around and proceeded He always takes a little more off the internal than

April 5, 1913. AUSTRALIAN MEDICAL JOURNAL. 970

the external condyle to overcome the tendency to Dr. Ochsner's Clinic at the Augustana Hospital. gene valgum. The top of the tibia must be concave and the intercondyloid ridge mist be preserved. The other two men whorl I wanted to see in A good deal of chiselling had to be done. Chicago were Dr. Bevan, of the Presbyterian Hos- The patella was freed: A flap of fat and fascia lata pital, and Dr. Ochsner, of the Augustana Hospital. was now cut from the outer side of the upper part Dr. Bevan was away in New York, but I saw Dr. of the opposite thigh. The joint was thoroughly Ochsner, though I was evidently unfortunate, as wiped out and the flap inserted between the bones. some of the frequent visitors said it was the poor- I>r. Murphy said that he did not think that the flap est clinic they had ever seen there. with a pellicule lived through the pedicle, but, as connective tissue, by osmosis. Finally he re-estab- The time of starting is 7.3o a.m., and I was a little later than that, but was in time for the first lished the external lateral ligament and then ac- case. Dr. Ochsner is middle-aged, short, inclined curately sutured the wound. to be stout; he has a large head and hair inclined The next case had been diagnosed gastric ulcer. to be fair; his arms and hands are white and almost A vertical incision to the right of the micíline was hairless; he is slow of speech and inclined to be made, the rectos fibres were displaced outwards. sarcastic. When operating he wears ordinary No gastric or duodenal ulcer was found, no gall- shoes, white trousers, and a white coat with short stones, no adhesions. Dr. Murphy simply closed sleeves, no go wn , no cap, no gloves in clean cases. the abdomen, remarking that "formerly ill such a He wore gloves in a dirty case and in a vaginal case gastro-enterostomy would have been done, and case. His assistants wore gloves and had their later would have been undone." He further said : arms covered. Iodine was used freely and most "\Ve now only do gastroenterostomy for definite preparations were done in the operating-room. I lesion at or near the pylorus, and results are much was struck by the number of well-grown, fair- better than formerly. Seventy per cent. of gastro- haired nurses about the operating room, and learned enterostomies are cured, 15 per cent. are benefited, subsequently that this was a Scandinavian Hos- pital. Chicago has • a Scandinavian population al- 15 per cent. are not benefited." most as large as Christiania. The fifth case was a subacute metastatic inflam- The mation of the knee, following vaginitis, not Neis- first case was of a woman suffering from a large ventral hernia and adhesions after an ab- serian in origin. This vaginitis was epidemic in a dominal hysterectomy, and from - gall-stones. Dr. factory, it followed a coryza. Fibrous anchylosis Ochsner remarked that some years ago it was a had resulted; the knee had been forcibly moved. Dr. common practice in this country to treat gall- Murphy was about to inject liquid paraffin into the stones and appendicitis by removal of the uterus knee, and it would be necessary afterwards to use and its appendages. This woman had consulted extension. Extension should also always be em- him six or eight years ago; he told her she had ployed after formalin had been injected into a gall-stones, and advised her to have them removed. joint; "it was wicked to give an injection of forma- Ilut just then her husband was transferred to an- lin in the office and send the patient hone." other State, so she had her uterus removed instead. Ile made a long mid-line incision over the old scar I have made free use of my notes to give an idea in the lower abclomen, freed adherent omentum, dis- of Dr. Murphy's methods of operating and of sected out the stump of the cervix uteri, which, he teaching. There were several other points of in- said, was pressing on the bladder; accurately su- terest. One was that Dr. Kammerer, of New York, tured peritoneum over so that no raw surface was was present in the clinic one clay. 'Twenty-five or left; removed the vermiform appendix. He next more years ago I used to read articles by him, in made a short vertical incision in the gall-bladder region, drew out the gall-bladder; he would not American medical journals. He was a straight, remove it because he wanted to drain it ; he opened fairly tall, active man, but grey, and probably the gall-bladder, removed the gall-stones, turned about 70 years of age. FM- the first time I saw a in the cut-edge with a suture, tied in a drain, and nurse, armed with a sort of battle-lore arrange- dropped the gall-bladder back. He then closed the ment, on guard against flies in the operating room. wound except the drainage opening. The big mid- If she saw a fly on the floor or on anyone or any- line incision was next attacked. The rectus mus- thing within reach she attacked it. One lodged on cles were freely exposed, the scar tissue was dis- Dr. Kammerer, and she made a hit at it and greatly sected away until firm, normal aponeurosis was astonished the visitor, who, apparently, was not obtainable for suturing. Dr. Ochsner in closing The assistant to the c verts the peritoneum in the sane way as Dr. prepared for the attack. -1 urphy does. operator took no notice when he was struck. I too had a considerable shock in this clinic. I had There was little else of interest, and the morning many times heard technical words derived was a disappointing one; but to have seen Dr. from the Latin or Greek, whose' syllables should Ochsner was quite worth the trouble. have a settled relative lengttl, pronounced in a way I was sorry that I had not arranged for a longer that would seem strange to a man educated in Aus- stay in Chicago, and on another occasion I certainly tralia or in England. shall. I Y} C ^ n i

930 AUSTRALIAN MEDICAL JOURNAL. April 5, 1913.

A TREATMENT FOR CONSTIPATION, BY only articles to assist in putting the body into the

GRAVITATION AND POSTURAL MOVE- positions necessary for carrying out this method of

MENTS. treatment are a box-couch, or some such article strong enough to support the weight of the hips

and legs, and high enough to keep these parts at a MAN LA\VRENCE, M.R.C.P., Edin. sufficient elevation, about 18 inches from the floor; Dermatologist, St. Vincent's Hospital.) and a pillow, or air-cushion, to rest the head upon.

The treatment should be carried out on awakening

:tinstipation, in its varied forms, is undoubtedly in the morning first thing, as it is as well to have a y» x"one of the commonest ills our flesh is heir to. So rest in bed for a little while after carrying out the that in Dermatology, as in all other branches of movements, and at any rate it is desirable there medicine, the effects of constipation, such as auto- should be at least one hour's interval after the intoxication, etc., play no small part in the etiology treatment before seeking the action of the bowels. of many forms of skin disease. And, no doubt, be- During this time the morning bath, breakfast and sides the large percentage of patients who recognise shaving, if indulged in, may take place. In obsti- their failure, as regards the normal carrying out of nate cases the treatment may, at first, also be re- this great excretory function, there are many others sorted to just before retiring to bed, which has the who, though they may have a daily evacuation of advantage of encouraging peristalsis of these parts the bowels, nevertheless suffer from reabsorption of during the night's rest.

toxic substances, on account of the faecal excretion 'I'he positions are six in number, and should not being thorough. That is to say, there is some be carried out in the following order :- retention of material, which is ready for excretion, No. 1.—Knees upon couch, head (resting upon but, owing to some fault in the normal transit pillow), and chest upon floor. This position is a along and exit from the lower portions of the in- difficult one, and, perhaps, should be omitted by testinal tract, there is a constant absorption of some material which produces a chronic poisoning of the system, the symptoms of which are not readily recognisable. The causes of constipation are numerous, and, as in other diseases, treatment should be thought out in the direction, if possible, of removing the cause. I have therefore headed my paper "a treatment," as it is aimed at remedying what I consider to be one of the commonest causes of constipation—viz., inertia of the lower portions of the intestinal tract. Sedentary life and carelessness are undoubtedly great factors in the production of many forms of constipation. But the effect, I particularly aim at, is remedying the artificial or unnatural stasis of the ileo-c;ecal and other positions of the lower abdo- minal content. What I mean is—your adult more particularly, has the parts first mentioned in a de- pendent and more or less immobile position, the parts (lo not receive much encouragement by the movements of the body to vary their positions, and so help in passim along their contents, that is, they remain more or less in a stagnant position. At any rate the functions, peristalsis, etc., of these parts are by no means encouraged by our artificial me- thod of living. The treatment I have found successful is aimed at remedying this unnatural stasis of these parts.

No medicines are given, no enemata used, the sole factor in treatment being gravitation, depending

upon certain postures or positions into which the body is placed, and certain movements of the body whilst in these positions. A cer-

tain amount of exercise of muscles must ne- Position 3. cessarily take place in carrying out the treat-

ment, but the less muscular strain that takes obese persons, or any Others who find it impractic- - place the better, I think, the idea of move- able. In this position the parts being treated are

ment of the parts and their contents by gravitation now practically in the opposite position, as regards

takes place, so that I do not suggest the treatment gravitation, to that which they assume in the sitting

as an exercise, although its carrying out must posture. For active and comparatively young per- needs cause a certain amount of exertion. The sons it is quite practicable. The abdominal con- April 5, 1913. AUSTRALIAN MEDICAL JOURNAL. 981

tents fall downwards and forwards, giving a feeling column is thus raised at an angle of about 4o de- of fullness in the lower thoracic region, and, at the grees with the floor. This is an easy position to same time, there is a feeling of tension with flat- maintain; three sets of movements should be tening of the lower abdominal wall. The buttocks carried out in this position, the buttocks and abdo- and abdomen thus supported by the knees upon the men are moved backwards and forwards for one couch, are swayed gently from side to side, the minute, then the body is swayed from side to side, right leg to be occasionally extended. It will be and thirdly the thighs are worked forwards and recognised that the ascending colon in this and in backwards alternately, the action being as if walk- all other positions of this treatment is really in a ing upon the knees. The duration of this position descending position as regards gravitation. In the is three minutes. first efforts of this position there may be some sensa- No. 4.—From No. 3 position rotate the body, so tion of discomfort in the ileo-c ecal region; it is as that the right hip is supported upon the couch; well not to go on with this position if such is the right shoulder on floor, head upon pillow, then ex- case, but adopt position No. 2. (The time for tend and flex left leg as in position No. 2. Duration keeping in position No. i is about one minute.) of position two minutes. No. 2.—Lie with left thigh upon box couch, rest No. 5.—Lower abdominal and pubic region rest- head (upon pillow) and left shoulder upon floor. ing upon couch, side of face upon pillow and chest The right leg should then be alternately extended upon floor. This is an important position, some- to its full length, and then flexed, bring the knee what similar to No. i, but easier to maintain. After

Position 4. Position S. one or two minutes, if not inconvenient to the over the right side of the abdominal wall. If the )atient, then rotate the body again for one minute hand be pressed upon the ileo-cæcal region during these movements, a feeling of borborygmus may be into position No. 3, then to No. 2, and, after one minute, to gradually slip down from the couch on noticed, evidencing some alterative action taking to the floor. It is as well to rest upon the floor for place in the statu quo of that region. The duration two or three minutes after the exertions of main- of No. 2 position is two minutes. taining these positions before getting into bed again No. 3.—Turn from No. 2 position so that head for a further rest or taking a bath, etc. Although rests upon pillow, neck and shoulders upon floor, the movements take from io to 15 minutes to carry and the feet are placed upon the couch, knees and out, the patient should shorten the time of main- trunk of body being thus supported, the spinal taining any or all positions until he or she learns 982 AUSTRALIAN MEDICAL JOURNAL. April 5, 1913. how to maintain the positions without unnecessary discuss the question of who are to certify to and authorise effort. the segregation of defectives for life, or as to what body —Education or Lunacy department —should administer No. 6.—Stand erect with feet 18 inches apart, residential schools, I shall leave to future speakers who then, with the left knee-joint flexed, make a move- may be actively interested because there is a large num- ment of the body backwards and forwards, and also ber of a type of defective who should be under legal recog- nition owing to bad influences on others, and, therefore, from side to side. This movement should be car- must be weeded out and have special accommodation. In ried out for two minutes one-quarter of an hour. Scotland, I understand, this matter will, under a new bill, before seeking an action of the bowels. be in the hands of the Lunacy Board, and Scotland is a good country to follow. It would be wrong to close my The following is the history of a case treated by remarks without referring to the work done at the Kew this method Idiot Asylum under Dr. McCreery, the late inspector- Mr. A., 2et 45, troubled with obstinate constipa- general of insane, favourably commented upon so far back as the Congress of 1889 and reported to the Journal of tion, with history of several attacks of mucus colitis, Mental Science by the late Dr. Manning, inspector-general during the past ten years. Has had much treat- of the insane in New South Wales. Mention must also be ment, including massage, enemata, laxative drugs, made of the work done in private by the late Dr. Fish- etc. Examination by bismuth meal and - X-rays gave bourne, who was always insistent on the need for legisla- a three-days' delay, especially marked at the ileo- tion on this problem." Dr. Yule said that he had very little to say, because caecal region.. A most of what he had to say had been already printed in Treatment started 3oth December, 1912. Three the "Journal." For the last year he had taken more in- days after the treatment a dose of cascara was terest in the question of the care of the feeble-minded than he ever had before. Like a good many others, not taken at night time, the bowels not having acted. only in the general community, but also in the medical Since that date (now three months) the patient has profession, he had formerly thought of the feeble-minded taken no medicine, the bowels have acted every as poor creatures, for whom they could not do very much, clay, and the patient has gained seven pounds in and that spending money on them would be really waste- weight. ful; but once he had begun to study the subject, he came to a very different conclusion. He thought now that the subject was anything but an unimportant one. The proper care of the feeble-minded was not only for the sake of the feeble-minded themselves, but also for the sake of the ,ftiebtcar 2155octRtton. general community. A census had been recently taken VICTORIAN BRANCH. throughout Australia, as far as the States could be got to join in. Forms were sent to all medical practitioners in Victoria, to private schools and State schools, returns DISCUSSION ON THE PROBLEM OF THE FEEBLE- being obtained from all to a greater or less degree. MINDED. Strange to say, the returns from the medical profession Dr. Beattie Smith, in opening the discussion, said were the most unsatisfactory of all. Forms were sent out that this meeting, held by permission of the Coun- to 824 medical practitioners, and 49 replies were received, cil of the B.M.A., arose out of a Congress de- which showed that the profession did not appreciate the cision in the Section of Psychiatry, and that he regret- seriousness of the subject. The returns that were ob- ted the absence of Dr. Mary Booth, the convener, whose tained showed that the trouble was quite as grave here work had been great and enthusiasm contagious. Dr. Beat- as in other parts of the world. Four hundred and sixty- tie Smith then proceeded:— two private schools were approached, but only 63 replied, "The problem of the feeble-minded presents difficulties so that the private schools were almost as bad as the in the method of attack, but is one to be faced with deter- medical profession. A good many defectives were, how- mination and circumspection. A central committee was ever, discovered in private schools. A very complete re- formed and State committees with hon. secretaries were turn was obtained from State schools, practically all re- arranged from which much was expected. The Central plying, and the fact was disclosed that there were over Committee reports to Congress early next year in New 4,000 in the State schools here defective to the degree of Zealand. This meeting is to deal with the subject in all mental dulness and a large proportion even to feeble- its bearings, and is purely Victorian in its incidence. mindedness. It was really the higher grade of mental de- Whatever may be done in a federal spirit by collective fective who was the trouble. The idiot or imbecile was investigation, I feel sure that those who will work in the incapable of taking care of himself, but the feeble-minded matter in individual States will pay heed to the general was dangerous to the community. Apart from the habit- view of combination and organisation, by using the ual criminal, he need only refer to the sexual outrages schedules arranged and distributed, according to local one read of, many of which seemed to be due to people not possibillties and local disabilities. My own portion of in their proper senses. The census taken, incomplete as this work has been small, and arises out of a Congress it was, showed that there were some 4,000 mental defec- sectional position, but my appreciation of the demands to tives in a State school population of 175,000. Reported by be made on the State ministries is great since profes- 49 medical practitioners, there were 92 mental defectives. sional work leads one to recognise that the unfit and the Obviously if all the medical practitioners had replied the misfits mentally are largely due to the want of early number would have been vastly increased. The medical recognition and care educationally and institutionally of practitioners were asked to name cases who were not at- the feeble-minded and backward, whose environments, tending school. Dr. Yule had hoped that Mr. Tregarthen, whilst not eliminating higher class surroundings, have an officer of the Government Statist's office, who had help- been largely prejudicial. Experience teaches us that as ed the Committee considerably, would have been present, a rule this class proves impossible of remunerative and but, unfortunately, he had not been able to come. The independent physical work or self-control, and the mental classification figures which Mr. Tregarthen had been good deficiency renders them irresponsible and unfit for pun- enough to supply, however, would be seen in the Journal. ishment. There is no appropriate place for such cases, Other speakers would say what was being done in other no suitable law for detention. Treatment in prison is parts of the world to obtain the desired end of protecting economically unsound and scientifically unjustifiable. Edu- alike the feeble-minded and the community. cation and segregation are the methods which suggest Dr. Jones said that he must begin by expressing his ap- themselves as treatment. Whether we need at present preciation of the honour done him in being asked to ad-

April 5, 1913. AUSTRALIAN MEDICAL JOURNAL. 983

dress the meeting. He thought this question of the care for, but the Committee also thought that they could only of the feeble-minded merited a much larger attendance of succeed if they had the whole-hearted assistance of the members, and he also regretted very much that invita- medical profession, and particularly of the Medical tions to attend the meeting were not sent to interested Society. These objects were:- laymen. This work was one which he thought the me- 1. The establishment of special day schools in large dical profession would do well to consider very much centres of population, or special classes in less populous more seriously than had been done in the past. If the areas, for those who are able to be looked after in their profession did not take it up it was pretty certain that own homes. the general public would do so. The public was begin- 2. The institution of a residential school for those de- ning to be educated on matters of this description. One fective children needing constant care and attention, and had only to turn to the results published of English, Ame- for those unable to reach a day school. rican and German conditions to find how closely all sta- 3. A segregational colony for adults unable to receive tistics were agreed in this matter. In all civilised coun- their liberty after education, with a boards: lg-out sys- tries there seemed to be a percentage of .45 of definite tem associated with the colony. feeble-mindedness, which, he thought, did not take into 4. Legislative powers. consideration the higher degrees of feeble-mindedness. These were the four things that the Committee thought Australian statistics practically bore out this same pro- they were justified in going to the Government and to the portion, although they had not been compiled as fully as public for. He quite understood that the medical profes- they might have been. Four or five years ago, when the sion was not particularly interested in this matter, be- Bent Ministry was in power, and Mr. Mackey was the cause to a great extent it seemed that the whole question Hon. the Chief Secretary, Dr. Jones had approached Mr. was one not very eminently a medical one. The medical Mackey on this question, and Mr. Mackey was very en- interest was comparatively slight in these cases of feeble- thusiastic about the matter of the establishment of schools mindedness. The economic and the educational side were for the feeble-minded under the Education Department. more important even than the medical. In conclusion, he Dr. Jones was asked to see what could be done, and he wished to say that the feeling of his Committee was ad- found a school in Fitzroy, which was then disused, and verse to the question of sterilisation. In fact, he thought he proposed that the school should be started as an experi- he could say that their motto was "no sterilisation," but mental day school, much in the sane way as was being education and segregation." done in English and German cities. He felt that the day Dr. J. D. O'Brien said that, in rising to offer some re- school was going to help them to demonstrate how much marks on this subject, he expressed pleasure in seeing so feeble-mindedness there was in the community. The Bent many of his professional brethren present, and more par- ministry went out, however, and the whole question was ticularly in finding them prepared to take concerted action lost sight of. He was glad to say, however, that the Edu- in a matter which to him has been one of personal con- cation Department had taken up the matter again, and, cern, of much anxiety, and ever a source of difficulty. As curiously enough, had fixed on the sane school to make a the Government Medical Officer, he had frequent oppor- start. Going into the matter with Dr. Harvey Sutton, he tunities of examining accused persons hi whom mental found, as the result of a visit to a Port Melbourne school, defects are suspected to exist, and, on the conviction of there were a large number of children ready to hand. The such individuals, the question always presents itself, What truant officer had gathered from a number of children with- is the most prudent course to follow or to recommend as in a "restricted area in South and Port Melbourne 40 cases. regards their welfare and the safety of the general public? Amongst them were definite idiots, imbeciles, two very Necessarily a matter of this character is of material im- well-marked cases of Mongolian idiocy, and a case of im- portance to the public, and hence any effort which tends becility with chorea. Out of 40 cases there were 23 de- to the amelioration and the better care and supervision finite imbeciles. This was a striking example of what of these degenerates will command their support. In would probably be found in other parts of Melbourne and dealing, however, with a question of this kind, we must Victoria. These day schools would, he thought, form a safeguard the position. We should not confuse the men- sort of receiving-house for what was bound to be wanted tal weaklings--combining the various degrees of imbe- very badly, a large residential colony. The question of cility—with those who are simply morally depraved. Kew Idiot Asylum would have to be reviewed: it was not These types are often seen in combination, but in certain large enough. There should be some central place where subjects are distinctly apart, and do not come within that the statistical work could be put into shape, and he wished much-abused term—moral insanity. It is often said crime to suggest that the medical officers at the laboratory of is hereditary, but he felt that the up-bringing of the off- the Mental Hospital would be only too glad to act as a spring in criminal surroundings, the vicious education centre for the collection of all the necessary work on the they receive, the scenes of debauchery which they witness, question of Eugenics, and also a library where records of the lack of wholesome employment, and the consequent family histories could be kept. It was very necessary for laziness which it engenders, have much to do with the the medical profession to realise how very helpful it was moral obliquity which offenders display. He would go a to the officers of the Lunacy Department to have correct ' little further, and say that many of the stigmata which histories of cases sent in. The medical officers of the distinguish the criminal, and make him known at once to Lunacy Department were getting very enthusiastic on this the officer in the criminal investigation branch, are largely the results of question, and persistent inquiry seemed to reveal the fact the life of debauchery which most of them that this was a matter very largely of heredity. To refer lead. Once admit, however, that the acts of all the morally to two of the big hospitals for the feeble-minded in Ame- depraved are the outcome of insanity, and there is not a rica, where Dr. Goddard was superintendent, and in an criminal in the land who would not at once insist, he adjoining State where Dr. Fernald was director, these two was the victim of a vicious organisation, and a subject gentlemen had for years been collecting statistics on this more fit for treatment than punishment. This is a very question, and they stated that not less than 65 per cent. dangerous theory: it opens up a large question, but show a definite history of inheritance, and he thought if should we admit it, any good which we may hope to ob- the assistance of the medical profession could be obtained tain by this meeting would be nullified. He was walking here they would not be behindhand in getting statistics on very dangerous areas in thus minimising the opinion which would bear out these resuits. They all realised, of of many authorities, and disturbing the sophistries of course, how much feeble-mindedness was due to syphilis, many excellent people, who see in every criminal act the and it could be easily found out, he thought, how much outcome of a diseased brain. To avoid volcanic upheavals the question of alcoholism in the parents was the cause of or to minimise their destructive powers, let me say that feeble-mindedness in the children. He thought they could moral insanity exists, and whilst it may do so without any demonstrate to the public that 95 per cent. of the cases of recognised deviation of the intelligence, yet my own ex- feeble-mindedness were due to inheritance, syphilis, or. perience goes to show that it rarely does. Longer super- alcoholism. The Committee had empowered him to lay vision and more exhaustive examination would convince before the members the objects which should be striven • the most sceptical of the general truth of my observation. 984 AU STRALIAN MEDICAi, JOUI2AÌAÍ.. April 5, 1913.

To fix honestly the degree of responsibility in the cases people closely, and you will find sufficient reason to send of the mentally weak who have fallen into crime is no them to an asylum, where, in the present want of better easy matter. It is possible punishment, in some cases, accommodation, they should be detained. outside a gaol might even be beneficial, yet, he confessed, Dr. W. A. Wood, in opening his remarks, said he would in the majority which have come before • him he had in- like to endorse all that had been said by Dr. Jones, and variably taken the view—and as at present it is the only he also wanted to express some disappointment at the view which may be taken—that, should the examination want of interest taken by the medical profession in the prove the accused to be of defective intelligence, that such subject. One might say, perhaps, that it was not work intelligence has not developed, is much below that which that would bring in more income, but it was more for the is rgarded as normal and inconsistent with the year at good of the community, and much good would be done which he has reached, that his state of mind is such that, by taking up the subject on similar lines to those adopted on a favourable opportunity presenting itself, he does not in Europe and America. Dr. Wood said that he had re- exercise normal restraint, then for his own sake, and in cently examined 29 inmates of one of the rescue homes the interest of the general public, such a weaking is bet- for females in Melbourne, the average physical age of ter within the walls of an asylum than shut up for a the inmates being 30 years, one 14, one 15, 17, and the others 19 years and over. Examined by the Binet test, term. in the corrupting environment of a gaol, which he the average mental age of those females was 9 years. leaves at the expiration of his sentence a greater danger Many were women from the police courts and many were to the community. He would impress, however, that the detained there at the request of their parents, but, as a utmost care is necessary in criminal cases, and the prac- matter of fact, they were not legally detained there; at titioner who did not discover any defect in the intel- any time they might have gone out. The more trouble- lectual operations of an accused person would find it very some ones were sometimes asked to leave by the matron. hard to convince a court of justice that such intelligence That was the present position, so far as our laws were was not capable of controlling the actions of his will. concerned, that such dangerous people were allowed to Mental delinquents comprise all degrees of imbecility, and go where they pleased, unless kept under suprevision at the nearer they approach the normal standard of intelli- the request of their parents. Dr, Wood said he had been gence the more difficult it is to determine the question of particularly asked to speak about how the inmates were responsibility. As a rule there is a bad heredity, the re- got into the institute in New Jersey, where he stayed for sult of disease or drink. Of the two, he was of opinion two or three days at the invitation of Dr. Goddard and drink played the more prominent part in the production of Superintendent Johnston,. This institution was not a the cases to which we are at present referring. Syphilis State institution. Dr. Goddard's researches on this sub- has a most decided influence on the weakening of the men- ject were most convincing and thorough. He had records tal and physical conditions of the offspring, but for- showing how some feeble-minded had been traced back tunately such degenerates frequently succumb within a generation by generation on the unmarried mother's side, short period of birth; or, where life is prolonged, the con- as in the "Kallikak" family; while on the normal father's dition is so manifest that confinement in the asylum soon side by another (normal) female the whole line possessed becomes compulsory. Not only is drink a factor in normal intelligence. Very valuable work had been done in heredity, but is a potent cause in the individual in the this Vineland institution. It was an institution that was acquirement of a mental enfeeblement. He had many originated by a few philanthropic Americans, who began opportunities in his daily practice showing the truth of to see the importance of the subject. After they had been thié statement. He said it with all due respect to our at work for some little time, backward classes were magistracy that the means adopted by justices to stamp started in all the States of America. Where it is found out drunkenness—to reform the unfortunate victims—are that in a community there are ten backward children, they altogether wrong. In dealing with them they do not re- immediately establish a special school for backward chil- cognise the position---+that it is their duty to prevent a dren. Every three months a specially trained medical man or woman becoming a derelict. They do not seem to officer examined those backward classes, and culled out recognise the absurdity (it is recognised by the victims from them any that were four or five years backward by themselves) of imposing sentences of 24 hours and the like the Binet test. This test was held to be the standard of on notorious habituais. What is also not observed by them feeble-mindedness. After some weeks with these classes, is that the sentences in such case should be more of a the teachers were supposed to be able fairly well to pick reformative than a punitive character. What happens as out suspicious feeble-minded children, and especially he had seen occur: the unfortunate falls lower and lower trained medical men examined those culled out. Once it till finally he joins the ranks of the criminal classes, if he is determined that they are feeble-minded, they are sent has not already fallen a victim to disease or been con- to the Vineland Institute. It was no use, Dr. Wood said, fined within the walls of an asylum. So strongly do I feel undertaking the treatment of these feeble-minded people, on this question, that, try anything you please, so long as unless it, was really determined to see the matter through. the justices regard the treatment of drunkenness as is At the Vineland Institute there were two classes of pa- done at present, no reformation is possible. There were tients: Private patients, who were received there at the other factors in the causation of imbecility, which it will request of their parents or guardians, and who pay any- be unnecessary for me to refer, and he would not attempt • thing from 30 to 60 dollars a month, and have just the to follow the school life of such children beyond stating same treatment as any other children do. Then there that much harm may arise by attempting improvement were the State patients. If the parents or guardians should require any aid from the State the child must be of powers that do not exist. In many cases these children between the ages of five and twenty-one years. Applica- evince some tendency in certain directions, and, when tions must be made to the Commissioner of Charities; healthy and normal, let the child be given a chance to cul- three blank forms are filled in and returned to the Com- tivate probably the only talent he possesses. After the missioner, who then communicates with the Institute; school period many of these weaklings, as ?they can never and, if the child is accepted, the parents or guardians are compete in the labour market with their fellow-man, join notified to that effect. For State pupils, the State from the ranks of the unemployable; they are addicted to habits which they cone desires the parents to pay what they are of a certain character; they are easily led; vain; most able. Any parent or guardian making application to have typical examples of cunning and lying, and are so easily any person admitted to any of the institutions under the influenced they soon join the ranks of the criminal classes. supervision of the Act must waive all right to remove such Even in crime the acts are confined to those of a definite inmate. Any inmate may be discharged on the recom- character, and at times the sense of the community is hor- mendation of the head of the Institution, and may be rified by an outrage committed by them on some woman, granted leave of absence for a limited time. This was the or more often, defenceless child. He fully and freely way pupils were received into the New Jersey Training admitted it is often difficult to determine the degree of School. As a matter of fact, not much law was required responsibility. Even when being examined these weak- for the compulsory reception of these cases. In Ame- lings often put forward a plausible story: many of them rica, Dr. Wood said, it was found that, although there have intelligence to admit they knew they did wrong, and was a considerable amount of accommodation for such that they were liable to punishment; but watch these' cases, they got more applications from parents to receive

April 5, 19i3. AUSTRALIAN MEDICAL JOURNAL. 985 children than there was room to provide for them, and members of the staff should remain for five years before Dr. Wood felt sure that that would be the experience here. they were removed. They were, however, handicapped There were dozens of cases at the Children's Hospital, tremendously by the absence of money. This little place where mothers wanted to know what to do with such was opened originally for 40 patients, and when it was children. The parents could not manage them at home, handed over to Dr. Jones some years ago it contained 320 and the parents thought theist wilfully dull and stupid, patients. It was, however, really impossible to get de- and they were consequently made a butt of at home and finite plans carried out at the time, but still they were their lives made miserable. They got into trouble and able to get things into fairly good working order. There were treated as wicked children, whereas, as a matter of were four school-rooms and a teacher in charge of each fact, if they only had the advantage of such an institution room. There was also a large drill room attached to the as the Vineland Institute, where one could go and find the school rooms. These children could not keep their atten- happiest children, their lot would be infinitely better. At tion fixed for any long time, however, and the word teach- the Vineland Institute their motto was, "Happiness ing was, of course, very elastic. There was always a cer- above all things, and all else follows." if the child shows tain amount of house work to be done. By degrees, also, a special intelligence in any particular way, this is fol- workshops were built. Many of the boys were taught to lowed up, so that the child has pleasure in doing some- make door mats; for years the door mats of the Lunacy thing. They had a poultry farm, garden, and engineering, Department were made there. The boys were also taught carpentering and basket work were carried out, and any to mend boots and shoes. For years they mended all the spark of intelligence the child possessed was followed up. boots and shoes for all the children there. Some of the These children were kept in the backward classes as boys also managed sewing machines very well, and did the feeble-minded children until 12 years of age, and were not mending. Carpentering work was also done, and there sent to Vineland. Unless they were considered danger- was a small vegetable garden established. The girls found ous to the community. Thus parents had to bear the ex- work in the laundry, and also in cooking and sewing. It pense of board and lodging of these children, and allow was proposed at one time to enlarge the school and take them to go to the daily classes and come home up to the in day scholars from outside—feeble-minded children—but age of 12 years. in that way the State did not have to Dr. McCreery was not enthusiastic about this matter, and bear the expense of board and lodging of the children, the point was not, pressed. He did not think a few hours a when they were not dangerous 'o the community. After day would do much good in these cases. A good many that age they were received into the Vineland Institute. medical men came and saw how things were going on, and After attaining the age of 21 years, they were removed to were apparently satisfied. This, Dr. McCreery said, was a different homes, the men to one home, the women to an- very short account of the work which was done at the other, where the different pursuits were still carried on. Kew Asylum. Fie had all the forms for admission used in America, Professor Laurie said that the address given by Dr. which he would be pleased to hand over to the Commit- Wood was most instructive, and showed not only what tee to aid them in darfting suggestions for the Govern- cold be done, but what had been done most successfully ment. Once the parents got their children into the Vine- in :other parts of the world with very great advantage to land Institute they never wanted to take theist out again. the community as well as to the feeble-minded themselves. Another point in connection with this institution was that Dr. A1cCreery's remarks were very interesting from this it was not only for the care of these people, but also point of view, that he showed what had been done in con- for the study of the whole question of feeble-mindedness. nection with the children who had passed the line separat- They had women trained there, who went all over the ing feeble-mindedness from idiocy, and he himself could States, in order to obtain complete family histories of in- bear witness to the fact that even in these cases very mates. They had a biological laboratory, also elaborate a great deal of valuable work was done, making these chil- testing rooms, and had a very complete system of the study of this question. These, Dr. Wood said, were the main dren very much happier than they were before, and more points he wished to bring forward. in conclusion, he useful and less a burden to those by whom they said that if by these means we could get the feeble- were surrounded. It stands to reason that much minded segregated it would be money well spent, as in a more could be done for those who had not generation or two it would mean fewer criminals, fewer passed the dividing line. When he went to the Kew Asylum, at Dr. llcCreery's invitation, it was prostitutes, and less syphilis. Dr. McCreery said that he had been asked to speak about strongly impressed on his mind that a very great deal his experiences in connection with the Kew Asylum. could be done for feeble -minded children. This subject Before the year 1887 the imbecile and idiot children under was taken up many years ago by a committee consisting the care of the Lunacy department were kept in the of Dr. Fishbourne, Dr. McCreery, Mr. Mackey, and him- ordinary asylums. At Yarra Bend there were two cottages self among others. Movements of this kind were some- devoted to these children, and they were kept apart from times slow in coming to anything, but at last something the adults to a certain extent, but there was no education was decided upon, and the Bell-street school was to be and no training given to them. There was a Royal Com- used as a special day school for feeble-minded children. mission on the Lunacy Department in the year 1884, and This was not going very far, but it was something. Too one of the suggestions made was that there should be much importance, however, need not be attached to these a separate institution for feeble-minded children. In special day schools, but something might be accomplished order that this should be carried out, a building was by their means or by means of special classes attached to erected on the ground of the Kew Asylum. At that time State schools. These special day schools must become, I)r. McCreery wasSuperintendent, and these buildings as was pointed out previously, chiefly useful as centres of were handed over to him. There was no plan of any kind observation. The children going to these schools could be drawn up for the working of the institution, and the Go- carefully watched and classified in various ways. It would, vernment did not purpose doing anything more in the no doubt, be found, as borne out by the experience of matter apart from the buildings. He was instructed to other countries, that something more was required, that select a number of adult harmless patients to take charge residential homes were wanted, and over and above all, of the children, and a few warders were assigned to him farm colonies were wanted for these cases to control those to carry out the work. He pointed out that it was abso- who had power to control themselves, and who would al- lutely essential that the children should be kept apart most certainly relapse into crime otherwise. All these from the adult insane population, and for a time this point things were included in the programme drawn up by the was conceded. One attendant there had an experience of Committee. He hoped that the movement would be some years in an English asylum, and Dr. McCreery found pressed forward, and that they would not be content with his services very useful. On several occasions the idea of half measures. He felt quite certain that the measures bringing teachers out from England was brought under recommended would pay the community over and over the notice of the Government, but they did not see their this. Dr. McCreery was able to get certain again. It would surely be to the interest o f the commun- way to do ity to do away with degenerates altogether if possible, and changes made which gave him a little more voice in the Selection of new members of the staff for the children's he thought they had a very strong case with which to go asylum, and he was able to introduce a measure that to the Government now. He did not think there was a 986 AUSTRALIAN MEDICAL JOURNAL. April 5, 1913.

single thing in the whole region of education that cried more loudly for effective measures than the care of these feeble-minded children. liBritigb SaszOCiati0n. VICTORIAN BRANCH. Dr. Stephens took exception to what Dr. Jones had said —that the problem of the feeble-minded was of very little Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. interest to the medical nian. He thought that the me- Secretary. dical man always took great interest in the feeble-minded for the reason that the feeble-minded always came to the NOTICES. medical man first for diagnosis, prognosis and treatment. At the Children's Hospital the percentage of the feeble- minded was fairly large. He was sure that the feeble- MELBOURNE PEDI.1TRIC SOCIETY. minded children, not including imbeciles and idiots, who At the next meeting of the Pediatric Society, on Wednes- came to the Children's Hospital amounted, at a moderate day, April 9th, Dr. R. J. Bu ll will give a lecturette on the estimate, to •5 per cent of all cases. Compulsory segrega- `Bacteriology of some Diseases of Childhood, with Prac- tion was, in his opinion, what was required. In order to '•ical Suggestions as to Treatment." diminish the increasing amount of insanity, he thought these people should be prevented from marrying, and Warning Notices. should be segregated, so that they would not be a menace to the community. The offspring of two recessives, e.g., Medical practitioners are asked, before applying for any two mental defects, or a mental defect and an epileptic, appointment advertised by the United Friendly Societies according to the Mendelian theory, would be all deficient. of Invercargill, N.Z., to communicate in the first place With regard to the individual who might be classed as an with the Secretary, British Medical Association, 26 Yarrow- "impure dominant," it was impossible to legislate for street, Invercargill; or H. E. Gibbs, Secretary B.M.A., Box them on account of the difficulties of diagnosis. He 156, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; thought with Professor Laurie, that the day school was or the Secretary, B.M.A., Melbourne, Vic.; or the Secre- totally inadequate, and they should strive to get something tary, B.M.A., 429 Strand, London. after the style of Vineland's and run on similàr lines to Court Sherwood and A. O. Foresters ; Launceston. Vineland's. Special day schools, he thought, were not ad- Medical men are advised to communicate with Dr. S. W. visable, because parents would take the children there at Ferguson before applying for positions advertised by great inconvenience for a time, and, not finding any Bullfinch Medical Fund, W.A. striking improvement, would discontinue. Unless the school was made residential, it would be of little value Telephone 1484 Central. practically. Dr. Barrett said that he had been asked to refer to the Montessori method of minded, whose attention cannot be held by formal work, educating children which he had and it was then applied to healthier children, because of witnessed in operation in Rame. He would like to make a its success in the first instance. short digression and refer to a remarkable institution he had seen in Rome—the Beni Stabili. The Beni Stabili, he said, is a public company, which erects workmen's dwell- GENERAL. ings. The particular set of buildings he saw consisted of a quadrangle of apartments, providing accommodation of from two to five rooms for a very large number of famil- The city of Toronto in the past decade has recorded the ies, which were let at from 13s. to 26s. per month. In the following typhoid figures:—In 1902, 130 cases, 25 deaths; centre of the great court-yard formed by these buildings 1903, 156 cases, 35 deaths; 1904, 133 cases, 41 deaths; was one central block, the Block of Public Utilities. In 1905, 197 cases, 45 deaths; 1906, 259 cases, 63 deaths; this block were lavatories, both-rooms, sewing machines, 1907, 186 cases, 58 deaths; 1908, 201 cases, 60 deaths; provision for laundry, and an excellent consulting room, 1909, 331 cases, 77 deaths; 1910, 739 cases, 151 deaths; which was attended by a nurse and a medical man. All 1911, 520 cases, 81 deaths; 1912, 304 cases, 52 deaths. these services were included in the rent; but, in addition, Ottawa had 1,000 cases of typhoid fever in August, 1912, there was a Montessori kindergarten, so that the children with over 90 deaths. Altogether the epidemic numbered of the tenants could be taken care of at the kindergarten, 1,500 cases. This was traced to the water-supply. At the and educated during the busy time of the day, while the municipal elections the ratepayers refused money for a mothers were engaged in household work, and, at the filtration plant. As a result of the epidemic a judicial same time, were quite close to their children. The kinder- inquiry was held, and the medical officer of health and the garten visited by Dr. Barrett was a large room, in city engineer were asked for their resignations. which forty children were engaged in singing a song when he entered. As soon as he entered a little hand was put out to greet him, and presently the four members of the PERSONAL. party found that they had, collectively, had 160 handshakes with the forty children in the room. The children sat at twenty desks, two at a desk, and worked with Montessori Dr. Walter E. Summons and Mrs. Summons (Dr. Viva toys, just as they pleased. When a child tired of one Sproule) are passengers by the incoming mail steamer exercise, it exchanged with another or helped another. Orontes, which is timed to reach Port Melbourne on Mon- There were two teachers—a head teacher and an as- day morning next. They return home after an absence sistant—and the whole bore the appearance of an excel- from the State of about ten months. Besides sight-seeing lently conducted kindergarten developed rather more in Britain and on the Continent, Dr. Summons has de- freely than an ordinary kindergarten, such as the Lady voted considerable attention to medical matters in London Northcote Kindergarten, but not differing from it in and elsewhere. It is his intention to commence practice essentials. Many extravagant claims, he said, had been in Melbourne forthwith. made for the Montessori system, which was a matter of extreme regret. It was, Dr. Barrett thought, an improve- The S.A. Board has registered H. E. M. Wall, M.R.C:S., ment on the older kindergartens, but there was no radical Eng., L.R.C.P., 1908 and the New South Wales Board has alteration of principle. So long as we live in a society in registered J. H. Anderson, M.D., Melb., 1911, B.S., 1909; which inhibition and repression are a necessity, the child J. M. Rendall, L.R.C.S., etc., 1894. must be inhibited and repressed by some manner or means. In the Montessori method, the repression is re- Dr. Humphrey Marten has returned to Adelaide after duced to an absolute minimum, and great credit was due an absence of twelve months in Europe and Great Britain. to those who had shown that by a variety of occupation and tactful management the repression could be consider- Dr. C. H. Kellaway has been appointed Medical Re- ably attenuated with advantage. The system was first ap- gistrar and Dr. Tait Surgical Registrar at the Melbourne plied by Madame Montessori to the training of the feeble- Hospital. \ pril 12, tqIz. AUSTRALIAN MEDICAL JOURNAL. 987

SOME EFFECTS OF PRESENT METHODS causes disturbance, but mainly the sugar and fat. OF FEEDING DURING CHILDHOOD. Protein is generally, however, in insufficient quan- tity in milk mixtures, and, therefore, I find the \\. SPALI)1NG LAUR1E ì .D., B.S. addition of lactalbumin of considerable assistance. Physician to Out-Patients, Alfred Hospital.) Fat is usually deficient in a milk mixture, and it is difficult to obtain cream to make up the deficiency. Sugar in considerable amount is usually added, and, Holt has said that the question whether a child particularly if milk sugar or cane sugar is used, shall be strong and robust or a weakling is often fermentation is apt to occur. Many cases of afebrile decided by its food during the first three months of diarrhoea are probably due to the excess and de- lire. I would go further and affirm that that ques- composition of sugar. Sugar is one of the most tion may be decided by the feeding during any frequent disturbing factors in the dietary of young period 01 three months within the first three years, children, and there is a strong tendency to supply or even later. Many a baby well fed and healthy too large an amount in their food. It is rarely that during the first twelve months has its later child- parents, when told to add a certain quantity of hood spoilt by the manner of its feeding during the sugar to milk mixtures, will constantly adhere to second year. that amount; they usually sweeten the drink to \ny method of feeding must be judged, not by its taste." just aswith fats, it is the fatty acids, aris- immediate or temporary, but by its ultimate results, ing as bye-products in the digestion of sugar, that and, as Holt points out, it is the apparent imme- give rise to disturbance. Malt sugar is, generally diate. although temporary, result attained by pro- speaking, preferable to cane sugar or milk sugar, as prietary infant foods that has led to their adoption infants are able to take greater quantities of it as permanent foods, a use for which they are one without disturbance, and it is more rapidly ab- and all absolutely unsuited. 'l'he saving of a life is sorbed and utilised than other sugars. 'l'hc addi- the first consideration, but the physician's work tion of proprietary foods I rarely employ, if only for should not end there. For the saving of life a pro- the reason that their introduction into a house prietary food may he almost necessary, but the pro- stamps them ill the minds of the parents with an fession has not been sufficiently unanimous in its exaggerated importance, which is further enhanced prohibition of proprietary foods for more perma- by perusal of the wrappers. None of the proprietary nent use. The idea, fostered, perhaps, by legal foods are suitable for children. The proteins arc mainly vegetable; the fat, except in the case of two enactments, seems to be deeply engraver upon or most minds that up to the age of six months a three, is nearly absent, and what is present is child should have no starch at all, but that, after practically useless ; the carbohydrate is maltose or weaning. as much starch as possible should be starch. There is no particular objection to the in- crammed into the infant to the exclusion of other troduction of a small quantity of starch after the foods. Is it a matter of surprise that so many chil- first few weeks of life, since it has been shown that dren, apparently healthy and rosy during the first infants secrete a small amount of amylolytic fer- nine months, should show pronounced signs of ment even _before birth, but in such quantity as to rickets at eighteen months or two years of age? be of little use for the first few weeks. Starch is best supplied by the use of barley-water containing Some nine months ago I began to investigate the about two per cent. of starch as a diluent of cows' incidence of rickets among children under fourteen milk. Personally, however, I prefer to dispense years of age coming under my care in the out- with even that small amount during the first few patient department of the Alfred Hospital. I have months. Care must at least be taken that starch is not yet collected sufficient data to furnish the re- not substituted for the necessary food constituents, stilts, but inquiry into the early feeding of the chil- as is so often the case if proprietary foods are used dren examined has enabled nie to confirm some with milk. v,:. ry decided opinions I had previously formed con- So much for my advocacy of cows' milk cerning the subject of the feeding of infants and only as the young children. satisfactory substitute for human milk in in- fancy. I ant aware of the difficulties, sometimes A baby at the breast obtains milk containing the insuperable, of obtaining pure cotes' milk through- necessary constituents in proper proportions, and out the summer, but I do not intend to dwell upon these proportions remain nearly constant until the the questions involved. Nor do I intend to deal later months of lactation. But what happens in the with cases of difficult feeding. case of an artificially fed infant? If given cows' milk properly modified, the result may not be much The chief question I am considering is the effect of present methods of feeding upon the lives of divergent from those attained by breast feeding. children. I have extended my observations be- The chief obstacle in using diluted cows' milk is yond the out- the difficulty of supplying sufficient fat. It is often patients attending the hospital, and I said that a certain baby will not take, or rather can- find little essential difference between the poorer not take, cows' milk. While cases of cows' milk children and those of better class parents, although there are, of course, among the former more cases anaphylaxis are reported, I have never yet seen a of baby that I have been unable to feed on cows' milk actual underfeeding. A child is safely fed upon breast milk up to the age of nine or ten months, or if given a fair trial. It is now generally accepted longer that it is rarely the protein of cows' milk that in some instances, but by that time breast milk becomes insufficient, in several respects, as

988 AU STRALIAN MEDICAL JOURNAL. April 12, 1913. the sole source of nourishment. The point is that by, and we still act as though the direct contrary a child who has hitherto thrived upon the breast were true. milk alone, and is still thriving, must now be gradu- Hutchison, too, has tried to impress upon us that ally weaned. Inquiry from mothers shows some "any deficiency of protein in the diet will tell most such method of feeding, as in the following case :- unfavourably upon the young and result in impair- A.H., aet 6 years. Breast fed to 12 months, but ment of physique which may be irreparable." had biscuits and occasionally potatoes and gravy Czerny, who himself prohibits meat and eggs after six months. Now eats "anything going," but before the end of the second year, admits that most was not allowed meat until after five years of age. authorities recommend their addition to the diet Diet consists chiefly of bread and butter, biscuits, after the first year. We have a dread of meat, as we sago, cornina, digestive meal, milk, and milk pud- believe an excess produces high blood pressure, dings with occasionally stewed apples. The child arterial degeneration, kidney disease and gout. was brought to the hospital suffering from lack of Mott believes that any variety of food, greater in appetite and energy and frequent feverish attacks. quantity than can be digested or assimilated, will There were marked signs of rickets. lead to arterial degenerations. Cases such as this are seen frequently. Up to Variety of diet, with sufficiency of protein and six months the food was all that can be desired. fat and no excess of starch, will meet all the re- 'l'hen starch is added in the fornn of biscuits and quirements of the growing child, furnishing hint as potatoes. 1 may quote Cautley and Czerney in well with the requisite iron, phosphorus, calcium favour of early addition of starch to the diet, so will and other salts. In this connection it is worthy of not stop to criticise. So far the child may do well, remembrance that milk is rich in calcium, poor in but the subsequent (li ,et is far from satisfactory. iron : eggs are rich in calcium and iron ; meat and From an animal food of protein, fats, carbohydrates, most vegetables contain iron ; cereals, pulses, and and salts, all in due proportions, there is a rapid some green vegetables, are rich in calcium; meat, transition to food over-rich in carbohydrates, con- fish, fruits and potatoes are poor in calcium. taining an excessive amount of starch, very deficient I have stated that improper diet—and I am con- in fat, and deficient in protein, often deficient in sidering now a diet composed of an excessive phosphorus and iron, a transition, too, from wholly amount of carbohydrates with deficiency of protein animal to chiefly vegetable diet. and especially of fat—leads to evil results in the There is a prejudice among the people against growth and development of children. It remains to the administration of eggs to children and a still consider in what directions these evil e;2ec .s are greater prejudice against meat. "I never let my manifested. I shall make but passing reference to children have meat till they are five," is quite a the effects upon the teeth. Dentists tell us t' at frequent reply to the question, "Do you ever give decay is due to fermentation of carbohydrate food. him meat?" in one instance a mother told me her My experience fully bears this out, and I would child would eat almost nothing. I asked, "Not add that in carbohydrate-fed children there is a even sausages?" "Oh, she'd eat sausages all day lack of development that leads to early decay. long, but I never let her have any neat," was the Rickets is, in the minds of British-trained prac- reply. Why restrict protein and fat in the case of a titioners, essentially a disease arising from defective rapidly growing child who, far more than an adult, diet, from an excess of carbohydrate and a defic- requires tissue-building foods? I ant prepared to iency in fat, associated perhaps with bad hygienic admit that meat feeding may be carried too far, but environment. On the Continent it is, however, re- I would maintain that far more damage is caused garded as a constitutional hereditary disorder, as- by excess of starch in childhood than by excess of sociated with or characterised by an altered phos- meat. If a child develops asthma, meat is promptly phorus metabolism. We must pin ohr faith to the forbidden ; if skin troubles occur, meat is prohibit- British conception, but it may be that there is a ed; if the child gets "bilious" attacks it must have modicum of truth in the Continental idea. It is no meat or eggs. Surely we are depriving our coming to be believed that the growth of the body children of their birthright by forbidding them ani- ill its various parts is influenced directly by the mal proteins. Meat is supposed to be indigestible. secretions of the ductless glands, and, if so, we may We have not listened as we ought to men like so modify our conception as to suppose that the Eustace Smith, who says : action of these glands is exerted, their secretions "An excess of starch in their diet is to be avoided stimulated or inhibited in accordance with the for growing boys and girls. At no time of life do qualities of the foods assimilated by the organism. young children find the digestion of starch an easy Just as an excessive thyroid secretion leads to a matter, and it is unwise to overload them with a diminution of carbohydrate tolerance, or diminu- food which fattens but gives little strength, and is tion of the secretion of the posterior lobe of the but too apt to Make them lethargic and dull. pituitary to increased tolerance, may we not con- . r. . Meat is easily digestible. . . . At all ages ceive a contrary effect of long-continued excess of variety in diet is to be aimed at. . . . Let a child certain food constituents upon these glands? This have a good meal towards bed-time. . . . Rice, question is difficult of solution. I am not aware if sago and such like puddings are not light or easily it has hitherto been stated just in this form, but I digestible foods." put forward the suggestion as worthy of considera- This condensed wisdom seems to have passed us tion. I conceive rickets to he not a disease, but a .1pri1 12, 1913. AUSTRALIAN MEDICAL JOURNAL. 989

result of defective development, and I would pro- private practice illustrating most of the points I test against the diagnosis of the disorder from the have mentioned; but space will not permit. I will bony changes alone ; or, if we adhere strictly to the content myself with drawing attention to the con- changes in the skeleton, we must find sonie other ditions I describe in the hope that the dietary dur- tern to include its protean accompaniments and ing childhood may receive the consideration due to sequela. its importance. We meet in the literature with a partial recogni- tion of the evil effects of improper' feeding. Simple convulsions in children are universally regarded as CONTRACT PRACTICE IN NEW SOUTH WALES. having a rachitic basis or, as Neumann puts it, con- Dr. Clarence Read, as retiring President of the New vulsionsappear under the influence of the same South Wales Branch of the B.M.A., included the following deleterious factors of respiration and nutrition in his presidential address:— which act upon the development or exacerbation of I feel this a fitting opportunity for me to report to the rickets. Some authorities attribute all forms of members of our Branch exactly what took place at the spasmophilia in children, and even the neuroses of conference held last September between your council and the friendly societies and medical institutes, in the pre- childhood, to a like condition. Anaemia in children sence of, and under the chairmanship of, the Chief Secre- results chiefly from prolonged lactation, or a too tary. The friendly societies and medical institutes sub- great insistance upon milk diet during the second mitted a syllabus of what they wanted, and your council year. Stockman even attributes chlorosis partly to also submitted a syllabus of the improvements in contract work that the profession were desirous of obtaining. I a defective diet during the period of development. think the best way will be for me to go through the items Carbohydrate fever is, thanks to Eustace Smith, and then give you a summary of the result attained. now a well-recognised condition. Wage Limit.—The friendly societies' proposition was: Such are some of the more gross effects of (le- (a) That the B..111,A. be asked to eliminate this provision from medical agreements or to substitute the following fective diet, but in a larger number of cases the in lieu of the present proposals; (b) all members of lodges effects are manifested in minor ailments. These at January 1st, 1913, to be admitted to medical benefits at ailments are, however, of considerable importance ordinary rates; (c) those whose income exceeds £208 per in so far as they often interfere seriously with a annum to be charged an additional 10s. per annum for every £50 or major portion of £50 over and above the child's school life. In many of these cases we find said £208. After some discussion, it was decided to associated skeletal changes of rickets, hut it must consider remuneration of medical officers together with be remembered that with age the usually recog- the wage limit, and finally the matter was referred to a nised rachitic deformities gradually disappear. committee consisting of four representatives of the friendly societies and four representatives of the coun- Nevertheless, I think the fact is not sufficiently ap- cil to report to another sitting of the conference. Two preciated that the usual rachitic deformities give meetings of this committee were held, and a report sub- place to other well-defined conditions. The rac'hitic mitted to the conference. The conference then almost chest gives place to the angular chest, the pot belly, unanimously decided to allow the wage limit to stand as heretofore. The rates of remuneration to be: For the to an abnormally flat belly, and the lower ribs, City of Sydney, 19s. per annum, without medicine; and the which previously were bulged out, tend to be re- suburbs, including Hurstville, Parramatta and Hornsby, tracted, thus obliterating the Harriion's groove. 21s. per annum. :Transfer of Members. The muscular development is spare, and there is a — The friendly societies asked that deficiency of fat. Scoliosis, winged scapula, and a the following clause should be struck out: "A member of any other lodge of the said society or order, or of any tendency to flat foot, are not uncommon. These other society or order, desiring to be attended by the said conditions are often associated with adenoids and medical officer, under the terns of this agreement, shall be the adenoid facies. Glandular enlargements are entitled to be so attended on production of a certificate often met with in various parts of the body. from the medical officer of such lodge, stating that if resi- dent within the area of such lodge such member would Catarrhal conditions of the respiratory mucous be entitled to medical attendance by such medical officer, membranes are frequent, with constantly recurring and that such attendance is regulated in accordance with attacks of bronchitis, and even of asthma. I have provisions approved by the B.M.A. in respect of income. seen an asthmatic child completely cured by the No such member of any lodge as aforesaid shall be en- titled to be attended under the terms of this agreement alteration from an almost exclusively carbohydrate if such lodge is one to which members of the B.M.A. de- to a liberal protein diet. cline to give their services as medical officers." You will It must be admitted, however, that many of these observe that this clause is framed to prevent members of the A:N.A., Loyal Order of Moose, and similar organisa- cases, except that they are spare and ill-nourished, tions from obtaining medical benefit through the recog- exhibit no definite signs and sequels of rickets. nised friendly societies. After discussion it was agreed to Ordinary methods of examination show their organs allow this clause to stand, substituting the word "secre- to be apparently healthy, yet these children are far tary" for "medical officer," and eliminating the words "is from well. The symptoms for which the child is one" and putting in "is a branch of an order or society." Mileage. — The friendly societies suggested that the brought for treatment are often vague. Night-ter- mileage for the city and suburbs be three miles, and for the rors, night-sweats, screaming attacks, or, in older country districts two miles. The committee before re- children, morbid weeping, and so-called "bilious" ferred to suggested that the mileage be two miles through- attacks, are not uncommon. It is worthy of note out the State, which was unanimously agreed to. Clause 2, North - that many of these children, whose diet has been Eastern :Agreement. —The friendly so- cieties requested that bona fide residential members shall largely restricted to carbohydrates over a course of not be compelled to subject themselves or their wives to years, manifest a distaste for meat and eggs, or even examination by the medical officer. After discussion, we milk, in any form. Such cases are often very diffi- agreed to this. cult to treat. I could quote cases from hospital and Clause 5 provides for only quarterly lists. The friendly societies asked that this be amended to provide that the 990 AUSTRALIAN MEDICAL JOURNAL. April 12, 1913. lists shall be furnished to the medical officer monthly or force for the last four years; (2) exclusion of the mem- quarterly, as agreed 'between the medical officer and the bers of the A.N.A. and other bodies unrecognised by us lodge. This was agreed to. from participation in medical benefits through other so- Clause 5 also provides, in the case of a member of a cieties; (3) reduction of distance at which members were lodge meeting with an accident which entitles him to entitled to be attended from three miles to two miles; claim compensation or damages in a court of law, that (4) in the case of a member of a lodge meeting with an the medical officer shall be entitled to charge private fees accident which entitled him to claim compensation or for attendance rendered necessary by such accident. The damages in a court of law the medical officer to be en- friendly societies asked that this be amended to provide titled to charge private fees for attendance rendered ne- that, should a member succeed in his claim for compen- cessary by such accident; (5) a minimum accouchement sation or damages, the medical officer should be entitled fee of two guineas; (6) mileage rates of 5s. per mile to charge as if for a private patient. On Dr. Todd ex- one way above two miles between 8 a.m. and 8 p.m., and plaining the legal points involved, the original proposal 7s. 6d. between 8 p.m. and 8 a.m.; (7) a special fee of was allowed to stand. 5s. for lodge visits between 8 p.m. and 8 a.m.; (8) re- striction of transfer of members to bona fide residents; Clause 5 further provides for re-examination of un- (9) increase in remuneration from 16s. to 19s. in the city financial members. The friendly societies asked that the of Sydney, and 18s. and 20s. to 21s. in the suburbs; (10) words "if such examination be demanded by the medical adoption of a uniform agreement for the whole State, far officer" be added. We agreed to this. The fee for re- superior to the model lodge agreements now in force; examination in Clause 5 was stated as 5s.; the friendly (11) right to refuse to meet men ineligible for membership societies asked that this be reduced to 2s. 6d., but eventu- of the British Medical Association; (12) the trustees of ally agreed to a compromise of 3s. 6d. lodges to assist medical officers in collecting any moneys Accouchement Fee.-After discussion, the friendly so- payable for mileage or other attendance. set out in cieties agreed to the accouchement fees as We conceded (1) that on the certificate of the secretary Clauses 11 and 12 being approved of as a uniform arrange- of his lodge a member shall be entitled to transfer; (2) ment throughout the State. bona fide residential members shall not be compelled to Clause 13.- The friendly societies' proposition was that subject themselves and their wives to examination; (3) this clause be amended so as to provide that the me- list to be furnished monthly or quarterly, as agreed be- dical officer shall meet in consultation any qualified me- tween medical officer and the lodge; (4) re-examination dical man who is duly registered by the Medical Board of of unfinancial members not compulsory, left to option of New South Wales. When asked if they would work along- the medical officer; (5) re-examination fee to be reduced side free labour, they conceded that the clause as printed to 3s. 6d.; (6) examination of dependents, that is, children, was quite just, and agreed to it. step-children, legally adopted children, and widows'

Clause 17. - The friendly societies proposed that mileage mothers, left optional for the medical officer; (7) that if rates be reduced from 5s. to 3s. 6d. per mile for every this agreement and the rates included therein were adopt- mile or fraction thereof beyond two miles on the outward ed by the friendly societies, there should be no alteration journey in the daytime, but eventually agreed to 5s. being in any of the charges included therein for a period of five the rate. years.

Clause 19. - The special night fee of 3s. was not objected The committee of friendly society representatives and to by the friendly societies, provided the special fee is representatives of your council were appointed a standing not to be charged if the mileage charge is made. I may committee by the conference to fix the country rate and say here the night mileage fee is 7s. 6d. per mile, so that deal with any matter which might arise out of the confer- the request was not an unreasonable one. I want to make ence. The friendly societies' delegates have agreed on it clear to members that in the event of a lodge patient their part and your Council on their part to get their sending for you between 8 p.m. and 8 a.m. you are en- respective bodies, vii., friendly societies and members of titled to a fee of 5s. if the patient is inside the two miles the N.S.W. Branch of the B.M.A. to accept the proposals radius; if they live beyond they pay mileage above two of the conference. Your council have submitted the pro- miles at the rate of 7s. 6d. per mile or portion of a mile posed agreement to the various Local Associations; some on the outward journey. have accepted it, others have suggested amendments. I Clause 26.- 4The friendly societies asked that the words would earnestly appeal to members of this Association to "if passed by the medical officer" in sub-clauses (b), (c), accept without alteration this Agreement. I want you to and (f) be struck out. As a compromise the following realise that it is a compromise. It may entail some self- amendment was accepted by both parties: "If passed with sacrifice on the part of a few, but in my humble opinion or without examination by the medical officer," thus leav- the advantages to be gained far outweigh the disabilities. ing the medical officer the right to examine dependents Any alteration means indefinite postponement of the whole if he so desires. question. We now cone to the syllabus submitted by your Council. A meeting of the standing committee of friendly so- ciety representatives and members of your council met a 1. Medical Benefit Transfers. - Our proposal was that no member shall be transferred to a lodge of the same or fortnight ago, and the friendly societies agreed to submit another society in another place so as to be entitled to the following proposal to their grand annual conferences, medical benefit thereof unless he comes to such place as which will be held during the next few months: (1) That a bona fide resident. That is to say, with the intention the form of agreement, excepting the schedules thereof, of residing there for at least 12 months. We agreed to approved by the conference between the B.M.A. and the words or unless he conies to reside with the object friendly societies held at the Chief Secretary's Office, of following his usual occupation" being added to the end 14th to 27th September, 1912, be adopted as a common form of the clause. of agreement for use throughout the State; (2) that the date for adoption of the common form of referred to in 2. Remuneration of Doctors. -That it is reasonable that the rates of remuneration of medical officers and lodges proposition (1) be January 1, 1914; (3) that the agree- ment referred to hold good for five years; (4) that the should be increased. This was adopted unanimously. rate per member per annum be as follows, viz.: (a) lodges 3. Form of Agreement. - That the North - eastern Medi- outside the Sydney metropolitan area 26s. per annum cal Association's form of Agreement between Medical Offi- without medicine, and 34s. per annum with medicine, (b) cer and Friendly Society, June, 1912, not including the for lodges meeting in the city of Sydney 19s. without schedules thereof, be approved as a suitable form for medicine, (c) for lodges meeting in the Sydney metropoli- all agreements between medical officer and friendly so- tan area outside the city of Sydney 21s. without medicine. ciety throughout the State. A consequential amendment was made to this by inserting the words "as hereinbefore proposed to be amended" before "be approved as a suit- The friendly societies of Victoria are said to be en- able form." This was unanimously adopted by the con- deavouring to arrange a conference with the Victorian ference. Branch of B.M.A. to discuss the wage-limit principle and To summarise, we obtained (1) the wage limit as In the raising of remuneration, April 12, 1913. AUSTRALIAN MEDICAL JOURNAL. 991 journal treatment is systematically arranged. It is a little 2uOtrattan filebtcat depressing to read at the present time an "an- nouncement" that the Minister of Public 121h APRIL, 1913. Health is furnishing credentials for patients to visit Dr. Friedmann. At present the only THE STATE SUPERVISION OF TUBER- credential requisite for such an interview ap- pears to be CULOSIS TREATMENT. a well-lined purse. Cie question for the Minister and the advisory board is plain. Is it to It is difficult to arrive at any exact knowledge of be sanatorium treatment, or 'dispensary treatment, what is happening with regard to the problems of or both? And this being answered, the medical the treatment of tuberculosis in Victoria. Some director can formulate a comprehensive scheme time ago it was announced that a home for ad- which will blend the present organisation with vanced cases was being constructed at Heatherton whatever new features are desirable. which would accommodate roo patients. Then an announcement was made that, owing to some extra- Ordinary departmental management, this institution was to be part of a benevolent asylum. More ex- Poteg anb Comnnent5. traordinary still, it was admitted that an institution of such size had been constructed without a kitchen Once again the thoughtful consideration The Physiology of Professor Osborne's request for assist- of its o.wn, and without provision for medical or School ance in extending the Physiological la- nursing quarters. Further, it was announced that boratory is commended to former students the i\Im ister of Health had erected the whole of the of the Melbourne Medical School. Subscriptions have tuberculosis administration into a separate depart- been given up to the present to the amount of ;e500, which leaves only £300 wanting to claim a further .£300 from ment. hater an announcement was made with re- the University Council. Doubtless many who are sym- spect to a "tuberculosis bureau' ("bureau" is ap- pathetic have put the matter aside and forgotten that the parently a Avord related to Nlesopotamia for blessed- subscription list is still open. Some, perhaps, still ques- ness), and that an advisory committee had tion their obligation to be particularly interested. No Melbourne graduate, however, can say in his heart that been appointed to overlook this whole administra- the matter is without. a special personal interest. It is to tion. Now it is announced that the Heatherton his interest to give his school a world-wide standing and home is still waiting for an official opening and recognition. If brilliant research work should emanate that it still requires structural alteration. from any of its workers, the glory is reflected on all who claim its diploma. Therefore, quite apart from the altru- The one certain conviction that emerges from all istic interest of advancing general knowledge, and bene- these "announcements" is that the whole position fiting the profession as a whole, there is the personal seems to have got into a tangle, and that nobody interest of belonging to a school which is second to no appears disposed to make any intelligent or intel- other in the world. It is sincerely to be hoped that those who have forgotten will hereby be reminded, and those ligible effort to straighten things out. There is who are indifferent will herewith be convinced, and that little to he gained by recriminatory fault-finding, the £ 300 still wanting will be speedily contributed, but it seems time to suggest that there are some essential reforms desirable. In the first place, it • • would be well to define the controlling spirit of the In a short article in the "Liverpool Me- organisation. If a medical director is to be con- Anaesthesia dico-Chirurgical Journal" Dr. Kelly says: stantly overridden by a meddlesome minister, he "If a number of medical men were asked the question, "What is the best method of might as well have no existence in name. The administering an anaesthetic?" they would each give an Minister is concerned only with the policy and answer satisfactory at any rate to themselves. If there is finance of the scheme. He has an advisory hoard, one thing on which a man brides himself it is that his and a medical departmental head to arrange work- own method is the best. On the other hand, if they were each given a dog and a bottle of anaesthetic, and told ing details. to produce a pure anaesthetic death, compara- In the second place, it might be well to realise tively few would be able to demonstrate the desired re- and admit that the existing equipment is inadequate sult." The author then proceeds to notice Henderson's all round. The Greenvale Sanatorium, for example, views on Acapnia and Shock. These are based upon the dictum that 002 is the only stimulus to the respiratory is an institution which was made in a hurry, centre, and that by deep breathing or struggling in the and in the hurry the makers forgot to go hack and early stages the respiratory centre becomes dulled into give it a water supply such as a modern sana- inactivity. The theory admittedly does not explain all anaesthetic fatalities, but Kelly deduces the following torium should possess, i.e., an unlimited supply of aphorisms: hot and cold water. Don't scare the patient before anaesthesia. The obvious remedy is to reorganise the whole Never tell a patient to take long deep breaths. system. A beginning has been made, but it ought Don't prolong the struggling stage. Get it over to be a new beginning. It is futile to appoint an quickly as possible by constant administration. advisory hoard and give it nothing to advise upon. Never allow the surgeon to commence an operation It is useless to appoint a medical head and tie his until the patient is well under. hands with want of authority and discourage him Don't change from ether to chloroform after a stormy with lack of means. If we are to have sanatoria, induction. Such patients are particularly liable to cardiac failure. let them be the best possible. If we are to trust to Use a tuberculosis dispensaries, let tis have an intelligent large mask to allow of some re-breathing. Do not let a patient cone out of the anaesthetic until disposition of such establishments, where special the last stitch has been put in, 992 AUSTRALIAN MEDICAL JOURNAL. April 12, 1913.

9. To divide fees with, or give commissions to medical jgrtttztj lifitbtcat a95octatton. practitioners or laymen. VICTORIAN BRANCH. 10. To attend professionally a patient under the care of another legally qualified practitioner. We are asked to reprint the following draft recom- except—in consultation, or as a substitute in cases of mendations on "Ethics" arrived at by the Federal Com- emergency or other special circumstances, or when mittee. They will be brought up for discussion by the the attending practitioner has relinquished the case, Branch at the May meeting:— or been dismissed in due form. The report of the sub-committee appointed to draw up a It is customary both in Great Britain and Australasia Federal Code of Ethics was read and considered and, with for consultants and specialists to see at their consulting a few alterations and additions, was adopted by the Com- room any patients who desire their opinion, and such mittee as "A Report of the Federal Committee on `Medical practice is not generally considered unethical—notwith- Ethics.' " It was resolved:— standing the fact that when such patients, as is usually "That this Report be forwarded to the Branches for the case, are known to be under the care of another an expression of their opinions." medical attendant. Such practice is not in conformity with The following is a copy of the Report:— principle 10. REPORT OF FEDERAL COMMITTEE ON 11. To continue in attendance on, or subsequently at- "MEDICAL ETHICS." tend, a patient after seeing him in consultation with the regular attending practitioner, or as his substitute, unless The Federal Committee is of opinion that it is impos- with the consent of such practitioner. sible to draw up a Minute Code of 'Medical Ethics that will deal satisfactorily with every conceivable circumstance of In country and suburban practice, where consultations medical practice in Australasia, or that will impose suit- are held with, and assistance given, by general prac- able penalties for infringements of such a code. The fol- titioners, principle 11 cannot be followed absolutely, and lowing principles are suggested by the Committee as brief is generally held to apply to the particular illness for general guides. The Council of each Branch will have to which a practitioner may have been called in to assist. decide individual cases on their merits, and special cir- Patients cannot be deprived of the right to choose their cumstances, and determine the penalty of any infringe- medical attendant. ment of ethical principles. 12. For a locum tenons to commence practice within a As regards the ethics of consulting practice, the Com- period of three years in the same locality as his principal, mittee is of opinion that the time is not quite ripe for or to succeed to the practice of his principal, except by definite pronouncements on the subject, which is still un- purchase or with the consent of the principal or his rep- der consideration in Great Britain. The more nearly all resentatives. practitioners conform to No. 10 of the principles suggested 13. To administer anaesthetics for unregistered den- below, the better. tists or any unqualified person. Suggested "Principles of Medical Ethics." 14. To meet professionally in consultation, as assistant, It is unethical for a member of the British Medical As- or in any way, any practitioner who violates any of the sociation in Australasia above principles. 1. To designate his practice as based on an exclusive The Committee is of opinion, as before stated, that the dogma—such as that of Homeopathy, Osteopathy, etc. closer this principle is followed the better, and it is advis- able that patients who are known to be under the care 2. To prescribe or dispense secret remedies. of another practitioner should be seen by consultants, even 3. To hold patents for any surgical appliance or at their consulting rooms, only with that practitioner, or medicine. when sent with a letter from him, or with his knowledge 4. To advertise, either in the lay press or by card or and sanction. In a case where this is not practicable the circular. consultant should communicate, preferably by letter, with The following exceptions are generally permitted by the medical attendant. long-established custom in Australasia:— (a) On commencing practice. (b) On changing address. BENDIt O DIVISION. (c) On temporary absence from practice. A meeting was held at the Bendigo Hospital on 27th (d) On resumption of practice. March. Those present were the President, Dr. T. E. (e) On succeeding to another practice, death, vacancy, Green (in the chair), and Drs. J. D. Boyd, Catford, Cord- etc. ner, H. A. De Ravin, Ffrost, Lyons, Penfold, Williams, The advertisement in such cases must be as simple and Willis, Ker. direct as possible, and the number of insertions limited. Dr. Lyons showed two cases of night blindness in a 5. To permit the publication in the lay press: brother and sister, aged about 10 and 4 respectively. The (a) Of anything concerning disease or its treatment, children sometimes crawled to find their way about at in which the authorship is indicated. night, and saw well in the day-time. There was no con- (b) Of autobiographical, or biographical notices. sanguinity in the parents, nor any history of syphilis. The (c) Of advertisements of medical publications. fundi showed spots of pigment in the periphery of the 6. To give testimonials of any medical of surgical ap- retinae; some of the spots had slight atrophy of the pliance of preparation, or of any trade article. chorofd round them. The fields were much restricted. 7. To employ or sanction the employment of any The fundus changes were much more marked in the girl. agent or canvasser for the purpose of securing patients. Dr. Lyons also showed a young man who had had 8. To accept or hold appointment as medical officer to: thrombosis in the right iliac vein 14 years ago, leaving a (a) Any Medical Aid Association or Institution which lump present in the right iliac fossa. Six weeks ago, dur- touts or canvasses for patients. ing heavy work, pain was felt in the site, and this was (b) Any such Association or Institution carried on by followed by rise of temperature to 103 deg., several rig- laymen for their own profit. ors, enlargement of the liver with tenderness and (c) Any Friendly Societies' Institute where the ag- associated with jaundice. Intense pain was felt in gregate salary averages per member less than the sacral region, and, per rectum, marked the rate paid in the district by Friendly So- tenderness was elicited on the right side. After cieties to their Lodge Medical Officers. three weeks' illness the patient convalesced, and is now (d) Any Society or Institution in a State, if such apparently well. The superficial veins which normally Society or Institution has been declared by connect with the femoral are markedly enlarged, and the the Branch of the British Medical Association course of the blood in them is towards the thorax. Some in that State to he inimical to the interest of increased resistance could still he felt in the right iliac the profession, fossa. April 12, 1913. AUSTRALIAN MEDICAL JOURNAL. 993

The question was discussed as to what had happened cases in which exploration has been done unnecessarily; in the old thrombosed site, the general feeling being that and cases in which such treatment would have saved the suppuration had occurred, and by some means, lymphatic life of the patient. The question is essentially one of or otherwise, liver infection had taken place with the diagnosis. It is admitted that the "look and see" method most unusual termination in recovery. of diagnosis is sometimes justifiable, but it is a moot point Dr. Green showed a case of mediastinal gland enlarge- whether the surgeon is always the right person to decide ment in a girl aged ten, exhibiting lack of development, if there is sufficient evidence to warrant exploration. The interscapular dulness, bronchophony to the 4th dorsal modern physician is not averse from operative measures spine and marked impairment of air entry over the right to the extent supposed. In many instances he is more lobe, apparently due to pressure on the corresponding surgical than the surgeon in his opinion. Undoubtedly bronchus. Von Pirquet test was positive, and there was a there are many acute abdominal conditions which may be family history of tuberculosis, a brother being at present mistaken for affections amenable to surgical treatment. in a double Thomas splint for spinal mischief. Pleurisy, pneumonia, Henoch's purpura, haemorrhagic The minutes of the last ordinary meeting were read and colitis and the onset of coma in diabetes have all been confirmed. explored on account of intestinal symptoms suggestive of Dr. H. A. De Ravin read a paper on "Some Midwifery abdominal disease. The main symptoms and physical Experiences." signs on which a differential diagnosis can be based are The paper was discussed. vomiting, abdominal pain, constipation, the condition of Dr. Penfold spoke of the good results of morphia in the abdomen, the abdominal facies, collapse, taxaemia, eclampsia. He also was in favour of blood-letting in some pulse rate, respiration and body temperature. These were cases. considered in relation to the chief diseases, notably Dr. Green, in referring to some of Dr. De Ravin's state- appendicitis, intussusception, intestinal obstruction, ments, said he had seen bad rigor and shock following peritonitis, and simple colic. Special attention was uterine douching in septic cases. He thought a sound paid to Henoch's purpura, because of the liability to mis- could be passed through a soft spot in the uterine wall take it for intussusception and because intussusception without the surgeon feeling any resistance. In one may occur during its course. _Many diseases can be rapidly craniotomy he had done the cranial sutures were all ossi- excluded in the case of children, mainly on account of fied. The head was not particularly large. In this case their rarity, but it is necessary to bear them in mind- the mother became septic and anti-strepticoccic serum e.g., gastric crisis in tabes dorsalis, perforation of simple had been used with remarkably good effect. Dr. Green gastric or intestinal ulcer, acute pancreatitis„ cholecys- also spoke of eclamptic cases, of ruptured ectopics with titis and gall -stones, renal colic, embolism or thrombosis normal menstrual history, and the good effect of calcium of the mesenteric artery, and lead colic. Tuberculosis lactate given for a few weeks before confinement in pa- peritonitis may give rise to misleading symptoms of ob- tients who were known to be bleeders. struction due to bands or adhesions, the vomiting and Dr. Ffrost had had very satisfactory results from cal- constipation being really signs of the onset of meningitis. cium lactate. He mentioned a case of eclampsia he had Of the utmost impoo.tance in inflammatory affections is lately seen. He also thought it was not very uncommon the absence of abdominal movement and the presence of for a sound to pass through the uterine wall without bad abdominal rigidity and tenderness. The rigidity may be result, and quoted a case. the chief sign indicative of danger during the temporary Dr. Lyons had seen rigors produced by the uterine improvement due to the relief of tension in a case of ap- douche. pendicitis. In all cases of colic a dietetic cause must be Dr. Catford had not had any bad signs from douching. sought for, but the presence of such a factor is not always He always gave a lysol douche on third or fourth day, if the explanation. Many cases of appendicitis in the early there was a rise of temperature. With regard to eclamp- stage are ascribed by parents, and even doctors, to un- sia, Dr. Catford thought the worst cases were often those suitable food. A rise of temperature in such cases is of with a small amount of albumen, probably because those considerable assistance. Probably in all doubtful cases it with a large amount seek relief well before confinement. is to the advantage of the patient that both a physician and The question of the use of scopolamine and morphia surgeon should be called in consultation before deciding in labour pains was discussed. that exploration is essential. The model lodge agreement was read and discussed. Infections Following Tonsillotomy. Koplik ('The Amer. Journ. of the Med. Scs.," July, CURRENT LITERATURE. 1912) finds that there are three distinct forms of sepsis which may follow the surgical removal of the tonsil. Radium. 1. There is a type which runs an obscure fever for a Dominici communicated to the Academy of Medicine week or more without causing any endocarditic or other M. lesion. In these cases there is complete recovery. on February 4th, in his own name and in those of M. 2. ()heron and M. Rubens-Duval, the results of their investi- In this form there is a temperature and combined gations into the treatment by radium of tumours of with this a mild or malignant endocarditis. Those cases grave prognosis. The treatment has demonstrated with having a mild endocarditis recover except for the chronic great regularity the curability of deep angiomas, and also heart lesion. Those patients developing a malignant en- docarditis go on to a fatal issue. the frequent cure of superficial cancer. With regard to 3. deep cancers, radium was used with a purely palliative Finally there is a sepsis in which the infection is evi- aim, and its use was in most cases followed by a tem- dent. In this form there are severe destructive blood porary amelioration. In spite, however, of the faYourable changes and there may be profuse haemorrhagic ecchymo- results in some deep malignant tumours, still the authors tic areas on the surface of the skin, petechiae, haemor- rhages from the bowel, and areas or bronchopneumonia. think that the most advantageous field for the employ- ment of radium is as an accessory to proper operative measures. Sodium Citrate in Pneumonia. Weaver ("New Orleans Journal," September) points out Acute Abdomen in Children. that in pneumonia the following conditions are present: (Cautley, at the Harveian Society, delivered an opening (1) Obstruction to the circulation of blood through the address to a discussion. This abstract is from the "Me- hepatized lobe or lobules; (2) a somewhat high degree of dical Press and Circular," -larch 5.) viscosity and coagulability of the blood; (3) a diminished It hay be laid down as an axiom that the diag- alkalinity of the blood due to the rapid disappearance of nosis of acute abdominal conditions necessitates sodium chloride and other salts. a alental inventory of all the symptoms present. Some- The obstructed circulation is partly due to the exudate times accurate diagnosis depends on exploratory opera- about the arterioles and capillaries, which compresses tion. It is possible to quote cases illustrative of the diffi- them and reduces their lumen, and partly to the viscosity culty in diagnosing intestinal colic from organic disease; of the blood, As a result the leucocytes and antitoxins '0 w,

994 AUSTRALIAN MEDICAL JOURNAL. April 12, 1913.

with which the blood is charged do not gain access to the time or making the test gave a negative reaction, a fact diseased tissues. This condition persists until the exu- of great importance in interpreting the result of the Was- date or coagulum in the hepatized area undergoes some sermann test during this stage of the disease change of its own through contraction of the fibrin, or so- Of the total 5,216 individuals tested in this laboratory, lution or digestion by the alexin in the blood-serum. 1,544 were patients suffering from diseases other than While viscosity and coagulability are not the same syphilis, of whom ten, or 0.6 per cent., gave a positive thing, they are closely related. Viscosity, due to internal result. Three of the positive cases were in patients suf- or molecular friction, when carried to its highest point is fering from tertian malarial fever, the blood being tested coagulation, although coagulation is an additional fermen- during the febrile stage; in all, the blood became negative tation process. Means that reduce viscosity also delay after the subsidence of the fever. In one case the diag- coagulation. Both conditions are probably dependent in nosis was undetermined fever and the blood became ne- part upon the action of the calcium salts in the serum, gative during convalescence. The exact nature of the dis- which action is inhibited by the alkaline citrates. ease could not be determined in this instance. In three , On the basis of the foregoing facts the author is led to cases the diagnosis was tuberculosis; the patients recover- emphasise the necessity that in pneumonia: (1) sodium ed under specific treatment. In two of the cases a his- chloride and possibly some other alkaline salts should be tory of syphilitic infection was afterward obtained, while supplied to the system in about the normal daily amount in the other such an infection could not be excluded. In of 240 grains, with the diet or otherwise if necessary; three cases diagnosed as pityriasis rosea a plus reaction (2) sodium citrate should be given in sufficient dosage was obtained, which disappeared on the subsidence of the to render the blood non-coagulable and of the greatest eruption Other cases of this disease have been tested with possible fluidity. He was enabled by clinical observations a negative result, but the occurrence of the reaction in to show clearly the advantages of administering this sub- this disease should be noted. stance. Sodium citrate does not disturb the gastric func- It is well known that in some cases of leprosy, and in tions or appetite, and might be given in doses of 1 dram many of yaws, the Wassermann test gives a positive re- uw every two hours if that much were considered necessary. action, but these conditions can be easily eliminated clini- It may be administered with a little citric acid or in cally and for this reason do not render the test less valu- lemonade. The proper dose for an adult was found to be able under ordinary conditions. A weak positive reaction from 30 to 40 grains every two hours. For children the has also been obtained in such diseases as carcinoma, dose should be calculated from the larger amount. Active sepsis and scarlet fever, but the number of cases reported catharsis should be established at the beginning of the is small; the reactions obtained were weak, and in most a treatment. latent luetic infection could not be excluded. I believe that a large percentage of positive results in non-syphilitic The Wassermann Test. cases is certain proof of imperfect technic in the applica- Craig (Journ A.M.A., Feb. 22, 1913) writes on a basis tion of the Wassermann test or a wrong interpretation of of 10,000 tests made in the American'Army Laboratory at the results obtained. These reports must be viewed with Washington. suspicion. The conclusions regarding the interpretation of the If the diseases in which the Wassermann complement- Wassermann test given in this paper are derived from fixation test has occasionally been found positive can be the study of 10,000 tests made in the Army Laboratory in excluded a double-plus reaction is sufficient to enable one Washington. The total number of individuals tested has to diagnose the presence of syphilis. Under such condi- been 5,216, while 4,784 re-examinations were made, gene- tions, I consider the test absolutely specific, whether rally as a control of treatment. Of the 5,216 individuals symptoms of the disease are present or not and whether tested, 2,905 gave a positive reaction and 2,306 a negative there is or is not a history of infection. reaction. Of the total number, 3,516 were patients in Under the same conditions, and with a history of infec- whom the clinical diagnosis was syphilis or in which tion or the presence of clinical symptoms, a plus reaction there was a clear history of infection (this includes latent should also be interpreted as diagnostic of syphilis. cases) ; 1,544 were patients in whom the clinical symp- A diagnosis of syphilis should never be made on the !In toms or diagnosis were of some other disease; while 156 presence of a plus-minus reaction alone. Many normal were normal individuals in whom the test was made dur- individuals will give a plus -minus reaction at times and ing research work. therefore such a reaction cannot be considered as having All cases have been considered as primary that have any more value than a negative reaction, in the absence presented the initial lesion or that were tested before the of a history or symptoms. development of secondary symptoms. Of 654 primary cases, A single negative reaction is of no value in excluding 580, or 89.4 per cent., gave a positive result. It may there- syphilis. Only when such a reaction is obtained on re- fore be stated that about 10 per cent. of primary cases peated examinations for at least a year after cessation of do not give a positive Wassermann test. Table 2 gives treatment can it be considered as evidence of the absence the character of the reaction in the primary stage in 483 of the disease, and a luetin test should be made to cor- cases arranged according to the number of weeks since roborate the Wassermann result. the appearance of the intial lesion. In the interpretation of a negative result the history Of 1,434 cases presenting active secondary symptoms of of the patient, the presence of symptoms and the amount syphilis, 1,372, or 95.6 per cent., gave a positive reaction. of previous specific treatment must all be carefully con- In 4.4 . per cent. the reaction was negative and in many sidered. of these cases the test was repeated several times. There- fore, it must be admitted that some patients presenting active symptoms of the secondary stage of syphilis do not develop a positive Wassermann reaction, and in my ex- perience practically 5 per cent. of the secondary cases f300t15. have biven a negative result. This small percentage proves the great value of the test in the diagnosis of Lectures on Diseases of Children. Robert Hutchison, syphilis. M.D., F.R.C.P. Lond.: Edward Arnold; Of 465 patients presenting symptoms of the tertiary 3rd edition. stage of syphilis, 404, or 86.8 per cent., gave a positive re- Dr. Hutchison's lectures as presented in book form have action. The pecentage of positive results obtained in this long been a popular text-book, and the present edition stage of syphilis by different observers has varied greatly, enhances their value, as it contains six new chapters owing largely to the effect of previous treatment on the and has been generally revised. The work is a complete reaction. Many of our patients had received mercurial introductory study to the diseases of children and dis- treatment but generally in an intermittent manner, and it ease as encountered in childhood, while the colloquial style is probable that such treatment did not interfere greatly renders the text doubly attractive. The book is worthy of with the reaction. a place among the best short text-books in the language, Our results show that practically 15 per cent. of cases and general practitioners may read it with pleasure and of tertiary syphilis which presented symptoms at the profit. \ hril 12, 1913. AUSTRALIAN MEDICAL JOURNAL. 995

C. Mansell Moulliu. Loud.: H. article I am glad to see that she refers to the fact. that 'l'he Biology of Tumours. and, K. Lewis. the whole education of these children is utilitarian, unless under certain circumstances, no time is wasted This is a small publication of 39 pages of the Bradshaw over education in the ordinary sense of the three It's. (The lecture for 1912, delivered at the Royal College of Sur- underlining is geons. The author discusses minutely the fundamental mine.) principles underlying the origin of tumors, and, while he I am likewise glad to see that the colony system of promulgates no new theory, he attempts to correlate the segregation the defective is the one most approved. This existing theories of origin and aetiology, such as those is the system we require here, rather than the carrying based on age, heredity, chronic irritation, embryonic on of schools in centres of population. Anyone who has rests, etc., as all parts of one great disturbance—a dis- intimate acquaintance with the subject will not afford turbance of the "driving force," whatever that may be, that much countenance to the latter proposal. It should be directs development and controls growth. noted that no amount of education will ever enable de- fectives to engage on equal terms with their fellow-man He looks on the whole question as an interference with in the battle of life. the power of hereditary transmission which has beecc evolved in the course of ages to control the differentia- May I refer to an aspect of this subject which, perhaps, at tion of tissues, and to establish mutual relationship in the first sight may not be readily recognised. In a country such as this, it is a sad reflection on the upbringing of numbers development of contiguous cells. of our youths—a sad reflection on the training of our His efforts bring us no nearer to a solution of this schools—a sad reflection on the industrial problems—a perplexed problem, nor do they render any more hopeful sad reflection on our laws, which have made such things the prospect of finding a cure; but they help to show in possible, to find, as we do, numbers of boys and young what direction future efforts of research should be prose- men standing idly at street corners. The means of plea- cuted. sure, of excitement, of amusement are so varied and so The book is written in a simple, lucid style that it is numerous, and the tendency of such individuals leaning the exception to find in works on pathological subjects. rather to them than to honest employment, make us won- A.S.T. der by what means such desires are gratified. Numbers of young people appear before the children's courts, or the courts of petty sessions, charged with criminal offences. CORRESPONDENCE. under such conditions is there much hope for the future? With different methods the answer may be given in the Secret Remedies. affirmative. Let us adopt a different system in our schools (To the Editor of "The Australian Medical Journal.") (where much of the present work will not in after life be of any service to 50 per cent. of the scholars) ; on leaving Sir,—In the leader `The Test of Time," in your issue of school let us ensure that they are given opportunities, February 22nd, 1913, you speak of the somewhat unenviable yes, compelled to follow some useful trade or occupation; notoriety for the discovery of "cures" Germany is ac- let us enforce advice, and administer punishment on the quiring, and you complain of Dr. Friedmann's remedy parents themselves, because, as Henderson points out, being still secret. That reminds me of an episode in con- their own negligence or vice may be the primary cause of nection with the diphtheria antitoxins. At the time this the offspring's evil actions. Carry out these ideas pru- remedy had just been found and tested, a German daily, dently, thoroughly, setting aside the fulminations of this "Berliner Tageblatt," in severe ternis condemned the side or that, and the next generation will be found a much secrecy kept at the time and demanded Behring should more contented, a much more healthy, and a much more publish all about his remedy, etc. Thereupon Behring vigorous people.Gentlemen, ours is a young nation: ne- published a defence in a medical weekly, "Deutsche Me- glect of primary conditions may mean disaster. As mem- dicinishe Worhensehrip," pointing out that the investiga- bers of a noble profession, can we afford to allow this; tions leading to the discovery involved him in heavy can we legitimately ignore the writing on the wall, which financial debt, and asking who was to compensate him, tells us in plain and unmistakable language that our pre- and, further, pointing out that it meant suicide if a man sent methods are wrong, a reflection on ourselves, the in this position with a family—Behring had recently mar- guardians of the public welfare? Let us endeavour to ried and become a father, if my memory serves me right— educate public opinion to the absolute necessity of minim- acted in accordance with the traditional demand. Of ising present dangers, if we cannot at once get rid of them, course, I do not remember the whole of the arguments and by such means not only shall we be doing what our brought forward. But I do remember the article deeply pression demands from us, but we shall have the pleasure impressed me and caused me to doubt the rightfulness of of diminishing the numbers of the criminal classes, and the tradition—charity begins at home. likewise the frequency with which, nowadays, is seen As you mention tuberculin, saying that it was only the mental delinquent, the class to which my remarks have pressure of public opinion that deterred the German Go- been principally directed. vernment of the day from making tuberculin a monopoly, it may interest you that at the time there was among Unfortunately we are not all agreed on the necessity the medical profession and elsewhere in Germany a for this means of disposal, but, in support of my view rumour—and I think it was more than a rumour—in cir- (although experience is the best teacher), may I quote culation to the effect that Koch received a million mark- from an article (which was shown to me by the chairman i.e., 1:50,000—from the German (or Prussian) Government of this meeting, and which 1 have read with a great deal for the discovery of the tuberculin.—Yours, etc., of interest) to the following effect?:—"Every industrial Brisbane. P. HEYMANN. school, reformatory, and prison has a percentage of de- fectives as in this country, and money is simply wasted on this class, front the point of view of reform. . . The Feeble-minded. Again: "The problem of three institutions (which are (To the Editor of "The Australian Medical Journal.") named) are much the sanie as at Waverley—principally Sir,—The following was not included in my remarks of the difficulty of permanently retaining the adult defective the 19th inst., as I had been asked to speak only on —and every superintendent is unanimous in condemning "Mental Delinquents":— the discharge of these cases unless they will be very As to what the accommodation should be for the care of carefully looked after outside. Disaster is particularly apt . mental defectives, I would refer you to an admirable to occur in the case of the high-grade defective, whose article by Miss Muirhead, pathologist to the .Morningside excellent training still further masks a mental condition Asylum, in Edinburgh, and which appears in the "Journal which is already so deceptive to the general public. Dr. of Mental Science" for January last, giving her views as Barr, the able superintendent of Elwyn, says that less than to what is being done at some institutions in America for 5 per cent. of discharged cases do any good. The control the class under consideration. The point about it is that of the defective delinquent among the simple feeble-minded it does not contain one single recommendation which can- is another constant difficulty."—Yours, etc., not equally be adopted here, and which was carried out J, A, O'BRIEN, on a somewhat similar basis some years ago. In thQ Treasury, April 2nd, 996 AUSTRALIAN MEDICAL JOURNAL. April I2, ,1913.

UNIVERSITY PHYSIOLOGICAL LABORATORY. rtttfib Ifieòtcal ^^^octatton. Professor Osborne gratefully acknowledges the follow- VICTORIAN BRANCH. ing additional subscriptions in response to the appeal for

extending the laboratory accommodation and equipment:— Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. Secretary. Mr. Fred Bird .. .. .. . ..£10 o 0 Dr. David Grant .. .. . .. 10 0 0 Dr. Cowen .. .. .. .. 5 0 0 NOTICES. Dr. Norris . . .. .. 5 0 o Dr. Glen Knight .. .. 5 0 0 Dr. Ramsay Webb .. .. 5 0 0 Warning Notices. Dr. A. Black .. .. .. 5 0 0 Medical practitioners are asked, before applying for any Dr. T. Hodgson .. .. .. 5 5 0 appointment advertised by the United Friendly Societies Dr, Miller Johnson .. .. .. .. .. .. .. 5 0 0 of Invercargill, N.Z., to communicate in the first place Dr. Balcombe Quick .. .. .. .. .. .. .. 4 4 0 with the Secretary, British Medical Association, 26 Yarrow- The total amount definitely promised is now £ 460. Many street, Invercargill; or H. E. Gibbs, Secretary B.M.A., Box others have signified their readiness to help, and it is 156, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; hoped that this may be counted upon to bring the total or the Secretary, B.M.A., Melbourne, Vic.; or the Secre- so far to £ 600. The minimum sum of £ 800 is urgently tary, B.M.A., 429 Strand, London. wanted. Court Sherwood and A. O. Foresters Launceston. Medical men are advised to communicate with Dr. S. W.

Ferguson before applying for positions advertised by Bullfinch Medical GENERAL. Fund, W.A.

For Paris, in the 14 years (1880 to 1893 inclusive) pre- VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday

ceding the introduction of antidiphtheritic serum therapy, in month.

the mean annual mortality from diphtheria was 1721 r Clinical Meeting 3rd Wednesday deaths, with a maximum of 2244 in 1882, and a minimum in month. of 1266 in 1890. In the 15 years subsequent to the intro-

duction of serum therapy the annual mean was 348 deaths, PEDIATRIC SOCIETY.—Second Wednesday in month. with a maximum of 736 in 1901 and a minimum of 174 in

1906. EYE & EAR SECTION.-4th Tuesday in Month.

Appendicitis was the cause of a marked increase of MELBOURNE HOSPITAL CLINIC. IL SOCIETY.-4th Fri- deaths in Prussia in 1911. There died of this disease 2,547 day in the Month.

persons, as compared with 2,220 in 1910 and 2,128 in 1909.

The increase amounted to 327, or 14.7 per cent., while

in 1910 an increase of only 92, or 4.3 per cent. was noted. Telephone 1434 Central.

The age between 5 to 25 years is represented with special

frequency among the mortality statistics. While among

all the deceased in 1911, only 1.46 per cent. were between the ages of 10 and 15 years, among those who died of ap- EDITORÍAL NOTICES.

pendicitis 10.72 per cent. were of these ages. The same is

true of those who died between 15 and 20 years of age. The It is particularly requested that all literary matter, books percentage of all deaths in this age is 2.37, while deaths for review, etc., be addressed to the Editor, Dr. Alex. caused by apuendicitis amount to 10.29 per cent. On the Lewers, 65 Collins-street, Melbourne. other hand, in the period between 60 and 70 years the All business percentage of all deaths is 11.30; and 6.16 per cent. of communications and advertisement applica- tions should be addressed the Manager, "A.M. Journal," the deaths are caused by appendicitis;' in the period from Medical Hall, Brunswick-street, East Melbourne. 70 to 80 years the percentages are 12.21 and 4.20 respec- Single copies may be obtained from the Manager, at tively. the Medical Society Hall.

The new Sydney University Act makes some important innovations. Provision is made for the establishment of PERSONAL. evening "tutorial classes" in science, economics, ancient and modern history, and sociology, and probably no fea- ture of the new bill is so little understood. To many Dr. R, H. Morrison is progressing satisfactorily after minds the clause simply provides for evening classes for his recent operation for appendicitis. and will leave for undergraduates; to others it is merely another name for England at the end of April on a holiday trip of seven university extension lectures. In effect it is neither. The months' du ration. lecturer becomes actually a tutor, and each student will have a fixed purpose and continuity of effort. The Act Dr. F. J. Clendinnen and Mrs. Clendinnen will leave for provides for one exhibition or scholarship for every 500 England via Canada at the end of April. Dr. Clendinnen persons in the State between the ages of 17 and 20. Such will attend the International Medical Congress as a mem- exhibitioners are exempt from payment of matriculation,

ber of committee in the section of Radiology. tuition, or degree fees, and the exhibitions are tenable subject to satisfying the Senate as to progress and con- duct. Under what is called the limitation clause, 95 per Dr. C. Gordon Shaw has been appointed surgeon to out- cent. of these exhibitions are to be given for competition patients at St. Vincent's Hospital, Melbourne. among the secondary schools, whether State or private, provided the private school secures registration as effi- cient after inspection by a State officer. These students Dr. T. E. L. Lambert, who has been an inmate of Dr. are required to obtain a leaving certificate. showing that Moore's hospital, is recovering his health slowly: they have completed a four years' course in secondary education, and have satisfactorily passed a written ex- amination in such subjects and at such a standard as the Dr. E. T. Milligan's article on "The' Treatment of

Senate may determined. Five per cent. of the exhibitions Burns," which appeared in our January issue, is the sub- are reserved to what may be called adult students, who ject of an editorial reproduction in the "Lancet," March qualify for entrance to the University by matriculation. 8th. .\pi- il 19, 1913. AUSTRALIAN MEDICAL JOURNAL. 97

THE ANAESTHESIA OF NITROUS OXIDE The anaesthesia of nitrous oxide, the morphine AND ETHER WITH OXYGEN. combination and ether has quite a different status. The high resistance to vaso-motor reflexes afforded (E. H. EMRLEY, M.D., Melb.) by both ether and morphine is well recognised. (Hon. Anaesthetist, Melbourne Hospital; Lecturer Shock should be no greater from prolonged opera- in Anaesthetics, Melbourne University.) tions clone under this mixed anaesthesia than that under morphine and ether only. The diminished 'l'he low mortality-rate which the anaesthesia of liability to syncope is the same as that under nitrous oxide maintained for many years in short nitrous oxide. operations has, at intervals, led to the introd',.ct.ion As regards after-effects. In the recovery from of methods designed for its employment in pro- the anaesthesia of chloroform or ether the patient's longed operations. Hewitt did a considerable lot is always unhappy, and the nïoì-e of the anaes- amount of clinical research with nitrous oxide and thetic used the more severe and protracted is the oxygen. He concluded that its use was limited to unhappiness. by this nitrous oxide ether method short operations. Gardner, Flux, Hilliard, McCar- the unhappiness is always greatly lessened. the de- (lie, Coxon, Paterson and others have introduced gree of diminution being almost proportional to methods for more or less prolonged use in opera- the amount of ether used. This wakes the aim of tions, but none have met with general approval. the anaesthetist to be that of prolonging the period The disabilities which I found common to all of of nitrous oxide and oxygen administration and these methods that I have had the opportunity of delaying to supplement with ether as long as pos- trying were : the difficulty of maintaining adequate sible. In some instances it is possible to continue the anaesthesia, the failure to attain complete muscular nitrous oxide anaesthesia throughout without sup- relaxation, the extravagant use of the gas and the plementing with ether. Too mach zeal, however, the cumbersome apparatus required. should not be exercised in this direction since, for Crile, however, has created a great revival in its the reasons given. the light narcosis of nitrous use for long operations, and his methods have been oxide impedes the surgeon and increases shock. attended by greater success than those of Hewitt. Statistics available indicate that the pulmonary Hewitt, however, confined his efforts to the use of and bronchial after-effects are no more than those nitrous oxide and oxygen only, whereas Crile's me- from chloroform. thod is one of mixed narcosis—the well-known gas Not having a Teter apparatus, which is that and ether sequence to which has been added the chiefly used in America, morphine, scopolamine and atropine injection in I constructed several tem- order to permit nitrous oxide to be used instead of porary appliances, and used them with indifferent ether during a more or less great portion of the success. They failed chiefly in having too mach dead space. Finally, I found that the gas and ether administration. The oxygen is introduced to avoid apparatus of Hewitt answered quite satisfactorily, anoxaemia. Crile advocated nitrous oxide as the and that it had the least dead space. It is advisable best anaesthetic to combat surgical shock. to replace the gas-bag by the ordinary ether one, In this method none of the disabilities applying after having had a three-way tube inserted in its to nitrous oxide and oxygen obtain, except the outer end for letting in the gas and the oxygen. The cumbersome gas cylinders. Its adoption is ex- valve, which surmounts the wide bore Clover's in- tending in America, and its value is undergoing haler, admits of open expiration, or to-and-fro trial in England by Page and others. Time will breathing, into- the bag. All parts must be air- soon disclose the mortality-rate and enable a com- tight and close-fitting. The bag, of course, is made parison to be made with that of ether. With pro- of rubber. It can be detached without difficulty for per technique and the simplest apparatus there sterilising. The pedal valve to operate the gas and should be no difference. oxygen greatly facilitates manipulation. I did some investigation in Professor Osborne's The laboratory two and three years ago into the occur- manner of using this apparatus is the same ence of shock in nitrous oxide narcosis, some de- as that for the ordinary gas and ether sequence. A tails of which were given in my Address at the last hypodermic injection of morphine scopolamine and Australian Medical Congress. I was unable to atropine is given threequarters of an hour before confirm Crile's contention that nitrous oxide was commencing. The bag should be empty of air the best anaesthetic to combat surgical shock. before the gas isturned on, and the administra- Syncope certainly never occurred (because the tion of gas conducted with the expiration valve CO2 tension is raised by administering nitrous open. When eight to ten breaths of gas have been oxide in the closed method), but shock was ac- taken, the expiration valve is closed, the gas turned centuated, as was indicated by frequent vasocon- off and the ether turned on. The ether index is strictor reflexes. This occurrence of vaso-motor advanced and the induction completed in the ordi- reflexes was of a constancy unknown in the nary way. Spurts of oxygen are let into the bag anaesthesia of ether and was more frequent than in when signs' of anoxaemia begin to appear. When that of chloroform in which, however, the' reflex is the induction is complete, the bag should be emptied to allow the accumulated CO 2 to partly frequently vaso-dilator. The resulting shock in escape and to admit fresh nitrous oxide. This is nitrous oxide anaesthesia is not fully revealed until effected by Opening the expiration valve and then after the administration has ceased and the CO 2 closing tension in the blood has fallen to normal. it when the bag is empty and recharging. I his method of intermittent to-and-fro brea thing 998 AUSTRALIAN MEDICAL JOURNAL. April 19, 1913.

is, I think, preferable to the continuously open ex- ADMINISTRATION OF ETHER WITH THE piration method. It maintains better breathing and SHIELDS MASK. blood-pressure. The bag should be emptied and replenished about every two minutes, or as the in- FRANK L. DAVIES, M.B., B.S., Melb. creasing vigour of respiration indicates. When (Anaesthetist to St. Vincent's Hospital.) surgical anaesthesia has been induced the ether is In dealing with the method of administration of turned off and nitrous oxide alone used to main- anaesthetics used with the Shields mask, I shall go tain it. If the anaesthesia becomes too shallow, through the process from the beginning, considering which invariably happens sooner or later, the first of all the question of preliminary injections ether is turned on and the index rapidly turned to of morphia with or without atropine or other drugs. full, and so continued till surgical anaesthesia is I think in certain cases this may be of benefit. In eye operations, where the anaesthetist has to be a restored. This may be necessary two or three good deal out of the way of the surgeon, the patient tines during the earlier part of the operation, but may be kept sufficiently under by interrupted use is rarely required later. There is no necessity to of the mask, depending on the previous administra- overtax the breathing if the bag be regularly tion of morphine and the instillation of cocaine into emptied as already explained, and if anoxaemia be the eye, to keep him under all through. Again, in certain operations about neck—as goitre operations prevented by the judicious admission of oxygen to —atropine with or without morphia helps to limit the bag. the secretion of saliva, and, therefore, has a use. But Instead of the intermittent use of ether to restore excluding such special cases as these, the pre- surgical anaesthesia after a period of nitrous oxide liminary injection of different drugs is quite un- called for and may actually be of harmful influence, alone, the ether need not be turned off, but so that both during the operation and after its completion. the index is at one or sufficient with nitrous oxide The harmful effects during the operation are to maintain surgical anaesthesia throughout and shown in that the patient, instead of going properly discontinued later in the progress of the operation, under the anaesthetic, just goes to sleep, and the when it will be possible to maintain surgical breathing is slow and shallow, so that it is almost anaesthesia with the nitrous oxide alone. impossible to get enough anaesthetic inhaled to put the patient tinder ; it is only a painful stimulus as Except in cases of advanced cardio-vascular the incision commencing the operation, that will degeneration, and of defective lung ventilation, this cause him to begin to breathe up sufficiently to go method is suitable to all operations. It may be under, thus causing a good deal of delay. Of used to substitute ether with advantage in cases of course this is not always so, but sufficiently fre- bronchitis, phthisis, nephritis and diabetes, and for quent to make me very much prefer the absence brief operations in the exhausted. I have used it of morphia when giving an anaesthetic for a laparo- several times with satisfaction in the diabetic. As tomy. Hewitt mentions cases where the harmful with all methods of anaesthetising which involves effect of morphia was shown after the operation rebreathing, it is necessary to remember that sigh- was completed, and I can recall one case where ing respiration indicates overtax of its mechanism. symptoms which, fortunately, passed over, were put It is due to the heaping up of CO 2 when the ex- down to morphia by the surgeon. These came on after the patient was back in bed and I had left the piration valve has not been opened frequently hospital. I have always held the opinion that the enough. Slow deep breathing is invariably due to preliminary use of morphia should be in the hands tuo much morphine. of the surgeon and not the anaesthetist, because of its action continuing after the operation is over, Conclusions. shown especially by retarding the bowel action. This method of anaesthetisation appears to be as When it is left to me I always say `No' to its use. In different authorities we find various stages of safe as that of ether and much safer than that of anaesthesia, and the term "struggling stage" is of chloroform. everyday usage. It is very rare at the present clay Syncope is practically impossible, and the pro- to see three or four persons holding down a patient gress of shock is delayed by the morphine combina- who is being anaesthetised; and yet a few years back it was a daily performance. I think the modes tion and ether employed. Nitrous oxide alone does of. administration then in vogue had a good deal to not appear to me to assist in this respect. do with it. It is, anyway, a comparatively infre- The advantages which the method confers quent occurrence with the method I am about to above those of ether alone are, the elimination of a describe, but there is a definite stage in the induc- great deal of post-anaesthetic wretchedness and the tion noticeable by other signs than struggling, which may be called the stage of stimulation, for constancy of efficient blood oxygenation. These there is a general stimulation of the whole nervous advantages amply compensate the anaesthetist for apparatus—spinal, cerebral and medullary. It is the additional trouble and slight additional expense, shown by some stiffening of muscles and rigidities and they earn the gratitude of patient and nurses. which may, of cotfrse, go on to struggling—perhaps April 19, 1913. AUSTRALIAN MEDICAL JOURNAL. 004

some shouting out—'but certainly by an alteration impossible to give an overdose of the anaesthetic, of the respirations, which become deeper and more as the sponges would not hold sufficient frequent, and, simultaneous with this, an improved ether for this to come about. This doesn't mean that no circulatory condition. fatality can occur any more than a percentage dose This depends on action of anaesthetic on the of chloroform is absolutely safe. With excess of medullary centres. This stage can be definitely CO2 through imperfect aeration it is a different noted, and its occurrence is an important stage, as question; also, with the Shields mask an overdose Will be shown presently. I think when morphia has of A.C.E. could be given. been injected it has the effect of neutralising the I have read in an article appearing in the A.M. symptoms of this stage to a certain degree. Journal some time back that patients, when danger- Method of Using Shields Mask. ously tinder an anaesthetic — dilated pupils, etc.- Three bottles, coloured white, blue and brown, niay be quite rigid, and the surgeon wanting them are required for ether, A.C.E. and C.E. respectively. to be made deeper. I don't think such a state will Both sponges are wrung out of hot water. A.C.E. ever occur without the CO 2 element entering in. I mixture is dropped on to inner sponge, sparingly hold that relaxation must come about before the at first, so as to avoid too great pungency of vapour, limit of safety is passed provided the air-way is which would irritate respiratory tract; but as free and is kept free. Unfortunately, at times this quickly as possible the amount is increased. If is a state difficult to maintain. there is breath-holding or coughing the mask can In the management of the patient it is best to he tilted up a little off chin and some air let in, have no pillow, neither for head nor shoulders; the otherwise it should be closely applied to face. Be- head is turned to right ; mask and jaw are managed tween each dose of A.C.E. the lid of mask is closed with left hand tin(' the right is free for drop bottle. clown. This is continued until the stimulation As I have already suggested, the character of stage of which I have spoken is reached, and now breathing is the key to the whole situation. the lid is closed down more or less permanently IIewitt says respiratory phenomena depend on- and ether is poured freely on to outer sponge. e . Activity' of respiratory centres. I have men- From now onwards it is the aim to use ether en- tioned stage of stimulation, ‘vhich, if pushed, will tirely, but at the same time it may be necessary to be succeeded by stage of depression ; so we can tell supplement this with A.C.E., or even the C.E. mix- a good deal about the depth of anaesthesia from ture, on the inner sponge, and it is most effective character of breathing. when the mask is inverted and mixture is poured 2. Degree of patency of upper air passages. This on under surface of inner sponge. is quite under the control of anaesthetist, and it Several doctors, in discussing this method with applies to all methods. I find it difficult to impress me, have said they find a difficulty in getting the this as deeply on students as I should like. One patient under, or in keeping hint under, when using told nie another doctor had a way of giving open the Shields mask. That this may be the case I ether and not having to hold up the jaw. I replied fully realise, as it lias been my own experience. I if any methods he saw were preferable to what I remember that Dr. Shields once told me he had not was showing he had better adopt them; hut, at the seen anyone used to giving anaesthetics take so same time, nearly every case where difficulty long to get into this method. I know I always had occurred showed it first in some defective aeration a flannel mask with nie when I first used the through non- patency of air passages. I have heard a Shields mask and generally was using the flannel doctor remark he liked to get a good healthy snore. before the operation started. I have used the I certainly do not, and always try to avoid any noisy Shields method routinely for about five years now, breathing of any kind. I find majority require and I find that gradually T have been able to almost oral as well as nasal breathing. entirely discard the C.E. (2 to t), which may be 3. State of respiratory pomp. This, unfor- used in place of A.C.I. at commencement, and to tunately, is not so much under use far less A.C.E. during operation, relying almost our control. A case entirely on ether. coming under this heading I tried to anaesthetise last Monday, but, in spite of a clear air-way, he Condition of Patient. became progressively more cyanosed even at the When patient has settled down to anaesthetic, stage of active corneal reflexes. I may say he and the condition is a very satisfactory one—right to a woman dying from septicteniia are the only two the end of operations of between two or three cases I have come across where I was forced to hours' duration. The breathing is regular, quiet admit that anaesthetising was out of the question. and of good depth; colour is good, and there is In giving preference to open ether over closed entire absence of cyanosis, mucus or sweating. method, we may note:— Muscular relaxation is easily obtained, and it is It is claimed as an advantage for Clover's method surprising the amount of relaxation present with of ether administration there is a rise of blood- comparatively light anaesthesia, as shown by eye pressure; but is a rise of blood-pressure caused reflexes. Of course, close watching is required, as through a greater or lesser degree of asphyxia a a little less anaesthetic means the patient is rigid thing to be desired? I fail to recognise an advan- again; but this is not likely When anaesthetic is tage here. A normal supply of oxygen in inspired given up to the stage of a coming and going lid air and no excess of CO reflex. I think, with ether alone, after once getting 2 flutist be preferred to an atmosphere gradually being deprived of oxygen and patient under and a clear air-way, it would be CO2, as it is breathed over and over increased in 100i AUSTRALIAN MEDICAL JOURNAL. April 19, 1913. again. Experimentally these may be, but in daily mask, he writes: "I have never felt the ill-effects observation in the operating theatre I have failed of anaesthesia less, and to• have escaped my usual to note any disadvantage in the absence of this tongue-suture counts for a good deal." rise of blood-pressure. In a series of cases with I see there is another paper to consider the atti- Shields' mask, in which I noted the blood-pressure tude of the surgeon towards the anaesthetist, and before and at intervals during the operation, it was I feel that, in justice to those surgeons with whom found that the blood-pressure varied very little, the great bulk of my work is clone, I should say neither rise nor fall of any degree being noted; they have been considerate to a degree—always re- cyanosis produces venous congestion and swelling cognising a certain amount of give and take is ne- of veins at root of tongue, thus narrowing airway; cessary, and always prepared with their full share also, mucus is poured out, further narrowing the of give. air-way ; with narrowing of air-way there is in- creased cyanosis, hence a vicious circle. Sweating is more frequent and more profuse in REPORT OF THE SOUTH AUSTRALIAN closed than with open ether, and leads to chilling of COMMITTEE FOR THE FEEBLE-MINDED, body. 1913. Chloroform may be considered from- 1. Patient.—Ether is generally admitted to be '1'he South Australian Committee consisted of the safer than chloroform, the relative toxicity is 7 to I. following gentlemen :- The post-anaesthetic effects are no better with Sir Charles Goode, President of Minda, chairman. chloroform. The boundary lines between safe and Mr. A. Williams, Director of Education. dangerous zones merge into one another, more Mr. T. H. Atkinson, Chairman Destitute Board. abruptly with chloroform, and there is less working Mr. T. Rhodes, President State Children's Coun- margin. cil. 2. Surgeon.—Those who prefer chloroform to 1)r. R. Pulleine, Hon. Sec. Royal Society, S.A. ether are fewer every year, and I am pleased we Dr. M. H. Downey, staff, Parkside Asylum. are to hear more of the surgeons' view of chloro- Dr. R. S. Rogers, State representative. form presently. 'l'he last three gentlemen constituted a sub-com- 3. As an anaesthetist, I can say it is far less tiring mittee to which was deputed the task of securing ive ether, especially in a long or serious case ; statistical data. tot'in short ones it is of less account. Since its first meeting iii June, 1912, the com- Again, the A.C.E. induction in preference to ethyl mittee has to deplore the death of Mr. A. Williams. chloride. In early stages ethyl chloride is largely to whom it is deeply indebted for his great assist- used. I have used it very rarely, far too rarely, to ance in ' facilitating returns from the numerous be at all expert with it, but the reason is that what schools under his administration. I have seen of it doesn't commend its use to me. Memoranda formulated by the Central Commit- Its action is very rapid ; it hurries up things so tee in Melbourne were sent in this State to the that the border line of safety from danger must be head teachers of all public schools, to all our me- very abrupt. The frequent use of it and its trans- dical practitioners, to all institutions likely to ient effects don't counterbalance the objections I shelter "mental defectives," and to all known pri- find to its use. Quickness of induction is, of course, ate schools. a big thing, especially with nervous patients; but Returns did not at first come in as rapidly and the A.C.E. induction is not slow, it causes loss of spontaneously as had been hoped, but by steady consciousness quickly, but gives more time from and persistent effort the following respnose has then on up to surgical anaesthesia. It is a pleasing been obtained: method to the patient, as I have found out on vari- From about 800 public schools the response has ous occasions from those who have previously had been unanimous. other methods of anaesthesia. Almost all speak From 189 private schools 158 replies have been well of it as a pleasant induction. The after-effects received. are good, too; vomiting is frequently absent. From 228 medical practitioners 112 replies have come in. I am not claiming this method is everything to be From 6 institutions the returns are complete. desired, but I say it is the most satisfactory, from It will be seen that the response has been satis- all points of view, that I know. I shall not dwell on factory from all sources, except the medical pro- other points to be observed in anaesthesia, they are fession, from only 5o per cent. of which informa- familiar to you all ; but I have mentioned the breath_ tion was received. This, however, compares favor- ing, as I think it is the crux of the whole thing. ably with the experience of our fellow-workers in Another small point. Should it for any reason Victoria, who lament that they only received 49 be necessary to draw forwards the tongue, avoid replies from 824 medical men to whom they sent the tongue-forceps, if possible, and also the tongue- circulars. suture; a piece of gauze or towel between the Many of the returns from schools were accom- fingers will give a very good grip, and the tongue panied by explanatory references;, and the sub-com- can be kept out in this way. In a letter from a mittee has used its discretion in classifying such patient who had over three hours of the Shields results, occasionally placing the "defective" in a April 19, 1913. AUSTRALIAN MEDICAL JOURNAL. 1001

different class to that assigned him by the teacher. "Dumbness" without any reference to "deaf- Here 1,655 children were classed as "mentally ness" is not infrequently reported, and in one dull," but in a large proportion of cases the dul- specific instance the teacher says, "He is not deaf, ness was apparent rather than real, being often clue, but he cannot speak at all." in the judgment of the teacher, to some such acci- Of these defective children it is not uncommonly dental cause as "baci environment," "distance from stated that they are blind or "partially blind." school," "late entry at school," "irregular attend- With regard to other conditions, six cases of ance," "illness," and so on. What degree of intel- paralysis, six of chorea, four of deafness were ligence might have been displayed by such children reported. under more propitious circumstances is uncertain. The total number of children attending the 158 They therefore appear in a "doubtful" class to the schools from which information has been received number of 796. This leaves a balance of 859 chil- is not known, so that it is impossible to compare dren who may certainly be regarded as "mentally the proportion of defectives with those attending dull." public schools. In all 116 children were reported The lower grades of "defectives" are represented as being of subnormal intelligence and 31 doubtful. in our public schools thus:— Of the former, 84 were classified as "mentally dull,"

Feeble-minded . , . . 183 27 as "feeble-minded," and 5 as "imbecile." Imbecile .. .. .. .. .. .. .. 24 A total of 34.0 mental defectives was reported by Idiot .. .. .. .. .. .. .. 2 medical practitioners and from institutions. These included 31 "mentally dull," 98 "feeble-minded," 132 209 "imbecile" and 79 idiots. Of these it was thought Thus, out Of J5,000 State school children there are that about two-thirds (229) were to some degree at least 1,o68, or nearly 2 per cent., who would prob- educable and capable, therefore, of benefiting by ably benefit by special instruction. special training. Only to of the "mentally dull" It is difficult to estimate to what extent heredity were considered unworthy of such attention, the plays a part in the production of these unsatisfac- chief reason assigned being that they were "too tory children. There are numerous notes by teach- old." Sixty-three persons were returned as suffer- ers such as "parents cousins," "parents strange," ing from epilepsy in addition to their mental disa- "father insane," "mother weak-minded," etc., which bility and 33 from some form of paralysis. In some seem to indicate this as an important field for in- cases they were both epileptic and paralytic. vestigation. In one school the teacher reports that The chief institutions having custody of "men- one-eighth of his scholars are "mentally defective." tal defectives" in this State are, Parkside Asylum, He writes : "This district was settled in the early \linda, Destitute Asylum and State Children's De- clays by families, most of whom were exceedingly partment. In addition to the above, a few cases are ignorant and some of whom were mentally deficient to he found in Escourt House and in the South to a narked degree. One of them had as its head Australian Institution for the Blind, Deaf and a gipsy of whom it is still said, `he was never Dumb. Altogether 226 "mental defectives" in this known to sleep inside or to take his clothes off.' State are cared for in institutions. Mirada is about His descendants are numerous, as also are those of to erect a new wing, and in this way provision will another mentally defective family. A very large be made for 40 more cases in the near future. number of the children, 52 in reality, are in some The returns from all available sources show that way related to each other, and to one or other of there are at least 1,526 of these people scattered these two families. Alost of them have remained in throughout the State. This does not include the the district and have intermarried. It is not diffi- "doubtful cases" (which number 827), and unques- cult to show a distinct moral, physical and mental tionably falls short of the actual total, as there are weakness traceable throughout the families. When 116 doctors and 31 private schools from which no I came here some years ago, the older brothers and data have been received. Omitting the "mentally sisters of the present scholars were at school, and dull," there are still 55o persons who may be classi- things were worse than now. At one time I had fied as "feeble-minded." "imbecile" or "idiot." Of three children in attendance (from different homes), these 55o, there are 206 who are more or less satis- who are believed to have been incestuously begot- factorily guarded and cared for in institutions.* ten. In one family there are five children ranging This still leaves a residuum of 344 such persons in age from 13 to 30, all of whom were at school for either in private homes or uncareci for and a menace six years, yet not one can read and spell as well as to the national welfare. Many of these people an average first class child. . . . In several other marry and others breed without such a formality. families, single cases like each of the above are to In one such instance I was informed that a woman be found." had returned to an institution no less than eight There is a fair sprinkling of pure aboriginal chil- times in order to give birth to illegitimate off- dren in the returns and io half-caste children. spring. The extensions to Mincla will shortly ab- sorb a few of these unfortunates; but it is evident One cannot help being struck by the large num- that there will still be many for whom, in the public ber of associated speech defects, such as ,stammering interests, provision should he made. or those resulting from cleft palate or tongue-tie. =i iflniates of the Destitute Asylum cannot be de- Epilepsy was reported'as' tin associated condi- tained against their will. tion in II instances. (Tables are omitted.. Ed. "A.M.J."1 •

1002 AUSTRALIAN MEDICAL JOURNAL. April 19, 1913.

tor's office ; I crossed on the same vessel with him nuaraYían Orbital journal and talked with him, his assistant Dr. Benjamin, and his press-agent Mr. Hundt. I saw some of his - zyfh APRIL, 1913. patients at his office and met others and their friends at their hotels. . . . I was struck with DR. FRIEDMANN AND SECRECY. the superficial examinations and meagre histories kept. I would not have mentioned this had it not been corroborated by a number of physicians, pa- In the last number of the "Journal" a Brisbane tients and friends who had made visits to his correspondent expressed the idea that there was office. . . . It is hard for me to express in calm justification for the attitude adopted by Dr. Fried- language the impressions Dr. Friedmann, his clinic mann in keeping secret his alleged remedy for and his methods macle on nie. . . . His conduct tuberculosis. Of course no responsibility is accept- of secrecy, so far as the profession is concerned, ed for the views expressed by correspondents, but his appeal to the public press, his spectacular gift it seems desirable to point out that the opinion of his discovery to men of prominence, his trip to noted is in conflict with not merely the best tradi- America with a press-agent, in short his whole at- tions of the medical profession, but with common titude, have been such as to excite distrust." honesty of purpose. What the future of the remedy introduced by Dr. The possession of a medical qualification is Friedmann may be can only he pure speculation. It instituted and insisted upon by public opinion, not may be useless or it may be of value. But there for the benefit of the medical profession, but for need be no hesitation in concluding that the pre- the public protection. Its acquisition is a potential sent position adopted with regard to it by Dr. guarantee that no act of its possessor will be con- Friedmann is a departure from professional usage trary to the general approval of his compeers. and good faith, and, at the same time, exhibits a dis- That is the sole criterion upon which the public regard for the trust which, as a medical man, he may come to a conclusion as to the individual good has been given by the community. faith. It is quite permissible that an individual practitioner, or a section of practitioners, may dif- fer from their colleagues upon particular procedure, but the points of cleavage being available for ex- - Pote5 anb ComanentE4. amination, there is the safeguard of the opportunity for an independent judgment. The position be- comes very different when an individual refuses In view of the present alleged prevalence to make known the performance of a special thera- Epidemic of epidemic polio-myelitis, the account of peutic procedure. He at once breaks faith with the Paralysis an interesting case which was the subject of an action at law in America, is not un- general public and with the medical profession to interesting. A child of seven fell off a porch one Thurs- which he belongs. His duty to both is clear. It day evening and complained of pain in the hip. However, consists in making his method known to both. she was apparently well till Sunday evening, when she Public Opinion gives him the right to practise it in complained of pain. A physician who saw her the same evening diagnosed appendicitis. Operation was declined, the first place, and can only be guided as to the and at a consultation the diagnosis next day was typhoid validity of its claim by the verdict of the special fever. Twenty-one days later permanent paralysis of the body of trained judgment created to pronounce right hip and leg remained. The plaintiff contended that upon it. And it is obvious that no pronouncement this was due to injury unskilfully treated. T itle de- fendant successfully contended it was due to polio-myelitis, can be made upon what is not made known. It and that this was not recognisable at the outset, and may well be that he is right despite a public or pro- nothing that was done or left undone would have had any fessional hostility at the outset. Jenner had an effect, even though the diagnosis had been mistaken. uphill fight before vaccination was accepted, and It is sometimes forgotten that extensive paralysis may occur with very vague onset. Tn a case within our own Lister had no lack of opponents to the doctrine of knowledge, a young man applied for relief of a chronic the septic infection of wounds, but neither feared patch of eczema on the leg. A week later he returned publicity from the very beginning. walking with difficulty, and stated he had been laid up It may almost seem sacrilege to mention Dr. at his hotel with a slight attack of What he took to be influenza, but had not thought it worth while calling Friedmann in the company of two such august ex- medical advice, although he felt one leg weak. He was amples, but at the present moment it is impossible found to have extensive paralysis of the muscles of the to do him even justice, and for such a position he right thigh, which remained permanent. has only himself to blame. Nor is there any desire to do Dr. Friedmann any active injustice, in stating that such evidence as is available in the conduct of The report of the committee an Out- his own case is, to say the least, disquieting. The Out - patient patient Departments, appointed by the "Journal of the American Medical Association" for Reform King Edward's Hospital Fund far Lon- don, and published as a supplement to the March 15th publishes a letter from a Dr. Walker,.- "British Medical Journal" of February 22nd, is a valuable which contains sonic striking passages. He writes: document and bears evidence of extremely careful con- "I have just returned from Europe, where I spent duct and admirably judicial examination. One conclusion two months. I was alert to learn all I could about that seems extremely reasonable is the view that casualty departments at general hospitals are responsible for a Dr. Friedmann and his remedy. I questioned both good deal of the misuse of which complaint is made, and German and American medical men as to what they the report says:—"The use of the `casualty' department had seen or heard from others. I visited the doc- by persons not well-to-do, but able to pay or make pro- April 19, 1913. AUSTRALIAN MEDICAL JOURNAL. 1003

vision for the one or two treatments required, is not un- to either open ether or to chloroform, then back to open common. This is due to several causes:— (1) ether. This method had given him great satisfaction. Many of the cases are emergencies and must be Looking back to Sir James Y. Sinmpson's time, where Lord treated at once, without reference to financial cir- cum,stances. Lister learnt his chloroform, Simpson had three drugs, all of which were brought into vogue within four (2) The large numbers make inquiry difficult. years of one another. In 1844 nitrous oxide was used, in 1846 (3) It is often easier to treat cases outright than first sulphuric ether, and in 1847 chloroform. Simpson experi- to ascertain medically that they are not urgent, and mented with all of them, but particularly with sulphuric then to ascertain whether they are financially suit- ether and chloroform, and it was interesting to note that able. in his experiments with ether he gave ether by the open (4 There is a tendency to extend the casualty .depart- )nethad, almost as it was used to-day. He found he had ments to cases obviously not emergencies, either by to give a good deal of ether, however, and his results a loose definition of `casualty,' or by a desire on the were not satisfactory. He then devoted himself to part of junior medical officers to retain cases for practice, o•r chloroform, in which he became a firm believer. Dr. by a desire o.n the part of patients to Sutherland said he would like to read some extracts from avoid the inquiry systems in force in the out-patient department proper." Sir James Y. Simpson's lectures, showing his way of administering chloroform, and other points. He says:— The committee do not think that any system of external "Few men have had more practice in etheriing than sifting, as by only admitting patients on the certificate Dr. Snow, of London, and in full four-fifths of the cases in of practitioners, would be as efficient as the present ma- chinery possessed by most hospitals in the form of en- which he had administered the ether there was not the quiries made at the hospital. Another valuable and com- least flinch or groan during the cutting of the surgeon's knife. As a proof that such deep states of mon-sense recommendation is that "It is most important etherisation are not accompanied with danger, I may here that a general uniformity in the principles and methods of mention, though in the way of anticipation, that out of 39 out-patient administrationshould be adopted in all the surgical operations, nearly all serious ones, in which Dr. hospitals of London." That is at least a practical sug- Snow has exhibited ether at St. George's Hospital, two gestion that could still more readily apply to the hospitals of Melbourne. only of the patients died, viz., two on whom amputation of the thigh was performed, after they had been pre- viously reduced to an extremely weak and emaciated con- dition. Now two deaths in 39 hospital operations or one in 18, would certainly be regarded as a very satisfactory ^rttt^^j ,^Ï^btC^Y zwßOCtattOn. and favourable result under almost any circumstances, VICTORIAN BRANCH. and either with or without ether. Dr. Peacock, in his official reports of the Edinburgh Infirmary for 1842 and of the 1843, has published two tables showing the results ORDINARY MEETING, WEDNESDAY, 2nd. Principal operations in that institution from amputation and lithotomy down to the operation for harelip. The Discussion on Anaesthetics. tables include 150 cases in all, and 32 out of the 150 Dr. Tate Sutherland, in opening the discussion, said cases operated upon died, or about 1 in every 5. Ex- that they had four drugs which were in general use for cluding 57 cases of extirpation of tumours in various anaesthesia—nitrous oxide, ethyl chloride, ether, and parts, 32 in the 93 individuals on whom other operations chloroform. Nitrous oxide, he said, could be put out of were performed, or nearly 1 in every 3 died. count for ordinary use, as it was clumsy and heavy to "To produce the complete anaesthetic and soporific effects carry about, and could only be used in a hospital. It was of the chloroform, some conditions are necessary to be a question really of what method was the best. Each attended to. Without attending to these conditions you expert had his own particular method, and each method will have failures. (1) The chloroform vapor must al- was good. lt was a case of the expertness of the anaes- ways be exhibited as rapidly and in as full strength as thetist, which anaesthetic he preferred. Some prefer the possible, if you desire to have its first or exhilarating open ethyl chloride and ether, some prefer the closed stage done away with, and excluded, and you effect this method, some chloroform alone, and some induction by by giving the vapor so powerfully and speedily as to chloroform, and then going on to ether, some induction by apathise the patient at once. If you act otherwise and ether and going on to chloroform. He himself was brought give it in small or slow doses, you excite and rouse the up in a chloroform school, where chloroform was used, and patient in the same way as if nitrous oxide gas were nothing else. He had to admit, however, that although exhibited. (2) In order that the patient be thus brought he had only had one death, and that after a three hours' as speedily as possible under its full influence, the vapor operation, he had had some very great fights. The mar- should be allowed to pass into the air tubes by both the gin of safety between chloroform and danger was very mouth and nostrils, and hence all compression of the little compared with the margin between ether and dan- nostrils, etc., is to be avoided. (3) The vapor of chloro- ger. The time came when he had to teach himself to give form is about four times heavier than atmospheric air. closed ether, and finally, the open method. Dr. Davies' And hence, if the patient is placed on his back during its method had the disadvantage, in Dr. Sutherland's opinion, exhibition, it will by its mere gravitation, force itself in that it was inducing anaesthesia by chloroform. Call it larger quantities into the air passages than if he were A.C.E., if you will, he said, but you still have diluted erect or seated. As for the best instrument for exhibiting chloroform. This always incurred a certain amount of chloroform with these indications, the simple handker- clanger. It was much safer to induce anaesthesia by chief is far preferable to every means yet adopted. It is chloride of ether and ether, and then, if you wish, you infinitely preferable to any instrument I have yet seen, may go on to chloroform. There were certain cases, some of which merely exhibit it by the mouth, and not by however, where chloroform could be used apparently with the nostrils, in small and imperfect instead of full and immunity. Pregnant women took chloroform well without complete doses; and with instruments so constructed there any danger occurring, and also in old people with arterio- is no doubt whatever that failures and exciting effects sclerosis it could be given with safety, but as a rule would ever and anon occur. Besides, inhaling instru- chloroform was a dangerous drug to handle. The method ments frighten patients, whilst the handkerchief does not, he now employed was to begin with chloride and ether in and mental excitement of all kinds, from whispering and the closed inhaler. He might be considered old-fashioned, talking around the patient, is to be strictly avoided if he said, but still he had learnt that way, and had been possible. As to the quantity required to be applied to the very successful with that method, having had no trouble handkerchief, it has been stated that the average dose of a with his cases. He used three cubic centimetres of fluid drachm was generally sufficient to affect an adult, but chloride of ethyl in the bag, and the ether in the inhaler„ I have latterly seldom measured the quantity used. We turned on to zero. After half-a-dozen breaths of ethyl must judge by (its effects more than its quantity. The chloride, the ether was turned on, and in a few moments operator, gathering his handkerchief into a cup-like deep anaesthesia was obtained. If the patient *as shape in his hand, should wet freely the bottom of the breathing quietly, he went on with that; if not, he changed cup (so to speak), and if the patient is not affected in a 1004 AUSTRALIAN MEDICAL JOURNAL. April 19, 1 9 13.

minute or so, he should add a little more. It evaporates had had practically no experience of its use then, and he rapidly; and you must not yet your handkerchief, and thought it would be of interest again to show this Hoff- then delay for a minute or more in applying it. It must be man* open ether mask. When Dr. Wilkinson was in applied immediately. Not infrequently, when the patient London, he discussed this question with Dr. Buxton, the is just becoming insensible, he will withdraw his face, or finest anaesthetist he had ever seen, and particularly ex- forcibly push aside the handkerchief. If you then fail to pert in the use of the Vernon Harcourt Inhaler. Dr. reapply it to his face, and keep it there, you will be then Buxton said that it was the fashion nowadays to use open liable to leave him merely excited. But probably two or ether, and he used it. Dr. Wilkinson asked if he had any- three inhalations more will now render him quite in- thing to complain of as regards Clover's, and he said it sensible. The simplest test of its full value and perfect was as satisfactory a mask as one could get. Dr. Wilkin- effect is some noise or stertor in the respiration. Cease son always maintained that any trouble with Clover's it as soon as this is fully set in. But reapply it, of course, mask was due to one of two things, either not getting a from time to time, if it is wished to keep up its effects." proper air-way, or giving too much ether. Those who Seven years later Simpson says that: "Instead of using knew how to use Clover's inhaler, he felt sure, had always a folded towel or handkerchief or still more complex in- found it a most satisfactory apparatus, one in which the strument for exhibiting chloroform, it will be found that depth of anaesthesia could be regulated very readily. when its application is required in small and repeated Every now and then one had a patient who could not quantities, the concavity of the hand of the patient or breathe through the nose, and with the Hewitt's mouth- attendant is generally the simplest and safest and cer- gag shown, Dr. Wilkinson said he had no trouble in tainly the readiest and the least formidable instrument." getting a perfect air-way, and it was certainly one of the That, said Dr. Sutherland, was Simpson's method of giving most useful pieces of apparatus he knew of. He had been chloroform. In 1860, however, four years later still, he using open ether lately continuously. Some of the me- changed his ideas, then using a Skinner mask, on which thods of open ether were anything but open ether. When the chloroform was poured, drop by drop, and with much you come to putting several layers of gauze on a mask better results, and this method has been handed down to and jamming it down on a patient's face, and another the present day. towel on top, he thought the patient was getting a good Mr. Hamilton Russell, in opening his remarks, said that deal of 002, although that is not necessarily any detri- this subject interested him very much for this reason. He ment. He thought that Dr. Shields' mask was not exactly happened to be a pupil under Lord Lister at King's Col- an open ether mask. He thought that Hoffman's, however, lege. Lord Lister was not only the founder of antiseptic was an open ether mask. He had used it constantly surgery, but also a great authority on chloroform ad- during the past twelve months in all kinds of cases, and ministration. The result of Lord Lister's experience was very rarely indeed had he had any trouble. Occasionally, this. He used to state that he considered the administra- of course, one met with a case that was difficult to C,; tion of chloroform properly carried out was absolutely anaesthetic. It fitted the face beautifully and could be safe, and, on the whole, safer than ether. In spite of the breathed through easily. There was no difficulty what- opinions to the contrary that were held at the present ever in keeping it clean, and he had invariably got com- 61 plete anaesthesia. Patients did not complain in the early St time, DIr. Russell said that he had never seen any reason for doubting the truth of that dictum. He stages, there was no sense of suffocation. He thought 1 t regretted that from a variety of circumstances, chloroform there was a good deal in what Dr. Sutherland said, that a had been practically wiped out as an anaesthetic, rather man should become expert with his own method, modifying to the loss of the surgeon. Lord Lister's practice in this it according to the conditions of patients. He thought a respect was as .follows:—There was no anaesthetist giving good deal depended upon the anaesthetist rather than upon chloroform for him, and no other anaesthetic was used the apparatus. Regarding one or two points which had than chloroform, which was always given by one of his not been touched upon, and which, he thought, should be dressers, an unqualified man. Lord Lister had six brought under notice. One was the question of keeping chloroformists giving chloroform each year, each dresser the patient warm. One was constantly fighting people doing the work for two months. There was nobody at the in operating theatres with the way patients were brought chloroformist's elbow to look after him: that duty was in and put on a table;some seemed to think that the undertaken by Lord Lister himself, and he carried on this patient had no sense of heat or cold when under an work for something like 30 or 40 years without a death. anaesthetic. The whole of the abdomen, he said, was ex- Towards quite the end of his career he had one death, posed, and perhaps one or two cold towels put on top of being due to a palpable oversight. Surely, Mr. Russell the chest, and the patient might be under for an hour or said, this must prove that chloroform, properly admin- two, getting chilled continuously. If this was not the istered, must be an extraordinarily safe anaesthetic. It best way to produce surgical shock, he did not know what might naturally be asked, In what way did the ordinary was, and he thought many cases of bronchitis had been method fall short of the results obtained by Lord Lister? caused through neglecting to secure adequate warmth to In Mr. Russell's opinion, the greatest cause of bad results the patient's chest. He wished to draw attention to the in the administration of chloroform was the undue pro- matter, as it was,quite a common occurrence in operating longation at the second stage. If, for instance, one were theatres; more warmth should be applied to the patient's to represent the stages of chloroform by letters, and say body. Another point which he thought was not sufficiently that A represented the condition before the administration attended to was the keeping of the patient perfectly quiet began, B the intermediate stage, and C the condition of after morphia was given. Morphia was perhaps given an full anaesthesia ready for surgical operation: it was the hour before operation, and then the patient's friends were prolongation of the period B over a large number of min- allowed in to have a last talk, or something was being utes, 5, 10, 15, 20 minutes, as he had frequently seen, done by the nurse, and whatever benefit may be obtained which undoubtedly caused the patient to become exceed- as the result of the morphia was lost in this manner. The ingly bad, and introduced an element of grave danger. patient should be kept perfectly quiet after giving morphia, Death did not occur from an overdose of the anaesthetic: and silence should be maintained in the room during the it was the visible evidence of a profound effect upon the anaesthetisation; there should be no noise going on in the nervous system; but until the mystery of life was solved, room. At University College Hospital it was insisted upon the mystery of death was likely to present many features that absolute silence should be observed during anaes- that, in the present conditions of our knowledge, are thetisation. He thought these points should be insisted on, insoluble. Another striking feature of Lord Lister's me- and that it would lead to more satisfactory results. thod was that not only was there no fear of any sort of Dr. Trinca said that he would like to say a few words cardiac failure, and not only was the anaesthetist not about the question of the use of morphia and atropine, supposed to examine the heart or to feel the pulse, but with open ether. When he first started to use open ether, he was positively forbidden to do this under any circum- about three years ago, he did not use morphia and atro- stances before or during chloroform. In conclusion, Mr. pine, but later, following the fashion, he used it. Since Russell said that these were a few personal experiences then he had been comparing a series of cases given with in view of the paper just read. and without a preliminary injection of morphia and atro- Dr. J. F. Wilkinson said that a year ago he showed a *,Obtainable from H. R. Witting (agent for M. Schoerer mask which he happened to come across in his travels, He and C.o., of Berne), at Berners -street, Landon W. April 19, 1913. AUSTRALIAN MEDICAL JOURNAL. 1005

Pine. The advantages claimed by those who advocated of large doses. He did not see any reason for giving more morphia beforehand were:—(1) That it calmed the pa- than one-eighth of morphia and 1/150 atropine. He tient's frame of mind before operation; (2) that the thought the atropine reduced salivation. If he intended to amount of ether used during the operation was much give chloroform, he would not give morphia and atropine less; (3) that shock, vomiting and post-operative pain as a preliminary, but in open ether; he thought it was were minimised. He thought, however, that all these desirable. advantages claimed for morphia could be obtained with- Dr. B. Sutherland said there were just a few points he out using it, if the actual technique in the administration would like to mention in connection with the subject. of open ether were improved. He used a mask covered Anaesthesia was like everything else in medicine, a drug. with about ten layers of gauze and increased the concen- A good number of drugs acted excellently, and those from tration of vapour by covering the mask with a towel. Dr. which the best results were obtained were continued. It Wilkinson had objected to this procedure because he said was the saule with anaesthetics. His advice to anyone it increased the percentage 4f 002. According to Crile, who was going to give anaesthesia was to become pro- this would be a distinct advantage. Crile's latest theory ficient in one particular way; it did not matter whether it of the causation of 'shock is that it is due to "acapnia," or was open or closed ether, chloroform, or nitrous oxide. reduction of the CO2 percentage in the tissues, and, acting He quite agreed with Dr. Tate Sutherland that the Clover on this, he successfully treats after-shock by transfusion inhaler may be supplemented with a little atropine and with warm saline bubbling with CO2. The increase of could be used without any cyanosis and without much CO2 percentage is therefore a distinct advantage, and, mucus in the larynx at all. Personally, he used to use moreover, makes open ether given in this way approach the Clover's inhaler about three years ago, but 'when Dr. the closed method. Was it not better to give CO2 4- fresh Morton came back from America he 'suggested using the air than CO2 4- foul air, as obtains in the Clover inhaler? open mask, and Dr. Sutherland now used the ordinary Comparing the results of between 200 and 300 cases with- mask covered with about three layers of batiste, which out atropine and morphia with those given with prelim- did not absorb the moisture, and, consequently, one did inary morphia and atropine in small doses, he (Dr. not have to change the mask so frequently, which for Trinca) had found that there was very little difference in ordinary 'outside work was an advantage. Regarding the the two sets of cases. With regard to establishing a calm method ofanaesthesia, he himself certainly liked the frame of mind, this could be done by a few judicious re- open ether method supplemented by a small dose of marks to gain the patient's confidence—shock, salivation morphia. He personally used one-eighth morphia and and post-operative vomiting by inducing anaesthesia 1/150 atropine with the ether chloride on the open mask, slowly and by not giving too much ether. Since post- and after about ten or fifteen ccm., the patient was suffi- operative pain was not an invariable sequela to an opera- ciently under, and one quickly reached the surgical stage, tion, and since it was not always very severe if we gave less than five minutes. Dr. Davies mentioned that there morphia for that as a routine in many cases, we gave it was a difficulty to tell when the patient was in the anaes- unnecessarily. The greatest difficulty to overcome when thetic stage, with the preliminary dose of morphia. Dr. one did not use morphia and atropine, was salivation; but Sutherland did not think there was anydifficulty at all. this could be minimised by careful administration. He He had found it very valuable as a test to push his fingers had found atropine uncertain in 'action. There were one in behind the angle of the jaw; if thepatient would not or two grave contra-indications to the use of morphia. In stand incision, he would not stand that, and if he would some patients morphia produced troublesome apnoea, and, stand that, he would stand any incision through the skin. secondly, it may happen during anaesthesia that a sudden Dr. Davies had also mentioned about the mixing of anaes- attack of respiratory or cardiac failure occurs; and if the thetics, stating that he had several bottles, chloroform and patient's vitality has already been depressed by a pre- ether in one. Dr. Sutherland thought it was wise to keep liminary dose of morphia, efforts at resuscitation are not the ,anaesthetics 'apart as much as possible. One could apt to be as successful as if the collapse had occurred in a easily give chloroform and ether out of two bottles, and patient who had had no morphia beforehand. It seemed one did not know exactly what chemical action took place to be a custom, particularly in hospital practice, to give with these mixtures. Dr. Davies had also mentioned that morphia and atropine as a 'routine, irrespective of any it was almost impossible to give an overdose with the condition that might contra-indicate morphia. This, he open ether. In many instances Dr. Sutherland had tried thought, should not be done. He had come to the con- it himself, and after giving a patient open ether for about clusion that there really was no necessity to give morphia half an hour, by closing off the amount of air-way, he at any rate, and it was questionable whether atropine was found there was absolutely no difficulty. Regarding the always of use in preventing salivation. after-effects of ether. Some years ago he had the mis- Dr. Yule said that he would like to express his grati- fortune to have chloroform, and he thought it was lovely. tude to Dr. Wilkinson for mentioning these points. The Afterwards, however, he vomited for about a day and a requirement of warmth was the one they had all seen half. He had found that ether had a great advantage over violated frequently in the hospitals. That complete sil- chloroform in that the vomiting was not nearly so marked ence should be maintained during the administration was as with chlo ro form. There was a certain amount of also more important, and he hoped this would be remedied vomiting, but nothing like the same amount as with shortly at the Melbourne Hospital. The anaesthetising- chloroform. Mr. Russell mentioned that Lord Lister had room should not be made a thoroughfare. He thought atremendous number of eases anaesthetised with chloro- each method of anaesthesia had its own advantages. Their form without any fatal results. He thought that Lord old friend chloroform was unduly depreciated nowadays, Lister was very lucky in having only one death. One may but he did not think it would be wise for an inexperienced use it as few times, but sooner or later there would be man to use chloroform as a anaesthetic. It was routine trouble. He did not think, however, that a fatal :result wise for a man to know more than one method of anaes- would take place from an overdose of chloroform if thesia, as he had found a few cases where open ether had anaesthetist was 'attending to his patient. He personally not been sufficient to keep the patient under. For example, thought the danger with chloroform was in the preliminary in one or two cases of hæmorrhoids it had been necessary stage. to revert to the Clover. Its evils were mostly due to Dr. McArthur, from the surgical standpoint, said that it mal-administration. He thought there was no harm in did not matter to him in the slightest degree what method 'raising the blood-pressure a little with. CO2. The mask was adopted. He did not consider that for a moment. He s'hown by Dr. Wilkinson was certainly very useful, but he was only looking for the amount of experience and the had some objections to the Shields mask. It undoubtedly skill of the anaesthetist. He had, he thought, nearly was a mask which represented a semi-closed method. One every method given for him in private that had been gave A.C.E., too, for induction, which was practically described by previous speakers. He must say that he using chloroform at the most dangerous period, as it was found the morphia and atropine beneficial in small doses, during induction that trouble had arisen more often than as it reduced shock, and atropine reduced salivation. He at the end of operations. He did not see in what w:ay was very glad to hear Dr. Wilkinson thumping it in about either mask was better than the ordinary mask with ethyl keeping the patient warm. chloride and open ether. As to the use of morphia and Dr. Honman said that he would only speak in reference atropine, he agreed with speakers who condemned the use to chloroform in surgery. From Mr. Russell's remarks, it 1006 AUSTRALIAN MEDICAL JOURNAL. April 19, 1913.

would appear that the more ignorant the chloroformist was, the safer it was. If he (Dr. Honman) wanted chloro- form given, he chose the man with the most skill and the jßrtttO jilebtcar aogoctatton. VICTORIAN BRANCH. most experience. In his experience, the history of chloro- form was a history of very ghastly accidents, more so than Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. any other anaesthetic. If one took an expert, one felt Secretary. perfectly safe, but taking the average man, it was not an uncommon •thing to find an operation interrupted for a spell of artificial respiration. He thought in the hands of NOTICES. unskilled men chloroform had very few virtues and many vices. Dr. Taylor said that it seemed to him that the .anaes- EYl' AND HAIR sl.:C 'TUN. thetics of to-day were suffering from a multiplicity of The monthly meeting will be held at the Eye and Ear drugs as much as in the days of our forefathers. A Hospital on Tuesday, April 22nd, at 8.15 p.m. prescription containing 40 drugs was nothing very much 40 years 'agp. It was now quite a common occurrence to Dr. J. W. Barrett will give his impressions of British lead off with morphia, and atropine, and add chloroform, and Foreign Eye and Throat Clinics. ether, alcohol, and possibly during the course of the Several cases will be shown by members. operation infiltrate with cocain and dose the patient with oxygen. His protest particularly was the unnecessary Warning Notices. administration of atropine. It seemed to Dr. Taylor that this was adding one poison to another without any com- Medical practitioners are asked, before applying for any pensation in other ways. appointment advertised by the United Friendly Societies Mr. Syme said that he had had experience of all the of Invercargill, N.Z., to communicate in the first place methods of anaesthesia and of a great many anaesthetists, with the Secretary, British Medical Association, 26 Yarrow- and he thought that far more depended on the anaesthe- street, Invercargill; or H. E. Gibbs, Secretary B.M.A., Box tist than on the anaesthetic. Still there certainly was .a 156, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; difference in the methods of giving anaesthetics. His own or the Secretary, B.M.A., Melbourne, Vic.; or the Secre- personal experience was that in the days of chloroform tary, B.M.A., 429 Strand, London. one never did an operation without a great sense of Court Sherwood and A. O. Foresters Launceston. anxiety. As Dr. Honman said, it was a common thing to Wellington Mills, New Zealand. have to revert to artificial respiration during the course Medical men are advised to communicate with Dr. S. W. of the operation. As to the use of Clovers, there was very Ferguson before applying for positions advertised by much less anxiety to the surgeon, but in some respects it Bullfinch Medical Fund, W.A. was not so satisfactory. It used to be given in the early days with a great deal of cyanosis, very often a great deal VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday of struggling and rigidity. Since the introduction of open ether, the method of giving closed ether was much im- in month. proved. Apparently the anaesthetist had recognised that ff „ Clinical Meeting 3rd Wednesday the patient did not require to be suffocated with CO2. in month. Regarding the after-results, he was perfectly satisfied that with the open ether method there was far less discomfort to PEDIATRIC SOCIETY.—Second Wednesday in month. the patient afterwards, far less vomiting. With regard to the use of morphia and atropine, if the dose should ex- EYE & EAR SECTION.-4th Tuesday In Month. ceed 1/8 grain, he had seen what he believed to be troublesome results from its use, almost stoppage of MELBOURNE HOSPPPAL CLINICAL SOCIETY.-4th Fri- respiration, in some cases actual stoppage, requiring day in the Month. artificial respiration. Often, too, the patient'stongue was furred, and there was difficulty in getting the bowels to act. Personally, if he were asked whether the patient Telephone 1434 Central. should or should not have morphia., 'he would say no. He did not object to a small dose, however, and he would leave that to the anaesthetist, provided only a small dose EDITORIAL NOTICES. was given. Regarding atropine, he had not noticed much in the way of its after--effects, except, perhaps, in the way It is particularly requested that all literary matter, books of less secretion of mucous. There was no question for review, etc., be addressed to the Editor, Dr. Alex. that nowadays anaesthetics were given infinitely better Lewers, 65 Collins-street, Melbourne. than they used to be. Regarding nitrous oxide and oxygen, All business communications and advertisement applica- he saw this given in America, especially in Dr. Howard tions should be addressed the Manager, "A.M. Journal," Kelly's private hospital, and it was the most satisfactory Medical Hall, Brunswick-street, East Melbourne. method he had seen, but it required :a very complicated Single copies may be obtained from the Manager, at the and cumbrous 'apparatus, and required an expert also to Medical Society Hall. use it. It was quite satisfactory and safe, and could be given for .a long period. They were under the impression there that the shock was less with the nitrous oxide and thing, and if the anaesthetist was always on the look-out oxygen than with any other method. for this he would be prepared to act rightly—always re- Dr. 'Hornabrook said he felt he must answer Dr. Rus- move a wet mask when struggling (if any) was over. He sell's able address, in case there might be any gentleman himself was brought up in a chloroform school, and for present who might go away under the impression that years gave nothing else, and never had any grave diffi- chloroform was an anaesthetic which possessed many vir- culty. At the same time, one had to realise nowadays tues and few vices, instead of an anaesthetic of many vices that one did not prefer to give chloroform if one could and few virtues. use some other anaesthetic with equally good results. He Dr. J. Robert Lee said that he quite agreed with some thought in extra painful operations that chloroform was a of the speakers, that one should have more than one anaes- good anaesthetic, and tolerated in the presence of pain. thetic. As far as chloroform was concerned, he thought He had the greatest liking for ether chloride and the open the right way to give it was the continuous drop by drop ether sequence. He had never yet had any difficulty with method. Many of the so-called ghastly accidents with it, either when administering it or when operating. I-Ie chloroform were due to the way it was given, the way it also thought that it would help a great deal if, instead of was poured on, during the 'struggling stage" and the treating a patient as merely a "case," one were to quietly saturated mask left on during deep breathing. Above all reassure him. If one told the patient what to do, to things, he had told students that they should realise that breathe quietly and regularly, in his judgment, the patient any change of respiration almost invariably meant some- would take the anaesthetic better, Al,ril a(:), 1913. AUSTRALIAN MEDICAL JOURNAL. 1007

THE ADMINISTRATION OF TUBERCULIN free from all serum. 1 c.c. of S.B.E. contains 5 mgrm. of bacillary substance. For treatment only. IN PULMONARY TUBERCULOSIS. viii. Tuberculin Beraneck (T. Bk.). A mixture of equal parts of two compounds (a) a filtered culture of human tubercle bacilli in a medium free from albumose and not \V_AL'1'ER Sl"\I \1Ç)\S, Al.D., altered by heating, (b) an extract of the bacillary bodies in one per cent. of phosphoric acid. For treatment only. ix. Spengler's tuberculin. I.K. ( Immune bodies). This Tuberculin as a therapeutic agent has in the past is described as containing all the immune bodies that can had a chequered career, and in the English hos- be extracted from immune blood. I did not see it used. pitals at the present time there is a certain amount These preparations all have their advocates, and of diversity of opinion as to its value even amongst here it is advisable to give the comparative the leaders of the profession. Few of the right- strengths of those in common lise. By stand- thinking advocates for its use consider it to be the ardisation. T. and A.F. are placed un the ideal x -vcapon in our arnrantcntarium against tuber- market, so that same doses are equivalent and are culosis,' but by all it is still held to be the best held to be clinically much stronger than T.R., and provided its use is not indiscriminate and the ad- ILE., and SALE. Beraneck's tuberculin ('l'.hk.) is ministrator is mindful of the fact that he is em- a milder-acting tuberculin, and it is employed to ploying a powerful remedy, which may do a large surmount the initial difficulties of dosage, amount of harm to tlr, patient if wrongfully or carelessly administered. 'hhe active principle is not known, but it The object of this paper is to set out the modes is essential to be quite sure of the effect of administration at present in vogue in the London when tuberculin is administered to tubercu- schools. lous patients. Clinical experience shows that all tubercnlio, whether endoplasm or exotoxin, In the first place it is necessary to tabulate the is the same, and in the hands of careful administra- more common tuberculins. One may- be used to the tors the better known preparations all give similar exclusion of the others, or again, some physicians good results. 'l'he differences are of minor regard certain forms of greater value in different importance as, for instance, in tuberculin A.F. the classes of cases. The fact should ever be held in e xclusion of extraneous proteins gives security that mind that a tuberculous patient is continuotisly any untoward result is not due to a non-specific manufacturing auto-tuberculin in his own tissues. action. All "bovine" tuberculins are prepared in The following table is modified from the one in an analogous manner to the corresponding human use at the Brompton Hospital for Consumption, and tuberculins, the sole difference being that tubercle includes only tuberculin made from the human bacilli of a bovine strain are used. To designate type of bacillus :- that the preparation is bovine, the usual practice is to place P (Perlsucltt) in front of the designation i. Old Tuberculin (Tuberculinum Kochi). T. For diag- nosis and treatment. It consists of exotoxins and a certain of the "human" tuberculin, as, e.g., P.T., P.T.R., amount of endotoxins, and is the original broth concen- and P.L'.E. For dosage, T. and P.T. are regarded trated to one-tenth of its volume. as identical, and so on. ii. Tuberculin. T.R. Koch's new tuberculin. For treat- ment only. 1 c.c. of T.R. contains the active and insoluble The extract tuberculins T., T.O.A., A.F'. contain bacterial matter of 10 mgrm. of tubercle bacilli. the soluble exotoxins, whilst T.R. and B.E. are iii. New tuberculin bacillary emulsion (Tuberculin endoplasmnc bacterial vaccines. The absorption B.E.). For treatment only. 1 c.c. of B.E. contains 5 of tuberculin endoplasm is slow, thus the clinical mgrm. of bacillary substance. result is a Milder and more prolonged action, so iv. T.O.A. (Tuberculin Original Alt). For treatment that when the stage of large doses is reached only. It is the germ free filtrate which has not been con- greater care must be exercised to avoid accumula- centrated like (1). N.B. Deny's tuberculin B.F. (Bouillon tive action. Filtre) is prepared and used in the same way as T.O.A. v. Vacuum tuberculin. For treatment only. T.O.A. is So much for the therapeutic agent, but before a evaporated to one tenth its bulk at a low temperature and definite dose can be determined on, the patient's in partial vacuum. reaction to his autogenous tuberculin must be as- vi. Tuberculin A.F. (Koch's albumose free tuberculin). certained : that is, the case must be clinically ob- The tubercle bacilli of a human strain are cultivated in a served before tuberculin treatment is resorted to. special medium, consisting of inorganic salts and citrates. The practical clinical classification adopted for The sole nitrogenous constituent being asparagin. All ad- ditions of albumoses, peptones, and extractives from flesh cases of pulmonary tuberculosis is— and blood are omitted. The mode of employment conforms (i) Resting febrile. in all particulars with that of old tuberculin, with which it corresponds in respect of its açtive value. The advant- (2) Ambulant febrile; resting afebrile. age of A.F. over old tuberculin consists in the strictly specific character of the reactions induced by it, and that (3) Ambulant afebrile. anaphylactic symptoms are excluded in consequence of the absence of non-specific proteins. In (t) the immunity processes are'feeble, and Un- vii. Tuberculosis sero-vaccine. Emulsion of sensitised less the case mends the condition is incompatible tubercle bacilli (S.B.E.). It is the same as B.E. (No. iii.) with life. The indications for treatment are abso- save that the bacilli have been previously treated with a lute rest as strict as in a severe case of typhoid serum containing tuberculin antigens, and then washed fever. It is hardly conceivable that advanced 1008 AUSTRALIAN MEDICAL JOURNAL. April 26, 1913.

cases of this type can be benefited by tuberculin. For Treatment. A few cases of acute disease in the early stages have apparently benefited by small doses of tuber- 1.-Scheme for the use of Old Tuberculin:- culin. T.R. is the best form to use in doses from x:000m c.c., .000003, .000006 .00001 to .Door cc. given every second or third day. .00001 c.c., .00003, .00006 Alt. die. The cases must be closely watched, and, if improve- .0001 c.c., .0002, .0003, .0005, .0007 ment does not early appear, the tuberculin treat- .001 c.c., .0015, .002, .003, .005, .007 ment must be stopped. Twice a .01 c.c., .015, .02, .03, .05, .07 Week. Cases belonging to class (2) may be converted by rest into class (3), but this, unfortunately, .1 c.c., .15, .25, .4, .6, .8, 1 (Onoe a week). is not always the case. To those that remain in The maximum close may be repeated several the second class small closes (.0000l to .000i), and times at increasing intervals. continued only for a short time may give satisfac- 2.-Scheme for the use of B.E. or T.R.:- tory results. T. R. or B.E. are the best forms. One must not lose sight of the fact that the fever may .00001 c.c., .00002, .00003, .00005, .00007 Alt. be clue to secondary bacterial infections; but fever .0001 c.c., .00015, .0002, .0003, .0005, .0007 die. fides not always indicate a secondary infection. On .001 c.c., .0015, .002, .003, .005, .007 the other hand. in cases with a normal temperature .01 c.c., .015, .02, .03, .05, .07 Twice a week there may be a secondary infection. In many .1 c.c., .12, .15, .2, .25, .3 cases, however. it may prove to he feasible to sup- port tuberculin treatment by specific treatment .4 c.c., .5, .6, .8 Once a directed against the other bacterial infection, LO c.c., 1.1, 1.2, 1.3, 1.4, 1.6, 1.8, 2 week With the final class-ambulant afebrile-liber- The maximum dose, 2 c.c., both for Bacillary ties can be taken, yet special care must still be hmulsion (B.E.) and for the new Tuberculin exercised. These patients are getting autogenous (T.R.) may be repeated several times at in- doses, but not in sufficient quantity to produce a creasing intervals. febrile reaction. They, nevertheless, have the dis- 3.--Scheme for the combined use of P.T.O.A., P.T. ease slowly progressing, and our aim is to render and T. it quiescent and, in as many cases as possible, to P.T.O.A.-.0025 c.c., .00 00 00 destroy the bacilli. 35, . 55, 0075, . 95, .0125, .02, .03, .04, .055, .075, .095, .12, In London three methods of administration are .2, .25, .3, .35, .45, .55, . 65, .7. adopted, and each of them has its advocates :-(a) Y.T.-.o1 c.c., .02, .03, .04, .05, .o6, .07, .o8, .o9, .1, Rapid tuberculin immunization. Dr. Camac Wil- .2, .3, .4, .5, .6, .7, .8. kinson applies this method to dispensary patients in all stages of tuberculosis. In some cases im- T.-.1 c.c., .15, .2, .3, .4, .5, ,7, .85, 1.0. provement resulted and the patient continued at Doses given twice a week, or at longer in- his employment. Other cases in the febrile stage tervals if reactions occur. lost their temperatures and in the end did not react 4.-Wright's Method.-.o00o25 c.c. to .00005 c.c., to large doses of old tuberculin, yet obviously were T.R. given at intervals of about a fortnight, going down hill, and physical examination revealed to keep the opsonic index raised. extension of the disease. For this method to be efficacious reactions must be produced-local, focal, In both these methods the last dose does not get and general-so that a large amount of trust on the to the lesion, but the receptors take up the tuber- patient's part must exist or else he will terminate culin and toleration results. There is not always the treatment of his own accord. immunity to tuberculosis, but there may be im- munity to tuberculin, and hence the absence of re- (b) Slow tuberculin immunization. The common action. It must be remembered that once a con- method in vogue at the Brompton and Mt. Vernon siderable amount of tolerance is established this hospitals, in both of which the great majority of the falls slowly, taking perhaps three months or more cases suffer from auto-toxic disease. The aim is to to reach its former level. In the case of Wright's gradually increase the doses of tuberculin, avoiding, method with small doses at longer intervals, toler- as far as possible, all febrile reactions until the ance is not established to any extent, and the in- patient can tolerate large doses (5 to 10 mg. B.E.) jections must continue till the body has thrown off and ceases to react to large doses of old tuber- the disease. At the two hospitals mentioned above culin. The full table of doses is printed below there is a certain amount of choosing of patients The Use of Tuberculin at Brompton Hospital. for indoor treatment, but the better results ob- For Diagnosis.-Old Tuberculin. tained by the slow as compared with the rapid Immunization method were very striking. 1 1 1 1 (c) The third method introduced by Wright at c.c. c.c. c.c. C.C. St. Mary's Hospital for the treatment of localised 5000 1000 200 100 tuberculosis aims at the production of a mild im- 1 munizing response as shown by the temperature chart and the opsonic index. Small doses (.000025 5 m.g 1 m g. 5 m.g. 10 m.g. to .00005 c.c. of T.R.) given at intervals of about a April 26, 1913, AUSTRALIAN MEDICAL JOURNAL. 1009

fortnight, and not increased so long as any effect is A PLEA FOR THE MORE CONSIDERATE produced on the temperature or index. Increase in TREATMENT OF PATIENT AND ANAES- the dose is in most cases extremely slow, and it is THETIST BY THE SURGEON. necessary as a rule to continue the treatment for some time, even after all symptoms have disappear- R. W. HORNABROOK, M.B., Adel.; M.R.C.S., ed—perhaps as long as two years altogether. Lond. Now as to the relative merits of these three me- (Hon. Anaesthetist, Melbourne Hospital.) thods (I quote Dr. A. C. Inman, pathologist to the Brompton Hospital) : "In strictly localised, espec- (Read before the Victorian Branch of British ially closed cases, I can see no theoretical or•prac- Medical Association.) tical objection to the treatment (c) by focal re- It is not my intention this evening to deal en- actions induced by injections of old tuberculin any tirely with my own personal experience, as I think more than I can to the treatment of superficial reference from the lips of other anaesthetists will tuberculous lesions by means of the Finsen light, be of greater service. The question of the lack of etc., nor to the treatment of other localised tuber- status of the anaesthetist and the treatment he so culous lesions by. means of Bier's passive intermit- often tent hyperaemia." receives from the surgeon, not wantonly, but I think very often from lack of thought, has been "The rapid immunization (a) with T.R. and B.F. the subject of considerable discussion in England until large closes are tolerated leads often to dis- during the past few years. I would recommend tinct rapid amelioration of the general condition. every surgeon and anaesthetist to read carefully the But I have not seen a single case in which the me- "II• :l•.l. ' of September 14th, 1912. The President thod can be said to have led to arrest; indeed it is of the Section on Anaesthetics, Dr. Dudley Bux- difficult to see how any extensive area of disease ton, made, amongst others, the following remarks can become healed in so short a time—three to four in his opening address at Liverpool months. For this reason, and seeing the treatment "We still labour under many disabilities while is individual, and that each close is allowed those privileges which should exist as our right are to have its effect, I prefer the method accorded only to individuals in token of recognition of a long course of new tuberculin (b), the closes of personal distinction." Speaking of the anaes- being regulated with reference to the temperature thetist having facilities granted to him of studying chart and general condition of the patient." his patient before giving the anaesthetic, he says: "It is a One might also add that nature's way is by a detriment alike to the patient and to the operator, as well as to the anaesthetist, that the prolonged gradual immunizing response in those latter cases that recover spontaneously. Occasionally should be divorced from personal relations with the public. The confidence of good results from large closes are seen, as, for ex- gained, the patient ample, in a case of slow chronic pulmonary disease enables the anaesthetist to bring about a acute pleurisy superadded sometimes is a turning more perfect anaesthesia to avoid risks and to adopt point for the better, more often, however, it is the the best and safest choice of his method." Later on reverse. he says : "'Technique with patience may be acquired, but the real knowledge essential to the greater The decision of those who have had considerable problems of anaesthesia require years of patience experience with tuberculin is that it offers advan- and experience and a whole-time service. I spoke tages over the simple hygienic-dietetic treatment. of our disabilities, may I refer to A greater proportion of cases lose , the tubercle one which stands in the forefront and seriously impedes the know- bacilli from their sputum. Immediate results are ledge of our art? It is the lack of status suffered better and obtained more rapidly, whilst the perma- by the anaesthetist and the inadequacy of his nent arrested cases are greater in number. These rewards." results hold in spite of the fact that sanatorium "It may be said that the speciality cases are a specially selected class, whilst tuber- of anaesthe- tics is too narrow for its being placed in associa- culin treatment embraces a wider and less hopeful tion with the wider subjects comprised in class of case. When possible, of course, all forms medi- of treatment are combined. cine. This statement cannot be accepted by those who are conversant with the subject, or who have In tuberculin treatment one has to `remember followed the advances macle during the past few that it is not the administration of a drug. Every decades. That these advances have not been greater single case is an experiment in active immunization is clue to no small measure to the fact that com- against the disease. The successful treatment has paratively few of the ablest students will submit to always been over a long period. the equivocal position in which the anaesthetist is A detail with reference to tuberculin is the cost. often placed, nor will they devote time, energy and In London, Koch's original tuberculin T. is sold at money for research in a subject which is only now emerging into the goodwill of the public. 6%d. per c.c., which is remarkably cheap; whereas to-day the more Happily new tuberculin T.R. costs 8s. 6d. per c.c. How- enlightened members of our pro- fession recognise the valuable aid which the scien- ever, T.R. is usually used in small doses. B.E. is tific anaesthetist can also inexpensive-10/d. per c.c. Bovine prepara- give, and so extend to him the same treatment as to others. who tions are more expensive..than those made from the their craft." are masters of human type of bacillus. Speaking on the subject of the advantages of the 1010 AUSTRALIAN MEDICAL JOURNAL. April 26, 1913. anaestheist seeing his patient prior to the opera- the Alfred and the St. Vincent's hospitals, the tion, Mr. Kirby Thomas, anaesthetist to the Birm- hon. anaesthetists are on the hon. staff with full ingham and Midland Hospital for Women, said : "A privileges ; in the case of the Melbourne Hospital, few weeks ago I mentioned to a practitioner whose however, there is a different tale : of the four anaes- patient I had been anaesthetising that this discus- thetists connected with this hospital, one is a full sion was going to take place, and that I thoroughly member of the staff, the other three are called believed in it. He became quite indignant, saying assistant anaesthetists, though their duties are that he knew his patient, that the surgeon had seen identically the sane as the gentlemen recognised as him and that they were quite competent to decide on the full staff,. in other words, they are not assist- whether he was a fit subject for an anaesthetic or ant anaesthetists at all, but full anaesthetists to the not. I attempted to smooth his ruffled feeling by surgeon with whom they work and attend the hos- explaining that I did not question his competency, pital on certain definite clays. Within the past few or that of the surgeon, but that there was some- weeks these gentlemen have requested the Mel- thing more in the administration of an anaesthetic bourne Hospital Committee to revise the position of than the mere question as to fitness or not of the the anaesthetists connected with the hospital and patient to take an anaesthetic. He seemed rather to place them on the hon. staff, with the right of struck with the idea, and I left him ruminating being present at meetings of the lion. staff, and thereon." voting on questions dealing with anaesthetics and Mr. Carter Braine, anaesthetist at the Charing their administrator ; they did not ask for the right Cross Hospital and St. Peter's Hospital, said that of voicing their opinions on other questions, and in during almost a quarter of a century's work as that, I think we must all agree, was a very anaesthetist he had only on two or three instances moderate one. been called upon to examine his patient before On page 648 of Hewitt and Robinson's hook of anaesthetising him. On several occasions other Anaesthetists and their Administration, published individuals had been called in to advise upon the at the end of 1912, appears the following remarks anaesthetic to be administered, but the anaesthetist under the heading "Anaesthetics in Hospitals":— himself, who had all the responsibility, had been "The governing bodies of most hospitals to which neglected. Again, it was frequently the practice of medical schools are attached are now fully alive to the operator or the general practitioner to adminis- the importance of having anaesthetics administered ter drugs before the administration, and not even to by men who have received proper instruction and acquaint the administrator of the fact, and only possess practical experience. Anaesthetists are at when the anaesthetist found his patient getting into last being treated as. equal in position to the other an alarming condition was he acquainted with the members of the staff." fact that the patient had been drugged previously. The public are. beginning to recognise that the The amount of morphine administered previous to administration of an anaesthetic is an important the anaesthetic was frequently excessive. part of the operation. The "Australasian Medical Turning now to the status of the anaesthetist in Gazette" of March 8th writes as follows :—"There this country. It is only necessary to remark that certainly seems considerable force in the arguments if you look up your Melbourne University Calen- used by the anaesthetists. it is only right that they dar and refer to the special departments connected should have a voice in the discussion of nutters with the medical course, that the fee for instruc- which especially concerned the administration of tion for each course payable by the students is £.1 anaesthetics, and we have no doubt that the hon. 1s., with the exception of the course on Anaesthe- staff will be prepared to grant the request of the tics, for which no fee is mentioned. This is, I think, anaesthetists." merely an ovet'sight, but it gives rise to the ques- Turning now to matters of more general interest, tion as to the collecting of these fees, and I cer- more consideration should he shown by some sur- tainly think it ought not to rest with the instruc- geons towards their patients and the anaesthetist. tors that the fees should he asked for and obtained Some gentlemen seem to have no idea of punctu- from the student direct. but should he included with ality—half hour or threequarters of an hour late in the fees for clinical instruction collected by the the tinge of starting an operation seems to be noth- University authorities. There is every reason to ing to them, they never appear to think of what believe that this course will be adopted. that extra half-hour or so must mean to the patient, The instructors in anaesthetics recognised by the in many cases it must be a perfect hell. Here we University are naturally anaesthetists connected have a patient, possibly a nervous woman who has with the various hospitals round Melbourne; these worked herself up, to be operated upon at, a certain medical gentlemen have the practical training of hour ; she is prepared, wheeled into the operating the students and fulfil an important work. To or anaesthetic room, and kept waiting for what carry out this work to the best advantage it is ne- must seem to her endless hours. Such treatment cessary that the teacher should have some status. is not good for the patient, it makes the anaesthe- I am sorry to say this is not the case in all the tist's work considerably more difficult and danger- hospitals having honorary anaesthetists, who are ous, and cannot possibly improve things for the also instructors in anaesthetics recognised by the surgeon. It throws out the whole of the ward staff Melbourne University. Of the three Melbourne in their work, and loses half or threequarters of an general hospitals, in the case of two of them, viz., hour, which can never fie regained in the day's \p 2 ril 6, 1 913. AUSTRALIAN MEDICAL JOURNAL. 1011

work. 1 have vivid recollections of one excellent 1/2o gr. morphia and 1/20o gr. atropine was given surgeon, who I cannot remember to have ever been an hour before a radical mastoid operation. 'Phe punctual in starting his work on hospital days; he surgeon to whom I referred above had. abandoned may on a few occasions have arrived up to time, morphia, because he had mishandled it. He had but if he did, he would almost certainly spend a two deaths from respiratory failure following on quarter of an hour or more talking and finishing a operation; but you cannot give an overdose of a cigar in the resident's room before proceeding to respiratory depressant and combine it with another the operating theatre; and yet that same surgeon respiratory depressant such as chloroform without is generally very punctual for his private cases. being liable to get into trouble, but that is not the On one occasion, after waiting an hour for a well- fault of the method, but the fault of the man who known surgeon, I walked out of the operating misuses it. A woman under normal circumstances theatre as he walked into it. He remarked that he may take a 1/6 gr. without any harm at all, but was ready to start, and I told him that if he was I combine it with an anaesthetic, and especially if was not, and that if he wanted the patient put under that anaesthetic is chloroform, and you have an- an anaesthetic he had better get someone else to do other condition of things altogether. I cannot im- it, that the least he could have done, if he found it press upon you, gentlemen, too strongly to keep to was impossible forhint not to be up to tine, was to the small doses of morphia in anaesthetic work. I have sent a telephone message to the hospital say- have either handled myself or had under observa- ing that he would be late, and not keep the patient, tion a few thousand cases in which morphia and nurses and anaesthetist waiting for an hour. That atropine have been used, and l am certain that the night I received a letter of apology from my friend, entire absence of trouble is due to insisting on the and he has been punctual since, or let the hospital small dose of morphia. We must remember mor- know if he would be delayed. Surgeons with any phia has three stages—stimulating, sedative, and military training are, as a rule, punctual, the great- depressant—and it does not require more than est offenders are amongst the civilian surgeons, ordinary common sense to see that the larger the especially some of those high up in the profession. close the more quickly are the two first stages past Of the anaesthetist not being asked to see his over, and we reach the third ; whereas in the small patient beforehand I have already spoken this even- dose we do not really get to a depressant stage, but ing. There is, however, one other matter, and that have a long-drawn stimulating stage, followed by a is the one of morphia before an operation. Very long-drawn sedative one. In cases suffering from recently a surgeon rang m e up and asked me could shock and requiring an emergency operation, the Ìdo some anaesthetic work for him on a certain small dose of morphia and atropine, if only given day. I said Yes, and that I would go up to the just before operation, is a distinct gain. Burroughs, hospital on my way home to see the patient, and \\'ellcome and Co. are now making up tablets of order the morphia and atropine. He said to nre, "I 1/12 gr. morphia and 1/15o gr. atropine, also 1/2o don't mind the atropine, but I don't like niy cases gr. morphia and 1 /2oo gr. atropine. having any morphia." I went and saw the patient, One other question, a very nervous young girl, and told the sister in and I have done. The sur- geon, in relating- his various successes, is very apt charge to give 1/12 gr. and 1/150 gr. atropine an to give a fair hour before operation, as she would not be a amount of credit to the physician for good case to handle in her nervous condition. After his diagnosia, or to take it on himself ; and quite the operation I told him the patient had been given right that it should be so; but he very rarely ever morphia and atropine, as I thought it was neces- thanks his anaesthetist, or gives him any credit, and yet he may possibly play as important a part sary and to her advantage, and that I also knew as the surgeon. why he slid not like morphia for his cases, that in Only within the past few months a patient at one of the large hospitals suffered from his private work his patients had been receiving pneumonia of 1/6 gr. morphia with 1/12o or 1/15o gr. atropine the right lung, and empyema, follow- ed by a large collection of fluid in the pericardial before operation. Now, gentlemen, this dose of sac; the 1/6 fr. morphia is quite unnecessarily large for a empyema was drained, but the patient was still in a very low and dangerous state, and it was patient, especially a female, and also especially if decided to open and drain his pericardium. He was any chloroform is used in the anaesthesia; 1/8 gr. seen by the anaesthetist, and 1/8 gr. morphia and morphia and 1/150 • gr. atropine is quite large 1/15o gr. atropine ordered. In the operating enough for any case, male or female, if given at the theatre the surgeon thought that it would be im- right time, viz., about an hour before the opera- possible for the patient to take a general anaesthe- tion. I never under any circumstances give more tic, and novocaine was injected; but when he got for male or female than 1/8 gr. morphia and 1/15o down on to the ribs the patient had considerable gr. atropine for any patient over twelve . years of pain. Chloroform was out of the question, ether age, and up to any age. For 8-12 years I give 1/12 might have irritated his already inflamed lungs, and gr. morphia and 1/15o gr..atropine for 32-8 an anaesthetic had to he used that would not irritate years I give 1-20 gr. morphia and 1/200 gr. atropine and could be rapidly eliminated; so the patient was and use the tablets, not the made-up hospital solu- kept in an analgesia stage with open ethyl chloride tion, they are more reliable and not so apt to be for nearly half an hour, 70 c.c. of chloride of ethyl mishandled by a careless nurse. The youngest being used, of which, of course, the patient received patient to whom I have riven morphia and atropine very little, as the towel was held tip as to allow free was a child of one year and months, to whom circulation of air. In this case the anaesthetist 1012 AUSTRALIAN MEDICAL JOURNAL. April 26, 1913.

helped very considerably towards the success of the of the blood-vessels of the body, a powerful and usually operation, yet when the notes of the case were slowed action of the heart, the tone of which was increased, contraction of bladder, uterus and bowel, and the pupil of written up in full from a medical and surgical the excised eye in the frog was dilated. The substance standpoint, no mention was made of the morphia producing these results was of a relatively simple nature, and atropine, or the dose used, or the use of open was soluble in water and dialysable, and was not destroyed chloride of ethyl. I am afraid, gentlemen, I have by repeated boiling, nor by long keeping in a dried state or in a sterilised condition. It was insoluble in alcohol spoken at length, but more could be said. I hope, or ether. Intravenous injection of pituitary extract ex- however, what has been said will lead to a more cited secretion in certain glands, such as the kidney, and considerable treatment of the patient and anaesthe- in the mammary gland during lactation; there was a tist by the surgeon, with mutual advantage. dilatation of the renal arteries, though the effect on the general arteries of the body was constriction. The sub- In view of the interest taken in anaesthetic work stance producing effects upon blood pressure, heart, and in Victoria, it would be a distinct gain to the pro- kidney was contained only in the posterior lobe, and it fession that a Society of Anaesthetists should be had been found in the cerebo-spinal fluid. According to formed to maintain the high standard of work and the observations of Ott, Scott, and Mackenzie the galac- tagogue hormone of the pituitary was also confinel ro the improve the status of the anaesthetist. The society posterior lobe, and it was assumed to be identical with formed in England has been a gain in this direction. that which caused the other effects upon blood-vessels, We are now drawing near to the time of the next heart, and kidney. The anterior lobe seemed related to Medical Congress, to be held in New Zealand early the general growth of the body, especially that of the skele- in 1914, and I note with regret that no special sec- ton; while the posterior, including the pars intermedia, probably promoted the contractility and increased the tone tion has been set aside for anaesthetists and their of plain muscular tissue.—Lancet. . work. It is not too late, however, and I hope to see the defect remedied. X-rays in Phthisis. Sir R. Douglas Powell declared that no one appreciated The Pituitary Body. X-ray work more than he did, and especially the ad- vances in technique. The use of X-rays in connection with At the Royal Medical Society Professor E. A. Schafer lung disease he understood to be to correct or confirm opened a discussion. He said that that body was present what was revealed by auscultation and percussion. Dr. in all vertebrates which had been examined, therefore it Jordan, in a published work on the subject, laid stress on must be an organ of considerable morphological interest. the presence of streaks of shadows in the X-ray picture Its development occurred as an extension of Rathke's leading from the bronchial glands, and enlargements of pouch, which was an invagination of the buccal ectoderm those glands, but, the speaker did not regard that as neces- towards the brain. This was met by a hollow downgrowth sarily evidence of active tubercle; he would not be con- from the thalamencephalon, and the combination of the tent unless tubercle bacilli were found in the sputum. The two into one organ formed the pituitary body. The gland bronchial glands he regarded as the dustbins of the bron- consisted of three parts: (1) pars anterior; (2) pars inter- chial tract; they collected the unconsidered trifles which media; and (3) pars nervosa. Usually it was separated might gather in the bronchial tubes and get into the lymph into two parts—the anterior and posterior lobes. Remark- streams, and their enlargement need not be held to mean able alterations occurred in the pituitary as the result of that they were tubercular. Dr. Jordan himself had found thyroidectomy, and similar changes seemed to result where tuberculous disease present in 33 per cent. of people who atrophy of the thyroid ensued. The alterations after thy- met with an accident when apparently healthy and died. roidectomy included:: (1) enlargement of the pituitary The bronchial glands were also the lethal chambers of body; (2) the presence of a colloid substances in the tubercle bacilli. Children, and sometimes adults, might vesicles in the pars anterior, and a great increase in that have the bronchial glands affected, but rarely primarily. of the pars intermedia; (3) a great increase in the number There was some danger of being obsessed by intrument re- of hyaline bodies in the pars intermedia and the pars cords; hence infinite care was needed in taking and in- nervosa. It was not easy to explain these changes physio- terpreting X-ray pictures. X-rays have helped in early logically, because the functions of the two glands were not days in deciding whether a case was one of phthisis or one identical, though both were probably connected with sexual of foreign body. From a simple judgment of shadows a development, for in the case of removal of either there healing fibrosis might be regarded as an extension of was a stunting of growth and sexual infantilism. More- disease. To sum up, he considered that X-rays were over, castration hail been observed by most to be followed valuable in the case of pulmonary tuberculosis in the by hypophysial hypertrophy. The greatest enlargement of sense that percussion and auscultation were valuable; the pituitary body was found in giants and acromegalics; but X-ray usefulness did not go beyond that. the skeleton of giants was characterised by a disproportion- ately large sella turcica. The physiology of the pituitary body had been investigated experimentally by methods As a memorial to the late Lord Lister, and as a means of of both removal and addition, the latter by administration perpetuating his memory in a way that it is hoped will of extracts of the gland, and by implantation. The evi- prove both interesting and instructive to every member of dence following removal was conflicting. Young animals the medical profession for all time to come, one of the wards in theRoyal Infirmary, Glasgow, in which he work- which survived extirpation had their growth retarded, ed out and first put into practice the principles of Anti- and their sexual activity remained undeveloped. But some septic Surgery, is to be reserved and utilised in the fol- observers stated that total removal was not fatal, death lowing way. One part of the ward is to be refurnished —when it occurred—having been due to the complications as it was in his time with such objects as it may be pos- of the operation. Mere injury to the pituitary might sible to acquire; while the other part is to be made into a cause marked polyuria, but it disappeared after a few days. museum for the exhibition of anything associated with the Possibly this was the explanation of the polyuria some- life and work of the great master. It is, therefore, asked times seen in association with fracture of the base of the that any who may have letters, pamphlets, books, or other skull. Feeding with fresh or dried gland substance was objects of direct personal association with Lister and his normally not attended with any obvious result, even in work will either present or loan them to the museum. Pro- growing animals. There was certainly no retardation of fessor John H. Teacher, M.D., hon. curator of the museum, growth, such as had been described. Attempts to graft the will be pleased to receive any objects addressed to him at organ had usually been unsuccessful. Saline extracts of the Royal Infirmary, Glasgow, Scotland. The names of all pituitary injected intravenously, had a marked effect upon donors or senders of objects are to be affixed to the all involuntary muscles; they caused constriction of most exhibits. April 26, 1913. AUSTRALIAN 'MEDICAL JOURNAL. 1013

one upon which to arrive at any working con- 2uotrarf au Orbital journal clusion. Hitherto the class of evidence adduced has 261h APRIL, 1913. been the production of family-trees showing "feeble- mindedness" in the offspring of feeble-minded parents. Allowing that here the objection may be EUGENIC EXTREMES. waived that there is no working definition, and that the compilation of such pedigrees must rest to a In the fourth Galton Laboratory lecture on very large extent on hearsay evidence, since no "National Eugenics" Dr. David Heron, as reported single observer could of his own knowledge attest in "The British Medical Journal," said : "The the mental capacity of a score of such descendants, cardinal principle of national eugenics was the dis- no amount of such pedigrees, by themselves, are of tinction between the right to live and the right to any value at all. They only begin to become intel- ligible when contrasted with the proportion of parenthood. National eugenics denied - to none the "feeble-mindedness" in the descendants resulting right to live, but it taught that there were certain from unions of normal, or presumably normal, per- classes to which the right to parenthood must be sons. And until such a comparison is made it is denied ; and in the care of the feeble-minded it de- futile to talk about the "right" to parenthood. clared without hesitation that their children were If the extreme eugenists will abandon the talk of better not born." This is an example of the loose "rights" and come down to the lower plane of thinking which put into mouth-filling phrases passes expediency, they will at once enlist a much wider current as good logic. If national eugenics "denies sympathy and further, the progress of the objects to none the right to live" (a very bombastic gra- they have at heart. Nobody will deny the ex- tuity, by the way), it is obvious that the feeble- pediency of making the best possible provision for minded possess that right. If, at the same time, the the care of the existing feeble-minded, and that feeble-minded are denied the "right to parenthood" such care should be something apart from a con- nection with the ordinary asylum accommodation. on the ground that their children may be feeble- Such provision is expedient both for the unfor- minded, it is equally obvious that the "right to tunates themselves and the comfort of the corn- live" is denied in anticipation, and the distinction munity. The expediency of placing a legal veto on classed as a cardinal principle becomes a distinction marriage with a view to preventing parenthood is without a difference. a matter upon which present evidence throws no The truth is that the question is not one of light. The legal unions of definitely feeble-minded "right" at all, but merely one of expediency. No- parents must be very infinitesimal in number. The body has the power to grant a "right" to live, and number of children born of out of wedlock to nor- it is doubtful whether such a phrase as the "right mal mothers by definitely feeble-minded fathers to parenthood" has any meaning that could he must be inconsiderable. There remains the fact agreed upon by any two individuals. The first that definitely feeble-minded mothers may, and do, hear children out of wedlock to all and sundry. But question that admits of discussion is, whether the until definite comparison is adduced between the presence of a certain proportion of "feeble-minded" number of feeble-minded persons so resulting, and persons in a community constitutes an appreciable the number resulting from average unions, is it drag upon social comfort, or retards the progress of expedient to insist upon all candidates for matri- the community towards a higher social develop- mony endeavouring to establish their right to par- ment. The next question that arises is whether enthood by medical, or any other, examination, the numbers of "feeble-minded" persons in any which, at best, could only pronounce a dubious community tends to increase proportionately or' forecast. irregularly, and whether such an increase is mainly Nothing that has been said is to be taken as a du-e to the sexual union of persons already feeble- want of sympathy either with the problem of the minded, or is a variation of the results of sexual feeble-minded or with that larger movement desig- unions in general. nated as Eugenics. The care and control of the feeble-minded is a question that admits of imme- The first question permits at once of an intel- diate ligent examination since, as Dr. Heron himself and practical measures. The danger is of says, the majority of feeble-minded persons are al- those practical measures becoming lost in the specu- lative regions of eugenics, or of being put forward ready under State care in some form or other. Their in such a light of legal compulsion as to numbers and the cost of their maintenance are mat- arouse antagonism at the very outset. - The day of prac- ters that might be approximately arrived at by any tical eugenics may come, but it will never arrive by statistician who was provided with a working de- the aid of acts of parliament. Neither will it be finition of the term "feeble-minded." The difficulty brought about by sweeping generalisations based is that no definition is forthcoming. But even in upon imperfect understanding. Its sponsors must its absence the figures of our charitable institutions be éducation and example/and the care of the would at least afford a basis of suggestion. feeble-minded admits of becoming a shining ex- ample if only it be handled in a dispassionate The second question is a much more difficult manner. 1014 AUSTRALIAN MEDICAL JOURNAL. April 26, 1913.

right side. Could not say froni x-ray whether there was ^rítt^^j ftleòtcaY attoctatton. a 7th rib or not, and could not feel a 7th rib. No tuber- VICTORIAN BRANCH. cular disease in family, but one child had pleurisy with

effusion and was tapped on several occasions, and another

No clinical evening was held. had a renal condition suggestive of tuberculosis. The mother thought the child had occasional trouble on swal-

lowing, but a bismuth meal was seen to pass down the MELBOURNE PEDIATRIC SOCIETY. gullet easily.

6. Dr. Stephens showed a boy, aged 13 years, who was The usual monthly meeting of the Pediatric Society was quite well up to nine months ago. Since then he gets held at the Children's Hospital on Wednesday, March 12th, tiredness and indefinite pain in back of thighs on walking the President, Dr. W. Kent Hughes, in the chair. short distances. He can only go about 100 yards or so, and Notes of cases shown:- then has to rest. Mother delicate, one child died of con- 1. Dr. Milligan showed a case for Dr. Cole of a boy, genital heart disease, otherwise nothing of note in family aged ten years, an only child, who was . apparently history. Neurological signs normal, nothing abnormal on alright till seven years of age. Since then he has be- rectal examination, blood-pressure 96 to 106, mm. Hg., come less bright. Ten months ago he was seized with a very deep physiological cupping of the eyes, variable sys- fit, and since then has had them' frequently. For three tolic cardiac murmur, no temperature, negative Wasser- months he has not taken any interest in .anything. There mann, negative von Pirquet. Suggestion of pigmentation is difficulty in walking, he will not speak, simply laughs about face and abdomen. The diagnosis was obscure. He and cries, is dirty in his habits. He has no headache, nor appeared to do well on adrenalin, but has relapsed. vomiting. His birth was preceded by four miscarriages. 7. Dr. Stephens showed a case of spastic paraplegia, with The father died at 44 with pneumonia. On examination, strabismus, in a girl child 19 months old. Chloroform reflexes normal; painful sensations can be appreciated; was used at her birth, but no instruments, so far as the fundi normal; no Babinski; Wassermann negative, von mother knows. She is the youngest of four children, is a Pirquet negative. On lumbar puncture the fluid was in- seven months child, has fair intellect, and her arms show creased in amount, clear, no increase of cells. After the no sign of spasticity. He purposed lengthening the tendo lumbar puncture he began to have fits in the daytime. Fits achilles on the right side and performing tenotomy on the seem to start in both eyes, and then go down the left side, left. then an interval, and afterwards cross to the right side. 8. Dr. Officer's case. Child had infantile paralysis in No temperature, pulse-rate 76, urine clear, respiration right leg nine years ago. No splint was used. She at- normal, bowels somewhat constipated. Has been on tended the out-patient's department for 12 months, and grains 2 hyd. cum creta t.d.s., and salivates easily. began to improve after about three months. Now almost 2. Dr. Embleton showed for Dr. A. J. Wood a boy, aged normal. three years, with talipes valgus, left in-knee, wasting Discussion. and shortening. There has been weakness in left leg / ever since he started to walk, at 2 12 years; never crawled Case 1.—Dr. Milligan said that it was thought from the

at all; no history of an epidemic of paralysis in the dis- symptoms that there might be some lesion in the left

trict. Reflexes present and intellect (?). Had convul- frontal lobe. The family history was suggestive of a

sions as an infant, also diarrhoea. Was a bottle-fed syphilitic condition, probably a syphilitic meningitis or

baby. Three other children, all well and strong, one died encephalitis, but there was a negative Wassermann. He of appendicitis. No miscarriages. thought, therefore, that syphilis could be excluded. It

3. Dr. Milligan showed for Dr. A. J. Wood a girl aged was then thought it might be a tumour, but there were

10 years. Quite well till two years ago, when she com- none of the other signs of tumour. He thought a trephine

plained of tiredness on walking, and has been getting should be done over the left frontal area, to give the tired more easily lately. Will walk about 200 yards, child a chance. He had seen a glioma give rise to these starting off well, then begins to complain. Appears to be symptoms. weakness of left leg on walking with stiffness of right Dr. Kent Hughes said he had seen several tumours of

arm. Toe of left boot worn out; may fall occasionally the frontal lobe, and there was no mental condition about when tired. any of them. The only real symptom was pain.

Family History.-Mother and father living. On father's Dr. Stephens said that a negative Wassermann did not side, a sister has paralysis agitans; a half-'brother died exclude syphilis, but there could be no harm done by feeble-minded; one brother had fits and died, another had exploring the frontal area, as the boy was going from paralysis. Four brothers on mother's side, the youngest had to worse. He had a recollection of an hydatid of a being feeble-minded. frontal lobe that presented no symptoms, except gradu-

Knee jerks active, triceps and biceps jerks active, plan- ally diminishing power of attention. Then suddenly the tar re flex sluggish, Babinski obtained on left side, for- child developed double proptosis and died quickly. It merly it was more definite on right side; sensation nor- turned out to be a large hydatid of the frontal region. mal, no tremor or ataxia in either limb. Muscular power Case 2.—Dr. Kent Hughes said he thought it seemed to good, movements of joints good, spine movements good. be more a case of congenital defect. He thought one No wasting of limbs, no spasticity. Fundus clear, fields would find that the tarsal bones were not quite as de-

• normal, no nystagmüs. veloped as they should be. He would regard it as a 4. Dr. Hughes showed the case of a boy aged five years. congnital deficiency below the knee.

He operated on fifth and sixth C.N. roots at ten weeks old. Dr. Stephens said he thought the boy was decidedly A tremendous piece was removed from fifth root and part mental. He had marked spasticity of the lower extremi- of sixth, a good deal of tissue being present. The fifth ties, and the reflexes were exceedingly active. He would nerve was entirely disorganised, part of the sixth had a therefore suggest that the deformity was the result of blood clot in it. He did not show much improvement for birth palsy, cerebral type. about six months, but gradually the arm has been getting Case 3.—Dr. Milligan suggested the possibility of this stronger and stronger, and he has now almost normal case being hysterical.

movements of arm. Dr. Hughes said he did not think it was hysteria. In

5. Dr. Stephens showed a female child, aged 13 months, hysterical children of that age he had only seen one leg with torticollis, scoliosis and transposition of heart. The affected at a time; he had never seen both legs affected mother states there was a prolonged labour, no doctor in hysteria. being present. When a fortnight old it was noticed that Dr. Stephens said he thought the question of abiotrophy the child was holding its head on one side. When the came into the case. child tried to walk at twelve months it seemed to lean to Case 4.—Dr. Hughes's case of obstetric paralysis. Dr. one side. Breast-fed for ten months. When examined it Hughes said he operated on the child at ten weeks of age. was noticed to continuously hold its head towards right when the arm was perfectly useless. It was all very well side, it back was scoliotic with an S-shape curve and ro- to say that if one left it alone it might get better. The tation towards the left side and mid-dorsal area. X-ray fifth nerve tissue was entirely disorganised, and he had was taken, and showed distinct displacement of heart to to remove about half an inch of nerve. There was great April 26, 1913. AUSTRALIAN MEDICAL JOURNAL. 1015

difficulty in getting it together. He felt quite sure that directly into the blood and tissues of the human being suf- if the child had been left alone till 15 months (as the fering from tuberculosis. It is founded on the following Americans advised) one would never have got the nerves considerations and experiments: A germ settling in man, together. There was so much cicatricial tissue that one partly of itself, partly in combination with the tissues of would never have got approximation. In one boy he had its host, manufacturers certain poisonous substances, operated upon at four years old there was no hope of which poison the host, but are also harmful to the germ getting the nerves together owing to the enormous' amount itself. If the host is 'able to resist the poison the germ of cicatricial tissue round the area. itself is neutralised or destroyed by these newly-formed Dr. MacKay said he would like to thank Dr. Hughes for poisonous substances. The disease thus comes to an end, bringing this case forward after such a long interval. The leaving the patient generally protected against a further result, he thought, was excellent. That showed the wis- attack of the same disease. This is what 'happens with dom of treatment of any of these cases that came under typhoid, scarlet fever, measles, diphtheria, tick fever in notice at a very early stage. cattle, and other infectious diseases. Now, consumption Case 5.—Dr. Stephens said that there was an obscure differs from them, inasmuch as neither the bacillus Is history of tubercle in the family, and he would like to destroyed by the poisons, nor does the patient become im- know if members thought the twisting of the spine could mune. Koch hit upon the idea of preparing an•extract of be an acquired lesion in a child of this age. He did not these partly poisonous, partly salutary substances from think it was secondary to the torticollis, because of the pure cultivations of tubercle bacilli outside the body, and amount of fixed rotation. , which, if it were secondary, injecting this extract into patients suffering from tubercu- would be movable for many years. He considered the con- losis. This substance is the famous tuberculin, which in dition a congenital deformity of the spine. its old form as discovered by Koch, and numerous -modi- Dr. Silberberg thought the skiagram indicated a dis- fications devised by subsequent observers, has produced placement rather than a transposition of the heart. undoubted good effects and many cures. Now, Dr. Fried- Dr. Hughes said he thought a large amount of the mann's contention is this: These substances. which have spinal rotation might be due to the torticollis. He thought the curative effect, are so delicate that they are partially Dr. Stephens should call it a misplacement, and not a destroyed by the chemical method which kills the germ transposition, of the heart. in preparing the extract. The secret of success lies in Case 6.—Dr. Alan Mackay said that he thought the taking the living bacillus and allowing it to produce its trouble was quite possibly due to masturbation in a boy of own antidote in the living body of its host. Of course, it Is that age, and he thought the boy should be watched. He apparent that a bacillus must be chosen which, though had often noted the association of nasal catarrh, dilated belonging to the same species, is not virulent to the pa- pupils, and bad teeth, with sexual aberrations. tient. Such a bacillus Dr. Friedmann believes to have Dr. Garnet suggested intermittent claudication. found in the bacillus of tuberculosis of the turtle, which Case 8.—Dr. Hughes said there was a slight equino is also subject to consumption. Briefly put, man suffering varus present, which in another year or two would be from tuberculosis is inoculated with tuberculosis of the very well marked, if not operated on. turtles.

Dangers and Objections. —The first thing required of any FRIEDMANN CURE. remedy is that it shall do no material harm. In a new The Queensland Government has received a report from remedy which has not yet been sufficiently tried, experi- Dr. E. Hirschfeld, who was recently in Germany, and is ence alone is not a sufficient guide. Dr. Friedmann himself German Consul in Brisbane. The Brisbane "Courier," of states, and others corroborated it, that the injection is fol- April 3rd, has the following extract:— lowed by abscesses at the point of injection which in many The official announcement of his new method of treat- cases were sufficiently serious to make the patient give ing tuberculosis was made by Dr. F. F. Friedmann at the up the treatment. Dr. Friedmann partly overcame this ordinary meeting of the Berlin Medical Society on Novem- difficulty by injecting his remedy direct into the blood ber 6th. It was based on 1,012 cases of patients suffering instead of the tissues as he did at first, but as many cases from different forms of tuberculosis. The tubercle bacil- still require injection into the tissues abscesses still re- lus attacks almost every organ of the body; we speak of sult. Of course, it its rather an uncomfortable thought consumption when it affects lungs, bowels, or throat, to have living germs introduced into one's blood, but no but glands, bones, joints, skin and many other organs are evil results have arisen so far. But there are serious liable to its invasion. All the cases on which Dr. Fried- theoretical objections. It has been shown in a certain mann's report was based were treated exclusively by him- other infectious disease that a germ originally harmless self, the patients being sent to him by various medical was suddenly, without ascertainable reason, transformed men during 1910-1911-1912. In justice to Dr. Friedmann, into a 'harmful germ by processes not under our control. it is but fair to state that the results achieved were in this Such an event would, of course, be an extremely serious way controlled by , others besides himself. The success contingency to the patient, and Professor Citron, an obtained was most striking as far as tuberculosis of the acknowledged authority on the subject, urged reserve and bones, joints and glands was concerned, and corroborated caution for that reason, and as long as we do not know by such eminent observers as Professors E. Muller the factors which transform a harmless bacillus into a Schleich, and Kuester. In many instances they were harmful one of the 'same species. This was probably one chronic cases, which had resisted other methods of treat- of the reasons which induced Dr. Friedmann not only to ment, and in which operation had failed to bring relief. keep the use of his remedy entirely to himself, but also to Dr. Bier, the famous professor of surgery at Berlin, was avoid giving sufficiently explicit directions enabling other not quite as enthusiastic in his praise; he had seen im- observers to 'experiment for themselves and control his re- improvements, but nothing that could convince him so far sults. As a matter of fact, Dr. Piordewski was able to that the remedy was a specific in the treatment of sur- show with regard to the very bacillus of tuberculosis of gical tuberculosis. Dr. Karfunkel reported over 200 cases turtle that such a transformation could take place. The of pulmonary consumption, some of whom were cured, course adopted by Dr. Friedmann in withholding essential many others improved. Professor Heymann had treated details of his investigations has caused serious objections 17 cases of consumption of the throat, one or two of whom in many quarters. It must be mentioned, however, that he considered cured, while several others showed improve- Dr. Friedmann inoculated himself with his own virus be- ment; two died, and others did not persevere with the fore trying it on his patients. The experiments in animals treatment. A rather painful impression was created by were not altogether in favour of the new treatment. Ani- Dr. Friedmann stating that a case of tuberculosis of the mais suffering from tuberculosis and treated with the new kidney and bladder had been cured by his injections. It remedy lived longer than others not so treated, but died was afterwards shown by the medical man attending the 'ultimately of the disease. This result does not compare patient that such was not the case, the treatment having favourably with the effects of tuberculin and its modifica- failed to arrest the progress of the disease. This, how- tiens, which in many instances were found capable of -cur- ever, may be due to a misunderstanding. ing animals thus afflicted. Principle of Treatment. —The treatment consists in the At the 'annual court of governors of the Mount Vernon injection of living tubercle bacilli, derived from. the turtle, Hospital for Consumption, held at Fitzroy-square, Londóf, 1016 AUSTRALIAN MEDICAL JOURNAL. April 26, 1913.

a resolution was carried, with a few dissentients, to the following effect:— That the committee of management of this 3B?'ítiO InCbiCRt ZWOLiAti0n. institution VICTORIAN BRANCH. Summary and Conclusion. —What can the remedy do against pulmonary consumption? Can the new treatment Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. achieve more and in a better way than the methods at Secretary. present at our disposal? The fact that .a number of deaths have taken place under the treatment need not necessarily discourage us. It is not reasonable to expect advanced cases to be cured by any remedy. Ravages done cannot NOTICES. be repaired, though the cause of these ravages be ren- dered harmless. Early cases of consumption generally can be cured by our present methods of treatment, but Warning Notices. any treatment which assists us to eliminate the failures Medical practitioners are asked, before applying for any we have at present should be welcome. Pt is not yet proved appointment advertised by the United Friendly Societies that the new treatment will do that despite the reported of Invercargill, N.Z., to communicate in the first place cures and improvement. The consumptive patient is al- with the Secretary, British Medical Association, 26 Yarrow- ways most hopeful. When years ago Koch's treatment street, Invercargill; or H. E. Gibbs, Secretary B.M.A., Box was announced as a certain cure, nearly every patient suf- 156, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; fering from the disease improved astonishingly at first at or the Secretary, B.M.A., Melbourne, Vic.; or the Secre- the mere prospect of the promised cure, which had a tary, B.M.A., 429 Strand, London. vitalising effect upon mind and body as well. Every new Court Sherwood and A. O. Foresters Launceston. method of treatment of phth•isis, if only launched with Wellington Mills, New Zealand. sufficient authority, will, in the first enthusiasm, work Medical men are advised to communicate with Dr. S. W. cures and bring about improvement bordering on the Ferguson before applying for positions advertised by miraculous. Both Dr. Friedmann and the medical men Bullfinch Medical Fund, W.A. whose patients he treated laid great stress upon the dis- appearance of the complaints of the patients (pains, dis- comforts, etc.), even where the condition of the lungs had Telephone 1434 Central. not improved. These are just the symptoms likely to get better when the patient looks confidently forward to a cure. In visiting different sanatoria and institutions I saw results achieved by certain preparations of tubercu- mainly for the purposes of compensating those who have lin, which, with the necessary limelight on them, would lost financially through loyalty to the policy of the Association. have been as impressive as anything shown by Dr. Fried- mann. Summing up the whole of the evidence brought Encouraged by suggestions which have been made by forward so far with regard to pulmonary consumption, the one or two overseas branches and by many colonial mem- verdict must be "not proven." Moreover, are we justified bers who have recently visited this country. the council in submitting a consumptive patient, who can be cured has resolved to give members of the Association resident by other methods, to the injection of living bacilli into his outside the United Kingdom an opportunity of subscribing blood, when we do not know yet all possible risks and to the Central Insurance Defence Fund in order to defray contingencies? There is, however, no doubt that tuber- the heavy expenses already incurred, and to refund to the culosis of the joints, bones, and probably also of glands Association some of the money which it has expended (serofulosis) are benefited greatly by the new remedy. on this campaign. I enclose a form which I shall be glad These forms of tuberculosis, very frequent in Europe, are if you will fill up and return to me with a donation to the rare in Australia, more particularly in Queensland. The fund in the form of a money order payable to the British method of treatment devised by Dr. Friedmann is a great Medical Association. If every colonial member would give step in advance, though it may not accomplish all it claims the sum of £ 1, the amount thus realised would be not only to do at present. a most acceptable sign of sympathy with the profession at Before concluding, may I refer briefly to the frequently home, but also a substantial and greatly appreciated help expressed desire to have "the cure brought out to Aus- to the fund. I may mention that the Durban Division on tralia." The remedy is not one which can be bought or its own initiative has sent a donation of £50 to the Fund. procured at present. Dr. Friedmann has so far treated —I am, yours faithfully, each case himself, no other medical man having been en- ALFRED COX, Medical Secretary. trusted with it. In spite of the urgently and publicly re- peated requests of the leaders of medicine and surgery in (To Alembers of the Association outside the United Germany (Professors Orth, Beir and others) to give full Kingdom.) particulars as to the method and quantity used, he avoid- [Money orders should be enclosed with name and ed doing so. No other man has been able to repeat or address of sender and name of Branch.] verify his experiments.

The American Clinics. CORRESPONDENCE. (To the Editor of "The Australian Medical Journal.") Sir,—In common with many others, I was much inter- Central Insurance Defence Fund. ested in Dr. Moore's article describing the work seen in (To the Editor of "The Australian Medical Journal.") the American surgical clinics. The method of draining the gall-bladder after removal of gall-stones, as performed Dear Sir,— by Drs. Murphy and Ochsner, and described in your issue You are doubtless aware that for the past two of April 5th, is, however, not by any means new to Aus- years the British Medical Association has been actively tralian surgeons. The method consists of turning in the engaged in defending the interests of the medical pro- cut edge of the gall-bladder, tying in a drain, and dropping fession in connection with the National Insurance Act, and the viscus back into the abdomen, thereby obviating subse- that the campaign has been arduous and expensive. A quent trouble due to adhesions to the abdominal wall. Central Insurance Defence Fund was instituted for which In 1908, while house - the Council is acting as trustee, and a call on the guaran- surgeon at the Melbourne Hos- tors of £1 per head for administrative purposes has rea- pital, I first saw this method performed by Dr. R. A. lised some £ 15,000. But this is only about one-half of Stirling, and have seen it many times since. It was not what has been spent in the active work of the campaign at that time described in any of the text-books of surgery. during the past two years. The rest has been provided by —Yours, etc., the funds of the Association, on which the strain has been J, GRANTLEY SHELTON, severe. Another call is now being made on the guarantors, April 16, 1913. 1

April 5, 191 3. AUSTRALIAN MEDICAL JOURNAL. vii

I 11 I II 1 N' i h L II u l d l 1 I^I ^ 1 Ì Ì I^ 1 „^ I I I 1 ii IiI I lúúl I i I úÌiÌúl (liu.ulll ill I IIIII IIIIII w:du(:ili,uÌlÍllil IÍ!ÍIIIIIIII Llllldi;!

The Original and Standard

Preparation of Petroleum.

ANGIER' IJLSION

Angier's Emulsion is made with petroleum specially purified for internal use. It is the original petroleum emulsion—

the result of many years of careful research and experiment.

A Perfect Emulsion.

Placed under the microscope, physicians may see for themselves how minutely

and evenly the oil globules are sub-divided. Angier's Emulsion actually

duplicates cream in appearance and consistency, and like cream, mixes instantly

and perfectly with water. Bland and pleasant, it can be administered

undiluted or in any desired beverage, and may be continued for a long period without exciting distaste

Well borne by Sensitive Stomachs.

Angier's Emulsion never causes eructations, nor does it disturb appetite or

digestion. It is remarkably well borne by delicate stomachs, often being retained,

when even prepared foods are rejected. In the numerous cases in which a

sensitive, irritable condition of the stomach and intestines precludes proper

nourishment, these organs, under the administration of Angier's Emulsion,

become pacified retentive, digestion is strengthened, and the assimilation of food becomes normal and complete.

In use over Twenty Years. It Angier's Emulsion is not an experiment. has been before the medical

profession for over twenty years, and is extensively prescribed by medical men

•throughout the entire English-speaking world. A constant succession of clinical

reports give it absolute endorsement. We cannot be too emphatic in stating

that there is no substitute for Angier's Emulsion. Even a superficial

comparison will furnish abundant evidence of its superiority. In appearance,

in taste, in miscibility with water, in tolerance by delicate stomachs, in all that

constitutes a really perfect Emulsion, Angier's is easily first.

FREE SAMPLES TO THE MEDICAL PROFESSION,

THE ANGIER CHEMICAL CO., LIMITED,

7 Barrack Street, Sydney, N.S.W.

n111 ^ ^ I'"'1" 1"1,!!!'1111111 , I I 1!11!11!1 1^II ;^ !E 11 I I ^ ^^, ^ I I ^ !I il I^ !II II !l";;;'^^^^, ; l il ^jl^l^ ^ !III'i!I 1 1 ' 111 I' 1 1 " !I ^ , r I v'ii AUSTRALIAN MEDICAL JOURNAL. April 5, 1913. BRITISH MEDICAL ASSOCIATION f' (VICTORIAN BRANCH).

LIST OF MEMBERS.

Adam, Ivanhoe. J Black, A. G., Carlton. Cole, Frank Hobill, Rathdown Adam, G. Rothwell W., Collins Blakie, J. L., Surrey Hills. St., Carlton. Street. Blaubaum, A., Toora. Adamson, J., Sunshine. Colquhoun, A. G. H., South Mel- Blaubaum, H., St. Kilda. bourne. Adey, J. K., Asylum, Yarra Bend. Boake, W., 294 Glenferrie Road, Connell, E. J., Warrnambool. Agnew, James Francis, Erin St., Hawthorn. Connor, S., Coleraine. Richmond. Bona, Percy A., Maffra. Cook, H. W. J., Shepparton. Aitchison, Alexander Smith, Al- Booth, Mary, Trinity College bert Park. Cooke, John, Prahran. Hostel, Yorkville. Cordner, E. R., Melbourne Hos- Aitchison, R., North Brighton. Bottomley, W. F. S., Fitzroy. Aitken, W. h., Stawell. pital. Box, John, Union Road, Surrey Costello, Al. J., 291 Church Si., Allan, E. B., Elsternwick. Hills. Allen, H, 13., The University. Richmond. Box, M. .II., Footscray. Coto, D. S., Koroit. Allen, Sydney H., Carlton. Boyd, T. H., Richmond. Alsop, C. J., Bairnsdale. Cowen, Alfred, Drouin. Boyd, W. R., Richmond. Cowen, B. S., Canterbury. Altmann, C. A., South Yarra Bradford, W. A., North Fitzroy, Amess, Janie, Collins St. Cowen, Herbert Osburn, Kew. Brenan, A. J., "Mount Ievers," Craig, W. B., Warrnambool. Anderson, Abred Victor. Millard, Parkville. Craig, Walter Joseph, Box Hill. Collins St. Breton, H., Terang. Crellin, B., Abbotsford. Anderson, C. II., 8o Collins St. Brett, John Talbot, Collins St. Anderson, J. I ., Woodend. Crivelli, Marcel, Sth. Melbourne. Brett, Percy G., Hawthorn. Crookston, R. M., Melbourne Anderson, J. H., Melb. Univ. Brown, Alfred A., Sanatorium, Hospital. J. E. , Hawthorn. Green Vale. Crowley, C. G., 12 Malvern Rd., Andrews, W. A., East Melbourne Brown, R. C., AVindsor. Malvern. Andrews, Wm., East Melbourne Brown, Thomas AV., Corryong. Angwin, Stuart Letcher, St. Cuscaden, G., Collins St. Brown, W. H., Colac. Cuscaden, W. G., Preston. Arnaud. Brownell, W. F., Alfred Hospital. Argyle. S. S., Kew. Bryant, H. W., Collins St. Armstrong, G. W., 24 Collins St. Buchanan, J. S., Collins St. Daly, L. B., Hawthorn. Daly, U. A., Gisborne. Atkinson, Geo., 18 Gellibrand St., Buick, James, Jolimont. • Kew. Bull, Richard Joseph, Melbourne Daniel, C. J., Elsternwick. Atkinson, J. L., Birchip University. Davenport, Arthur F., St. Kilda. Burns, F. J., Carlton. Davies, F. L., high St., Malvern Bage, Charles, Toorak Road, Burton, W. H., Richmond. Davies, Leslie, Nagambie South Yarra. Butchart, J. E., Austin Hospital, Davies, M. C., Stawell Hospital. Baird, J. C., Dalyston. Heidelberg. Davis, AVm., Middle Park. Degenhardt, A., Northcote. Baldwin, Gerald R., Warrnam- Cade, D. D., Murtoa. bool. Denehy, W. J., Melb. Hospital. Cahill, H. J., Flemington. Denton-Tethers, P., 28 Collins St. Balfour, Lewis John, Hawthorn. Callander, R. S., Royal Park. Barrett, Edith H., S. Melbourne. De Ravin, E. A., Kew. Cameron, W. J., Mildura. Deravin, Arthur F., Casterton. Barrett, James \V., CUllins St. Campbell, Colin, Warrnambool. Baxter, J. M., Camberwell. Deravin, AV. E., Canterbury. Campbell, D. A., Yarra Bend. Desailly, Julian Gilbert, Camper- Beckett, T. G., r32 Nicholson St., Campbell, S. J., Melb. University Fitzroy. down. Carr, M., Leongatha. Devine, H. B., Begg, W., Korumburra. Catarinich, J., Asylum, Kew. Collins St. Bennett, F. G., Prahran. Dickinson, G. D., Moonee Ponds. Cave, F. W., Outtrim. Donald, Benjamin P., Warrack- Bennie, Alex. Bruce, Armadale. Cave, M., Wallace Avenue, nabeal. Bennie, Peter Bruce, Collins St. Toorak. Berry, R. J. A., Melbourne Uni- Donaldson, Wm. I:I., Drummond Chambers, R. W., Melbourne St., Carlton. versity. Hospital. Bill, George, Euroa. Douglas, R. O., St. Vincent's Christie, Charles, Rushworth Hospital. Birch, Lewis, John, Oakleigh. Clayton, W., Hawthorn. Bird, Frederic D., Spring St. Downes, R. M., 127 Collins St. Clendinnen, F. J., Hawksburn. Downie, Thomas T., Clifton Hill. Bird, R. K., Natimuk. Clendinnen, L. J., Women's Hos- Bird, W. J., .Canterbury. Downing, H. D., 34 Geelong Rd., pital. Footscray. Black, J. J., 92 Victoria St., Carl- Clucas, Elizabeth, 448 Burwood ton. Drake, F. J., Mitcham. Road, Hawthorn. Drew, Thos. M., Cobden. Ap ril ; . i913. AUSTRALIAN MEDICAL JOURNAL. ix

Duguid, C., I inyip. Greig, Jane Stocks, Education Jermaine-Lulham, F. S., Collins Duncan, II. R., Sunbury. Department. Place. Duncan, R. B., Kyneton. Greig, Janet Lindsay, Fitzroy. Joel, B. C., Coliins St. Dunhill, T. P., Collins St. Greville, S. J. R., Sth. Melbourne. Johnson, Frederick Miller, South Dunkley, F. E., Oakleigh. Griffith, Christopher, Berwick. Melbourne. Dyring, C. P. W., Coburg. Grindrod, W. C., Mordialloc. Johnson, J. I-1., Alexandra. Gross, Rachel H., St. Kilda. Jona, Jacob, Richmond. Eadie, Jas., Balaclava. Groves, W. R., Kyneton. Tones, I). E., Collins St. Eastwood, F. H., Collins St. Jones, I., Trinity College, Park- Eccles, Jacob V., Collins St. Hagenauer, G. A., Sale. ville. Ellis, Constance, Wattle Tree Hagenauer, II. A., 'l'raralgon. Jones, R., Power St., Hawthorn. Rd., Malvern. Halford, G. J. A. B., Malvern. Jones, W. Ernest, Toorak. Embleton, D. i\1., Children's 1-lam, B. B., Board of Public joske, A. S., Prahran. Hospital. Health, Melbourne. Joyce, A. F., Moorabbin. Embley, Edward H., Latrobe St. Harbinson, J. AV., Brighton. Erson, E. G. Leger, 157 Collins Harbison, J. A., Numurkah. Street. Harcourt, C., Kyabram. Keane, F. IL, Glenferrie. hsler, A. W., Williamstown. Harkness, E. E., Lang Lang . Kellaway, C. lI., .11elb. Hospital. Ewing, S. A., Collins St. I Tarse, W. T., Sandringham. Kelly, Jas. P., Carisbrook. Ilayes, J. B., Hamilton. Kelly. Joseph P., Dookie. Kenny, Augustus Leo, Collins St. F., 175 Moore St., Haynes, A., Richmond. F'airley, J. Hayward, A. C., Diamond Creek. Keogh, Eustace Julian, South Moonee Ponds. Hearne, W. \V., Sth. Melbourne. Marra. Farmer, Paul Ward, Collins St. Heffernan, E. B., Heyfield. Kerr, lames, Orbost. Faulkner, W. C., Sunbury. Heily, J. V., Rushworth. Keyes, F. J Nathalia. Felstead, J. G. R., Nhill. Collins St. Henderson, A. V.. Burke Road. Kilvington, Basil, Camberwell. Ferguson, Stewart W. , Camberwell. King, H. K., Heidelberg. Fetherston, R. H. J., 4 Collins- Henderson, J. Hunter, \Varrnam- Knight, Glen Album, fort Mel- street. Wil- bool. bourne. Fetherstonhaugh, Chas., Henderson,Mary A., Toorak. liamstown. Henderson. N. R., Mildura. Flanagan. P. J., Moonee Ponds. Henry L., Collins St. Laidlaw, D., Hamilton. Fleming, C. W. H.. St. Arnaud. Herlitz, H., Cheltenham. Lambert, Thomas Edwin Lle- Fleming, II. I I., St. _Arnaud. Hewlett, H. M., Fitzroy. wellyn, Collins St. Florance, J. AW., ALooroopna. Heymann, P., 24 Collins St. ',amble, G., Queen's College, Forshaw, W. J., Stawell. Hicks, John N. C., Beeac. Carlton. Foster, Bryan., Horsham. I-Tiller, K., Collins St. bane, Footscray. Forsyth, R. L., Surrey Hills. Hodgson, G. j., St. Kilda. Lang, .AI., Collins St. Forsyth, AV. A., Koroit. Holmes, H. 1., \Varrnambool. Langlands. F. II., Collins St. Fowler, Ruin., Richmond. Holmes, Mervyn J., Port Darwin. Langley, F. F,., I)andenong. Fox, John Raymond, Stawell. IIonman, Andrew, Spring St. Langmore, P. V., Berwick. Fyffe, Edward Henry, Gore St., Hood, Lionel J., Armadale. Latham, L. S., Collins St. Fitzroy. Hooper, J. W. 1)., Collins St. Laurie, Henry, Brighton Road, Hope, William \Waugh, Colac. St. Kilda. Gamble, M. F. I-I., Kew. 1Tornabrook, R. W., Malvern. Laurie, AW. Spalding, Hampton. Gandevia, N. 1;., 34 Collins St. Horne, George. Clifton Hill. Lawrence, II. I'., Collins St. Garnett, W. S., Children's Hos- Howard, G. T., Collins St. Laycock, George L., Windsor. pital. IToward, Henry, Queen's College, Leary, T. G. S., Sandringham. Gault, Edward Leslie, Collins St. St. Kilda. Lee, H. B., St. Vincent's Hospital Gawne, F. j., Jeparit. Howden, R., Leongatha. Lee, John Robert, Collins St. Gibbs, Richard H., Colac. Ilowitt, G., Fitzroy. Lemon, F. A., _Armadale. Gibbs. N., 34 Collins St. I1ughes, A. H. A., 599 Elizabeth Lemon, R. D., Were St., Brigh- Glassford, j. G., Il airnsdale. St.. City. ton Beach. Glowvrey, Mary, Eye and Ear Hughes, W. N., Collins St. Iew ers, :Alexander, Collins St. I ospital. Hughston, Robt. Wilson, Essen- Lev. G. I., AV'arragul. Godfrey. C. G. S., Brunswick. don. Ley, _Mark A., 'ratura. Gordon, john, Lygon St., Carlton. ITurley, T. E., AIelb. Hospital. I iilies, Ilerbert, A rmadale. Grant, _Andrew, Fulton St., S:. Hutchings T. S., Euroa. Lind, W. A. T., Cotham Rd., New Kilda. Lindsay, E. H., Bealiba. Lloyd, H. Cairns, Collins St. Grant, David, Collins St. Ingham, J. H., Dimboola. Gray, F. A., Middle Brighton. Looney, F. H., Wonthaggi. Pl., Iredell, C. L. AF., Collins St. Loosli, Robert James, Camber- Green, A. I., 53 St. Vincent's Irving, Harold, Glen Thompson. West, Albert Park. well. Green, II. I'., Melbourne Hospital Lorimer, G. N., Camberwell. Greenhorn, D. P., St. Vincent's Jackson, James, Collins St. Loughrey, Bernard, Elgin St., Hospital. James, AWilliam Arthur, Kew, Fawthorn, x AUSTRALIAN MEDICAL JOURNAL. April 5, 191 3. Lynch, M. E., Collins St. Miller, A. G., Avoca St., South Lyons, M. M., Port Fairy. Patrick, T. F., 34 Brighton Rd., Yarra. St. Kilda. Milligan, E. T. C., Children's Perl, M. M., Collins St. Macansh, W., Brighton. Hospital. Pern, S., Yarram. McAdam, Robert Louis, St. ì\litchell, L. J., 4 Collins St. Perrins, R. B., Rainbow. Kilda. Mollison, C. H., Collins St. Perry, Charles, Prahran. McAree, F. E., Middle Park. Montgomery, J. P., Terang. Pestell, J. H., Brunswick. McArthur, A. N., Collins St. Moore, W., Flinders Lane. Piper, J. E. Morris, Arthur, Collins St. \McColl, Donald S., Collins St • Player, Chas. Richard, Malvern. McCreery, J. V., Collins St. Morris, E. S., Yarra Bend. Plowman, S., Frankston. MacDonald, A., Sale. Morris, J. N., 27 Auburn-road, Potter, \V. L., Port Melbourne. MacDonald, A., junr., Sale. Auburn. Potts, W. A. B., Harrow. McDonald, S. F., Children's Hos- Morrison, Reginald Herbert, Too- I'raagst, G. D., Murchison. pital. rak. Macdonald, V., Collins St. Morton, David Murray, Collins Quick, B., Collins St. Macfarlane, A. A., Asylum, Sun- St. Quirk, Thomas A., St. Kilda. bury. Morton, F. W. W., Collins St. McGee, J. H., Collins St. Morton, J. C., Seymour. Rabi, H., Murtoa. MacGillicuddy, Daniel Florance, Morton, R. L., Fitzroy St., St. :ail, AV'., Lancefield. Richmond. Kilda. :atz, M. \V., North Richmond. MacGillicuddy, M. P., Richmond. Morton, W. A., Merino. :ead, S. D., Horsham. Mclnerny, J., North Fitzroy. Moss, William Joseph Alleine, :eid. C. M., Branxholme. Maclntosh, W. I., "Aviemore," Kensington. :eid, M. A., Collins St. Kew. Murdoch, D., Romsey. :eid, P. M., Richmond. Mackay, C. V., Collins St. Murphy, John, High St., Kew. :eid, R. G., Elsternwick. Mackay, Edward Alan, Toorak. Murphy, Thomas, St. Kilda. :eid, W. A., Sale. Mackeddie, J. F., Collins St. Alurray, FI. L., Collins St. Rhodes, '1T., East Malvern. McKenna, J., Shepparton. Richards, B. R., Box Hill. MacKenzie, A. S., Naval Depot, Nattrass, J. II., 85 Spring St. Ridley, S. F., Oakleigh. Williamstown. Naylor, A. G. E., Loch. Rigby, George Owen, Kyneton. Mackenzie, J. F. C.. Clifton Hill. Newman, Francis Alexander, 83 Riordan, Thos. F., 137 I-Iigh St., MacKenzie, Wm. C., Collins St. Collins St. Prahran. McLaren, W. W., Melb. Hospital Nicholas, J. J., Melb. Hospital. Robertson, A. S., Bairnsdale. McLean, Donald, 167 Bay St., Nicholls, G. G., Korumburra. Robertson, A. \V. D., Collins St. Brighton. N ihill, J. E., Collins St. Robertson, B., Health Depart- Maclean, Hector Rath, Williams- Noonan, T. P., East Malvern. ment. town. Norris, W. P., Acland St., South Robertson, Ernest M., Mansfield. McLean, J. S., Morwell. Yarra. Robertson, Margaret H. A., McLean, T. A., Traralgon. Noyes, A. \V. F., Collins St. Kyneton Hospital. McLelland, W. C., Mid. Brighton Nyulasy, Francis Armand, Too- Robinson, \V. M. S., Horsham. McLorinan, M. H., Clayton. rak. Roche, C., Melbourne Hospital. Maclure, F., 127 Collins St. Rosenfield, R. L., Port Melbourne McMahon, J. J., Kew. O'Brien, John Aloysius, Haw- Rosenthal, J., Camberwell. McShane, C., Fairfield Hospital. thorn. Ross, D. M., Camperdown. O'Donnell, N. M., N. Melbourne. Rudall, J. F., Collins St. Mailer, Melrose, Collins St. Officer, David McMaster, Collins Russell, R. H., Spring St. Mailer, R., Collins St. Street. Rutter, J. H., Yarram Yarram. Major, James Perrin, Wellington Oliver, C. J., Pakenham. Ryan, C. S., Collins St. St., Windsor. Orchard, W. H., Port Fairy. Ryan, Edward, Collins St. Makin, F. Humphrey, Warrnam- Ormond, J. S., Malvern. Ryan, James Patk., Collins St. bool. Orr, Wm. Francis, Collins St. Ryan, Thos. Francis, Nhill. Malone, W. C. L., North Mel- Osborn, H. H., East Malvern. Ryan, Wm. B., Bacchus Mary h. bourne. Osborne, Wm. A., Melbourne Manly, R. A. A., Werribee. University. Sabelberg, C. J., Port Melbourne. Salter, A. C. H., Portland. Marsden, C. E., North Melbourne Osier, W. D., Willaura. Salts, Richard, Kilmore. Marshall, C. C., St. Kilda. Ostermeyer, Wm., Carlton. Sawrey, Martin, F. B., Queen's College, O'Sullivan, M. U., Collins St. E. R., Collins St. Carlton. Owen, A. G., Camperdown. Scantlebury, George James, Maudsley, Henry, Collins Cheltenham. St. Schalit, Moise A., Wellington St., Maxwell, Chas., Frankston. Parer, P. A., 37 Princes St., Fitz- Windsor. Meares, A. G ., Hopetoun Road, roy. Malvern. Scott, E. N., Hamilton. Park, C. L., Gillies St., Fairfield. Scott, J. A., Hawthorn. Mendelsohn, D., Northcote. Parker, R. A., Mildura. Merrillees, J. S., Hawthorn. Scott, John D. K., Finch St., Paton, D. M., 151 Collins St. East Malvern. Meyer, Felix, Collins St. Paton, J. S., Lismore. Scott, T. W., Terang. April 5, 19 13. AUSTRALIAN MEDICAL JOURNAL. xi

Semple, John, Kilmore. Stillwell, Effie, Patna, India. Vance, \W. B., St. Kilda. Seton, M. C. C., 24 Collins St. Stirling, R ._A., Lonsdale St. Vaughan, A. P., Box Hill. Sewell, S. V., Collins St. Stone, Grace Clara, Collins St. Vogler, H. H., Yarra Glen. Shanasy, T., Nhill. Strahan, E. A., Carlton. Shaw, A. E., Healesville. Strangman, Thos., Seymour. Watkins, A. M., \Vonthaggi. Shaw, C. G., 28 Collins St. Strong, Robt. Henry, Collins St. Wawn, R. N., Prahran. Shaw, Patrick, Asylum, Kew. Sturdee, Alfred H., Northcote. Webb, F. E., Williamstown. Sheahan, J. G., Brunswick. Summons, Walter E., Stawell St., Webb, J. R., Footscray. Shelton, J. G., 33 Collins St. Kew. Webster, P. S., Spring St. Shelton, P. G., Alfred Hospital. Summons, W. H., Collins SC Webster, Reginald, Melbourne Shields, J. W., South Yarra. Sutherland, B. M., Moonee Ponds Hospital. Shields, Oswald C. G., Yea. Sutherland, R. T., Collins St. \\'eigall, A., Cheltenham. Short, R. E., Lilydale. Sutton, Chas. S., North Carlton. \\'eigall, G. C., Elsternwick. Shuter, R. E., 16 Collins St. Sutton, Harvey, Trinity College, \Weigall, R. E., Elsternwick. Silberberg, M. D., 54 Collins St. Parkville. - \Weir, Albert A., Terang. Sweetnam, F'. A., Penshurst. \Velchman, J. A. C:, Shepparton. Sinclair, T. W., Town Hall, Mel- Sweetnam, AVm. Francis, Mort- Weld, J. C., Dromana. bourne. lake. Skinner, G. H., Casterton. \Vest, G. R., Kaniva. Sleeman, James Henry, Portland. Syme, G. A., Collins St. \Vettenhall, R. R., Collins St. Sleeman, L. O., Wonthaggi. Tait, J. T., i\Ielbourne Hospital. White, A. E. R., ,Spring St. Sloggett, H. P., Albert Park. Taylor, A. E., Dandenong White, Edward R., 84 Collins St. Southey, W. G., Molesworth St., Teague, D. G. M., Hamilton. Wight, John Cani, Kyabram. Kew. Thomas, Elsie L., Fairfield. Wilkinson, A. M., Glenferrie. Smith, Charles, Rockley Road, Thomas, H. I)., Caulfield. Wilkinson, John Francis, Collins South Yarra. Thomas, J. C., Canterbury. Street. Smith, Julian Augustus Romaine, Thomson, H. Barry, Wilkinson, W. C., South Preston. to Collins Williams, H. J., St. Vincent's Collins St. Street. Hospital. Smith, William Beattie, Collins Thomson, J., Williamstown. Williams, John, Collins St. Street. Thomson, John Rae Menzies, Willis, T. R. H., Malvern. Smithwick, G. W., Trafalgar. Violet Town. Wilson, A. M., Melbourne Hos- Somers, Jas. L. E., Mornington. Thwaites, J. S., South Melbourne. pital. Speirs, N. L., Clifton Hill. Travers, G., Elsternwick. Spence, H., Numurkah. Tregear, W. G. H., Warrackna- Wilson, H. C., Foster. Spowers, Edward A., East del- beal. Withington, R. C., Bunyip. bourne. Trinca, A. J., Hawthorn. Woinarski, G. H. T. Z., Asylum, Spring, J. F., Essendon. Trood, C. J. Prahran. Kew. Spring, John P., 107 Rathdown Troup, J. K., North Melbourne. Woinarski, S. G. A. Z., Morning- St., Carlton. Trumpy, David, Warragul. ton. Springthorpe, J. W., Collins St. Tucker, C. F., Brighton. Woinarski, V. J. E. Z., North Stanley, II. Riddell, Collins St. Tulloh, W. E., Omeo. Melbourne. Stapley, W., Veterinary School, Turnbull, H. H., 85 Spring St. Wolfenden, J. H., Dunolly. Parkville. Turner, W. C. B., Cressy. Wood, Arthur Jeffreys, Collins Stawell, R. R., Spring St. Tuthill, J., Cunninghame. Street. Steel, W. I I., Brunswick. Tymms, A. S. M., Melbourne Wood, F. A., Toorak. Steell, J., Asylum, Yarra Bend. Hospital. Wood, W. A., South Yarra. Stephens, C. V., North Melbourne Upjohn, W. E., c/o Dr. Cole, Young, A. S., High St., North- Stephens, H. Douglas, 2 Collins Carlton. cote. Street. Yule, John Sandison, Collins St. Steuart, H. St. C., St. Kilda. Utber, F. L., Women's Hospital. Steven, Alex., Elsternwick. Vance, Noel Crawford. Atterbury, Zwar, Bernard Traugott, Collins Stewart, D. E., Brunswick. Bacchus Marsh. Street.

BALLARAT DIVISION.

Barker, W. H., Hospital for In- Courtney, C., A., Learmonth. Fankhauser, H. W., Kingston. sane, Ballarat. Cunningham, P. H., Talbot. Forster, Arthur E. B., Climes. Barrett, Wm. A. H., Skipton. Bennett, H. V., Ballarat. Dane, P. G., Ballarat East. Garde, G. E., Maryborough. Bonnin, F. J., Ararat. Davies, W. E., Ballarat. Gardiner, J. M., Ballarat. Brown, T. F., Ararat. Deane, Edward W., Park Road, Grimmer, C. G., Avoca. Buzzard, G. C., Ararat Hospital. Maryborough. Hardy, C. H. W., Ballarat. Dennis, C. E., Ballarat. Hayman, Frederick Dell, Ararat. Campbell, A. B., Ballarat. Donaldson, J. B., Linton. Champion, E., Ballarat East. Jackson, Allan G., Beaufort, Chaplin, W., Ballarat. Eadie, G. A., Beaufort. Johnson, W., Avoca, xii AUSTRALIAN MEDICAL JOURNAL. April 5, 1913.

Kelly, M. F., Ballarat. \lcArthur, G. A., Ballarat Hos- Langley, A., Ballarat. Scott, G. A., Ballarat. pital. •Scott, R., Ballarat. Lethbridge, R. W., Ballarat. McGowan, A. G., Ballarat. Liddle, Percy H., Daylesford Sleeman, G. F., Creswick. Naylor, R. G., Ararat. Sloss, W., Ballarat. Longden, F. R., Buninyong. Pern, H., Smvthesdale. Spring, W. A., Ballarat. • Loughran, H. G., Daylesford Philpott, A. J. W., Ararat. Matthews, J. T., Ararat. Steele, L. R., Ballarat. Richards, J. K., Ballarat. Trewhella, W. J., Daylesford. _Miller, W. F., Maryborough. Rogerson, Henry, Hospital for Mitchell, J. T., Ballarat. Wilson, T. A., Creswick. the Insane, Ballarat. Vale, Grace, Ballarat. Morrison, W., Ballarat. Ruddle, Reginald G., Daylesford. BENDIGO DIVISION. Atkinson, H. L., Bendigo. Greer, Claude, Sea Lake. Moss, M. K., Echuca. Barnard, J. F., Kerang. Griffiths, Ada, Quambatook. Boyd, J. D., Bendigo. Nankivcll, A. Y., Cohuna. Hamilton, R. H., Bendigo. Owen, Frederic J., Heathcote. Catford, H., Eaglehawk. Hill, A. M., Castlemaine. Cohen, B. W., Bendigo. l'enfold, O., Bendigo. Hutchinson, F. E., Echuca. Plante, G. R., Swan Hill. Colquhoun, K. G., Swan Hill. Jackson, II. Cordner, H., Bendigo Hospital. E., Bendigo. Rockett, P. J., Bendigo. Deane, T. E. J., Eaglehawk. Jacobs, Morris, Pyramid. Rowan, J. J., Ultima. Deravin, Garnet" W., Inglewood. Johnson, C. H., Kerang. Sandison, A., Rochester. Deravin, H. A., Bendigo. Ker, T. C., Bendigo. Stewart, C. A., Wycheproof. S. H., Charlton. Lease, C. R., Rochester. Stoney, R. B., Echuca. I frost, A. E., Golden Square. Legge, F. R., Swan Hill. Taylor, G. A., Wedderburn. Long, Gaffney. A. E. B., Bendigo. William John, Bendigo. Thompson, J. L., Castlemaine. Gaffney, C. B., Bendigo. Lyons, A., Eaglehawk. Gaffney, F. C. B., Bendigo. Webster, E. E., Boort. \lcEniry, J. J., Kerang. Wilkinson, A. N., Inglewood. Gray, Colin, Maldon. MacKenzie, J. G., Kaneira. Green, F. W., Charlton. Willis, J. R. L., Bendigo Hospital Maxwell, K.. Castlemaine. Williams, M. I,., Bendigo. Green, T. E., Bendigo. \lerrillees, C. R., Pyramid Hill. GEELONG DIVISION. Clarke, P. G., Portarlington. Grimwade, A. S., Geelong. Croker, P. A., Geelong. McPhee, R. G., Geelong. Kennedy, T. Newman, F. J., Geelong. Darby, G. R., Geelong. J. i\1., Geelong. Eddie. A. AV., AVinchelsea. \tarwood, A. W., Geelong. Small, J., Geelong. Elvins, H. T., Geelong. Moreton, F., Geelong. Morgan, A. \V., Geelong. F etlierstonhaugh, R. T., Geelong. Pacey, F., Drysdale. McCallum, G., Geelong. Pollock, J., Queensclif. BORDER DIVISION. Barrington, A. E., Benalla. Harkin, C. F., Chiltern. :Magee, Boyes, W. I., Wangaratta. Henderson, J. 1,., Wangaratta. C. C., 'l'ungaimah. Bush, Hubert S., Rutherglen. _AIcl,av, R. G., AWangaratta. Hollow, J. 'l'., ;Asylum, Beech- Nish, J. Docker, Wyatt Bristow, Wanga- worth. A. D., Benalla. ratta. O'Brien, J. A., junr., 1V'angaratta. Morgan, J. P., Yarrawonga. Patterson, J. I-L ., Ebsworth, R. H., Benalla. Jamieson, S. C., Yarrawonga. Tallangatta. H arris, John Richards, Ruther- Schlink, R. H., Wodonga. Kennedy, J. T., Cobram. Sutton, E. glen. Kidd, L. S., Bright. R., Myrtleford. ASSOCIATE MEMBERS. Lyle, T. R., Melbourne Univer- Masson, D. sity. Orme, Melbourne Stuart, 'l' P Anderson, Sydney. University. Williams, Martin, Charles James, Lister Spencer, W. Baldwin, Melbourne Surgeon Major-Gene- Institute, London. University. ral, Melbourne. SUSPENSE LIST. Gardner, M. C., "Hazelwood," St. Jolla, J. L., Lister Institute Patterson, S. W. Kilda Road. Kennedy, J. Hutton, J. R. I'innock, Dudley. billies, G. L. Scholes, F. Jamieson, James , 12 Lambert Newton, H. A. S. Rd., Toorak. Sexton, Helen. O'Leary, R. D. Weihen, A. W. LIFE MEMBERS OF THE MEDICAL SOCIETY OF VICTORIA. Barrett, J. W., Collins St. Lawrence, H. F., Collins St. Tenfold, Oliver, Bendigo. Bird, F. D., Spring St. Lawrence, Octavius Vernon, Hawthorn. Fletcher, A. A. Thomas, Aalalter, Christchurch, Morton, F. W. W., Brunswick New Zealand. Jackson, James, Collins St. St., Fitzroy.

Library Digitised Collections

Title: Australian Medical Journal 1913

Date: 1913

Persistent Link: http://hdl.handle.net/11343/23179

File Description: Australian Medical Journal, April 1913

Terms and Conditions: Articles from the Australian Medical Journal have been made available as permitted under the Copyright Act 1968. Any further reuse or reproduction is subject to the following:

Terms and Conditions: Copyright has expired:Where the author of an article died before 1 January 1955, copyright has expired under Australian copyright law and the material has passed into the public domain. Please note that this may not be the case in other jurisdictions, and it may be necessary to refer to the copyright law in your region when using this material.

Terms and Conditions: Articles still subject to copyright:Where the article is still protected by copyright, articles have been made available as permitted under section 200AB of the Copyright Act 1968. This material is subject to copyright and any further reproduction, communication, publication, performance, or adaptation is only permitted subject to copyright legislation in your jurisdiction.